UNIVERSITY  OF  CALIFORNIA 

CALIFORNIA  COLLEGE  OF  MEDICINE 

LIBRARY 

AUG  1  4.  1972 

IRVINE,  CALIFORNIA  92664 


THIS  BOCK  WAS  DONA. 

^    BY  J>jr  W  J.  nadsca 


THE 

DISEASES   OF  INFANCY 
AND   CHILDHOOD 


FOR   THE   USE   OF  STUDENTS 
AND   PRACTITIONERS   OF   MEDICINE 


BY 

L.   EMMETT    HOLT,   A.M.,   M.  D. 

PROFESSOR    OF    DISEASES    OF    CHILDREN    IN    THE    NEW    YORK    POLYCLINIC  ;    ATTENDING    PHYSICIAN 

TO    THE    NURSERY    AND    CHILD's    AND    THE    BABIES'    HOSPITALS,    NEW    YORK; 

CONSULTING    PHYSICIAN    TO    THE    NEW    YORK    INFANT    ASYLUM,    AND 

TO    THE    HOSPITAL    FOR    THE    RUPTURED    AND    CRIPPLED 


WITH   TWO  HUNDRED  AND  FOUR  ILLUSTRATIONS 
INCLUDING  SEVEN  COLOURED  PLATES 


NEW    YORK 
APPLETON    AND    COMPANY' 


Copyright,  1897, 
Br  D.   APPLETON  AND  COMPANY. 


VIRGIL   P.   GIBXEY,   M.  D., 


CLINICAL   PROFESSOR  OF   OBTHOP.ilDIC    SL'RGERY   IX   THE   COLLEGE   OF   PHYSICIANS 

AND   SURGEONS   (COLUMBIA   UNIVERSITY),   NEW   YORK  ;   SURGEON-IN-CHIEF 

TO   THE    HOSPITAL    FOR    THE    RUPTURED    AND    CRIPPLED, 

THIS   VOLUME   IS    INSCRIBED 

AS    A    TRIBUTE   TO    HIS    PERSONAL    WORTH    AND    HIGH    PROFESSIONAL   ATTAINMENTS, 
AND    IN    GRATEFUL    REMEMBRANCE    OF    MANY   ACTS   OF    KINDNESS, 

BY  THE   AUTHOR. 


PREFACE 


The  rapid  advance  made  during  the  past  few  years  in  this  department 
of  medicine  is  a  sufifjcient  justification,  if  one  were  needed,  for  another 
general  work  on  the  Diseases  of  Infancy  and  Childhood.  It  is  not 
claimed  that  the  present  work  is  a  complete  one,  for  completeness  in  so 
broad  a  subject  in  a  single  volume  is  impossible.  However,  by  omitting 
much  material  which  does  not  strictly  pertain  to  children,  I  have  en- 
deavoured to  give  a  somewhat  full  discussion  of  matters  which  are  peculiar 
to  early  life,  the  space  allotted  to  each  subject  being  in  some  degree  com- 
mensurate with  its  practical  importance  to  the  physician  and  student.  I 
have  intentionally  avoided  entering  into  a  discussion  of  many  questions 
which  belong  to  general  medicine  and  ^vhich  are  fully  treated  in  w^orks 
upon  that  subject. 

The  pathology  and  symptomatology  of  disease  in  children  who  have 
passed  their  seventh  or  eighth  year,  really  differ  little  from  those  of  ado- 
lescents and  young  adults.  It  is  in  infancy  and  early  childhood  only 
that  the  peculiar  conditions  exist  which  separate  paediatrics  from  general 
medicine  and  entitle  it  to  be  ranked  as  a  special  department.  These 
pages  therefore  are  chiefly  devoted  to  a  consideration  of  the  subjects  of 
the  nutrition  and  the  diseases  of  infants  and  young  children. 

The  discussion  of  questions  relating  to  operative  surgery  has  been  pur- 
posely omitted.  What  is  said  regarding  surgical  diseases  has  been  from 
the  standpoint  of  the  physician,  not  that  of  the  surgeon,  and  relates 
chiefly  to  symptoms  and  early  diagnosis. 

Kather  more  space  than  is  usual  in  a  clinical  work  has  been  given 
to  pathology  and  the  description  of  lesions,  my  reasons  for  this  being, 
first,  that  most  of  the  processes  which  are  peculiar  to  very  early  life  have 
received  but  scant  attention  in  works  on  pathology;  secondly,  such  knowl- 
edge is  absolutely  indispensable  to  the  correct  understanding  of  these  dis- 
eases clinically;  and,  thirdly,  because  I  have  been  fortunate  in  having 
rather  exceptional  opportunities  for  post-mortem  study  in  connection 
with  my  clinical  work.  It  is  hoped  that  the  drawings  and  photograpiis 
of  pathological  conditions  which  have  been  inserted  will  render  this  part 
of  the  work  of  interest  to  the  general  practitioner,  and  be  of  some  assist- 
ance and  value  to  those  whose  opportunities  for  the  study  of  disease  in 

V 


yi  PREFACE. 

children  are  limited  to  the  bedside.  These  illustrations  have  been  se- 
lected with  reference  to  their  bearing  on  the  symptomatology  of  disease 
and  for  the  benefit  of  the  practitioner,  not  the  pathologist.  In  this  as 
in  all  parts  of  the  book  I  have  tried  to  keep  constantly  in  mind  the 
every-day  needs  of  the  physician  who  practises  among  children  and  of 
the  student  who  expects  to  do  so. 

The  material  has  been  gathered  from  eleven  years'  continuous  hospital 
service  among  young  children,  and  much  of  the  statistical  matter  which 
has  been  introduced,  relates  to  cases  which  have  been  under  my  own  ob- 
servation. 

While  as  a  whole  the  book  is  very  largely  a  record  of  personal  experi- 
ence, I  must  express  my  great  indebtedness  to  the  rapidly  increasing  num- 
ber of  active  workers  in  paediatrics  both  in  America  and  in  Europe. 

The  arrangement  of  the  book  differs  somewhat  from  that  of  other 
works  on  the  subject.  The  space  given  to  nutrition,  to  its  derangements, 
and  to  the  diseases  resulting  therefrom,  is,  I  think,  not  out  of  propor- 
tion to  their  importance.  There  can  be  little  question  regarding  the 
propriety  of  placing  rickets  and  scurvy  in  this  class.  It  is  hoped  that  the 
plan  of  grouping  in  a  single  chapter  the  various  therapeutic  measures  use- 
ful in  early  life  may  aid  the  reader  Avho  wishes  to  consult  the  book  on 
these  j)oints.  In  the  parts  relating  to  treatment,  great,  but  I  think  not 
undue,  stress  has  been  laid  upon  diet  and  hygienic  measures,  since  in 
them  rather  than  in  drug-giving  lies  tlie  secret  of  success,  certainly  in  all 
disorders  of  digestion  and  nutrition. 

The  illustrations  are  for  the  greater  part  original,  being  either  from 
photographs  or  drawings  of  my  own  cases.  Most  of  the  drawings  are  by 
Dr.  Henry  Macdonald.  For  all  borrowed  illustrations  credit  has  been 
given.  For  some  of  the  latter  I  wish  to  thank  Messrs.  William  Wood  & 
Co.  and  the  J.  B.  Lippincott  Company,  who  have  allowed  the  use  of  cuts 
from  their  publications. 

I  wish  to  express  my  obligations  to  Prof.  James  W.  McLane,  who 
kindly  placed  at  my  disposal  the  valuable  records  of  the  Sloane  Maternity 
Hospital,  from  which  the  statistics  relating  to  the  newly-born  child  have 
been  largely  drawn. 

I  am  also  deeply  indebted  to  Drs.  Charles  Gr.  Kerley  and  Martha  Woll- 
stein  for  the  tabulation  of  cases  from  hospital  records  and  for  other  valu- 
able assistance ;  to  Dr.  Thomas  S.  Southworth  for  suggestions  in  the 
chapter  on  Diseases  of  the  Blood  and  for  the  preparation  of  the  index ;  to 
my  brother.  Dr.  N.  Curtice  Holt,  for  the  revision  of  the  proof  sheets  of 
the  entire  book ;  and,  finally,  to  my  publishers  for  their  uniform  courtesy 
and  hearty  co-operation  at  every  stage  of  the  work. 

L.  Emmett  Holt. 

15  East  Fifty-fourth  Street, 

New  York,  November  25,  1896. 


TABLE   OF  CON^TEXTS. 


PAET  I. 

CHAPTER  PAGE 

I. — Hygiene  and  General  Care  of  Infants  and  Young  Children  .   .   1 

Care  of  the  newly-born  child;  bathing;  clothing;  care  of  the  eyes;  care  of 
the  mouth  and  teeth ;  care  of  the  skin ;  care  of  the  genital  organs ;  vaccina- 
tion ;  training  to  proper  control  of  rectum  and  bladder ;  general  hygiene  of 
the  nervous  system ;  sleep  ;  exercise ;  airing ;  the  nursery  ;  the  nurse  ;  the 
amount  of  air  space  required  by  infants ;  the  care  of  premature  and  delicate 
infants;  incubators  ;  the  feeding  of  the  premature  infant. 

II. — Growth  and  Development  of  the  Body .15 

Weight;  height;  growth  of  extremities  as  compared  with  the  trunk;  the 
head;  the  chest;  the  abdomen ;  muscular  development;  development  of  spe- 
cial senses  ;  speech  ;  dentition. 

III.— Peculiarities  of  Disease  in  Children     ....  .        .      30 

Etiology ;  symptomatology  and  diagnosis ;  pathology ;  prognosis  and  infant 
mortality ;  prophylaxis  ;  therapeutics. 


PART  II. 

Section  I. — Diseases  of  the  Newly-Born. 

I. — Asphyxia 67 

II. — Congenital  Atelectasis       .        .        .    ■ 72 

III. — Icterus 75 

IV. — The  Acute  Infectious  Diseases  of  the  Newly-Born    ....      78 
The  acute  pyogenic  diseases ;  ophthalmia  ;  tetanus ;  epidemic  hsemoglobinuria  ; 
fatty  degeneration  of  the  newly- born;  pemphigus. 

V. — HEMORRHAGES .93 

Traumatic  or  accidental  hsemorrhages ;  spontaneous  hoemorrhages. 

VI. — Birth  Paraly^ses 105 

Cerebral  paralysis;  facial  paralysis;  paralysis  of  the  upper  extremity. 

VII. — Tumours  of  the  Umbilicus,  Mastitis,  etc Ill 

Umbilical   hernia;   mastitis;  intestinal   obstruction;   diaphragmatic   hernia; 
sclerema  ;  oedema  ;  inanition  fever. 

Section  II. — Nutrition. 

I. — Introductory 123 

The  food  constituents  and  the  purposes  they  subserve  in  nutrition. 

vii 


Vlll 


TABLE   OF  CONTEXTS. 


CHAPTER  PAGE 

II.— The  Infant's  Dietary 126 

Woman's  milk;  cow's  milk;  condensed  milk;  kumyss;  raatzoon;  junket, 
curds  and  whey;  beef  preparations ;  cereals;  infant  foods. 

III. — Infant  Feeding 157 

Breast  feeding ;  maternal  nursing  ;  wet-nursing  ;  weaning ;  mixed  feeding ; 
artificial  feeding. 

IV. — Feeding  after  the  First  Year 185 

Healthy  infants  during  the  second  year;  difficult  cases  during  the  second 
year;  feeding  from  the  third  to  the  sixtli  year;  feeding  during  acute  illness. 

V. — The  Derangements  of  Nutrition 19a 

Acute  inanition ;  malnutrition ;  marasmus. 

VI. — Diseases  due  to  Faulty  Nutrition 209 

Scorbutus ;  rickets. 

Section  III. — Diseases  of  the  Digestive  System. 

I. — Diseases  of  the  Lips,  Tongue,  and  Mouth 238 

Malformations  ;  diseases  of  the  lips ;  diseases  of  the  tongue ;  alveolar  abscess  ; 
difficult  dentition  ;  cataiThal  stomatitis;  herpetic  stomuuds;  ulcerative  stoma- 
titis ;  thrush  ;  gonorrhoeal  stomatitis ;  syphilitic  stomatitis ;  gangrenous  stom- 
atitis. 

II. — Diseases  of  the  Pharynx 256 

Acute  pharyngitis ;  uvulitis ;  elongated  uvula :  retro-pharyngeal  abscess  ; 
adenoid  vegetations  of  the  vault  of  the  pharynx. 

III. — Diseases  of  the  Tonsils 268 

Follicular  tonsillitis;  phlegmonous  tonsillitis;  chronic  hypertrophy  of  the 
tonsils. 

IV. — Diseases  of  the  (Esophagus 274 

Malformations ;  acute  uesophagitis ;  retro-oesophageal  abscess. 

V. — Diseases  of  the  Stomach 278 

Digestion  in  infancy  ;  malformations  and  malpositions  of  the  stomach  ;  vom- 
iting; cyclic  vomiting;  gastralgia;  acute  gastric  indigestion;  acute  gastritis; 
gastro-duodenitis ;  chronic  gastric  indigestion ;  dilatation  of  the  stomach ; 
ulcer  of  the  stomach ;  hsemorrhage  from  the  stomach. 

VI. — Diseases  of  the  Intestines 306 

Malformatioas  and  malf)ositions :  diarrhoea ;  acute  intestinal  indigestion. 

VII. — Diseases  of  the  Intestines  {continued) 316 

Acute  gastro-entorio  infection ;  cholera  infantum. 

VIII. — Diseases  of  the  Intestines  {continued) 337 

Acute  colitis  and  ileo-colit'is ;  chronic  ileo-colitis;  amyloid  degeneration  of 
the  intestines ;  tuberculosis  of  the  intestines  and  mesenteric  lymph  nodes. 

IX. — Diseases  of  the  Intestines  {continued) 363 

Chronic  intestinal  indigestion;  intestinal  colic ;  chronic  constipation;  intus- 
susception. 

X. — Diseases  of  the  Intestines  {continued) 389 

Appendicitis ;  intestinal  worms. 

XI. — Diseases  of  the  Rectum 402 

Prolapsus  ani ;  fissures  of  the  anus;  proctitis;  iscliio-rectal  abscess;  haemor- 
rhoids ;  incontinence  of  faeces. 

XII. — Diseases  of  the  Liver 408 

Icterus ;  functional  disorders ;  acute  yellow  atrophy ;  congestion  of  the  liver  ; 
abscess  of  the  liver;  cirrhosis;  amyloid  degeneration;  fatty  liver;  hydatids; 
biliary  calculi. 


TABLE  OF  CONTENTS. 


IX 


CHAPTER  PAGE 

XIII. — Diseases  of  the  Peritoneum 415 

Acute  peritonitis;  chronic  (non-tuberculousj  periUjnitib ;  tuberculous  peri- 
tonitis; ascites;  subphrenic  abscess. 

Section  IV. — Diseases  of  the  Respiratory  System. 
I. — Nasal  Cavities 428 

Acute  nasal  catarrh;  chronic  nasal  catarrh;  clironic  rhinitis;  pseudo-mem- 
branous rhinitis ;  epistaxis. 

II. — Diseases  of  the  Larynx 439 

Catarrhal  spasm  of  the  larynx ;  acute  catarrhal  laryngitis  ;  pseudo-membra- 
nous laryngitis;  intubation;  submucous  laryngitis;  chronic  laryngitis;  new 
growths ;  foreign  bodies  in  the  larynx. 

Ill,— Diseases  of  the  Lungs 459 

The  peculiarities  of  the  lungs  in  infancy  and  early  childhood  ;  acute  catarrhal 
bronchitis;  fibrinous  bronchitis;  chronic  bronchitis;  reflex  cough  ;  asthma. 

IV. — Diseases  of  the  Lungs  {continued) 477 

Pneumonia;  acute  broncho-pneumonia. 

V. — Diseases  of  the  Lungs  {continued) 514 

Lobar  pneumonia ;  pleuro-pneumonia  ;  hypostatic  pneumonia  ;  chronic  bron- 
cho-pneumonia ;  gangrene  of  the  lung ;  acquired  atelectasis ;  emphysema. 

VI.— Pleurisy 543 

Dry  pleurisy  ;  pleurisy  with  serous  efl'usion  ;  empyema. 

Section  V. — Diseases  of  the  Circulatory  System. 
I. — Peculiarities  of  the  Heart  and  Circulation  in  Early  Life    ,        ,    558 
II. — Congenital  Anomalies  of  the  Heart 562 

III. — Pericarditis 569 

Acute  pericarditis;  chronic  pericarditis  with  adhesions. 

IV. — Endocarditis  and  Valvular  Disease 574 

Acute  simple  endocarditis  ;  malignant  endocarditis  ;  chronic  valvular  disease  ; 
myocarditis  ;  anaemic  murmurs  ;  functional  disorders  of  the  heart ;  diseases  of 
the  blood-vessels. 

Section  VI. — Diseases  of  the  Uro-Gexital  System. 

I. — The  Urine  in  Infancy  and  Childhood 594 

Functional  or  cyclic  albuminuria  ;  haeinaturia  ;  hemoglobinuria  ;  glycosuria  ; 
pyuria;  lithuria;  indicanuria;  acetonuria;  diacetonuria ;  anuria;  diabetes 
insipidus. 

II. — Diseases  of  the  Kidneys 606 

Malformations  and  malpositions;  urio-aoid  infarctions:  acute  congestion  of  the 
kidneys ;  chronic  congestion  of  the  kidneys ;  acute  degeneration  of  the  kid- 
neys;  acute  exudative  nephritis;  acute  diflfuse  nephritis;  chronic  nephritis; 
tuberculosis  of  the  kidney  ;  malignant  tumours  of  the  kidney;  pyelitis;  renal 
calculi;  traumatic  hydro-ncphrosis;  perinephritis;  general  oedema  not  de- 
pendent on  renal  disease. 

III. — Diseases  of  the  Genital  Organs 6-^5 

Malformations  ;  diseases  of  the  male  genitals  ;  diseases  of  the  female  genitals. 

IV.— Enuresis W4 

Vesical  spasm  ;  vesical  calculi. 


X  TABLE   OF  CONTENTS. 

Section  VII.— Diseases  of  the  Nervous  System. 

CHAPTER  PAGE 

I, — Introductory 651 

II. — General  and  Functional  Nervous  Diseases 653 

Convulsions;  epilepsy;  tetany;  larjngisnius  stridulus;  chorea;  other  spas- 
modic affections ;  hysteria ;  headaches  ;  disorders  of  speech  ;  disorders  of 
sleep;  injurious  habits  of  infancy  and  childhood. 

III.— Diseases  of  the  Brain  and  Meninges 699 

Malformations;  pachymeningitis;  acute  meningitis  ;  tuberculous  meningitis; 
chronic  basilar  meningitis  in  infants  ;  thrombosis  of  the  sinuses  of  the  dura 
mater ;  cerebral  abscess  ;  cerebral  tumour  ;  hydrocephalus  ;  infantile  cerebral 
paralysis;  feeble-mindedness,  idiocy,  imbecility;  sporadic  cretinism;  insan- 
ity ;  the  stigmata  of  degeneration  ;  deaf-mutism. 

IV. — Diseases  of  the  Spinal  Cord 759 

Malformations;  spinal  meningitis ;  myelitis;  compression-myelitis;  infantile 
spinal  paralysis  ;  tumours  of  the  spinal  cord  ;  syringo-myelia ;  Friedreich's 
ataxia ;  Landry's  paralysis ;  the  muscular  atrophies. 

V. — Diseases  of  the  Peripheral  Nerves 785 

Multiple  neuritis  ;  diphtheritic  paralysis  ;  facial  paral.vsis. 

Section  VIII.— Diseases  of  the  Blood,  Lymph  Nodes,  Bones,  etc. 

I. — Diseases  of  the  Blood 795 

Simple  anaemia ;  chlorosis ;  pseudo-leucaeinic  ameiuia  of  infancy ;  pernicious 
anaemia;  leuciEinia;  haemophilia;  purpura. 

II. — Diseases  of  the  Lymph  Nodes 816 

Lymphatism  ;  simple  acute  adenitis  ;  simple  chronic  adenitis;  syphilitic  ade- 
nitis ;  tuberculous  adenitis  ;  Hodgkin's  disease. 

III. — Diseases  of  the  Spleen 832 

IV. — Diseases  of  the  Bones  and  Joints 835 

Acute  arthritis  of  infants  ;  tuberculous  diseases  of  the  bones  and  joints  ;  syph- 
ilitic diseases  of  bone. 

V. — Diseases  of  the  Skin 858 

Congenital   ichthyosis;  miliaria;   seborrhoea:  eczema;  furunculosis;  gangre- 
nous dermatitis  ;  impetigo  contagiosa  ;  urticaria ;  scabies  ;  tinea  tonsurans. 
VI. — Acute  Otitis 879 

Section  IX.— The  Specific  Infectious  Diseases. 

I. — Scarlet  Fever 888 

II. — Measles 910 

III. — Rubella 926 

IV. — Varicella 929 

V. — Vaccinia — Vaccination 931 

VI. — Pertussis 936 

VII.— Mumps 947 

VIII. — Diphtheria 951 

IX.— Typhoid  Fever 1008 

X.— Tuberculosis 1010 


TABLE   OF   CONTEXTS.  xi 

CHAPTER  TAOS 

XI. — Syphilis ,        .        .  1052 

XII. — Influenza .        .  1069 

XIII. — Malaria 1075 

Section  X. — Other  General  Diseases. 

I. — Rheumatism 1085 

II. — Diabetes  Mellitus 1091 


LIST   OF   ILLUSTRATIONS. 


PLATjlib.  rACINO 

PAGE 

1.    Chart  showing  by  months  the  mortality  of  New  York  city  for  the  dif- 
ferent ages  for  three  years 41 

II.     Meningeal  haemorrhage  in  the  newly-born 106 

III.  Chart  showing  composition   of  various   infant   foods   compared    with 

woman's  milk 107 

IV.  Bone  in  rickets 219 

V,    Typical  rickets 222 

VI.    Deformity  of  the  chest  in  severe  rickets 225 

VII.     The  stomach  at  the  different  periods  of  infancy 278 

VIII.     Extensive  catarrhal  ulceration  of  the  colon 341 

IX.    Deep  follicular  ulcers  of  the  colon 342 

X.    Membranous  inflammation  of  the  ileum 344 

XI.     Chronic  hyperplasia  of  the  lymph  nodules   (solitary  follicles)  of  the 

colon 364 

XII.     Acute  broncho-pneumonia 484 

XIII.  Acute  pleuro-pneumonia 532 

XIV.  Chronic  broncho-pneumonia 535 

XV.    Acute  meningitis,  complicating  pleuro-pneumonia 707 

XVI.     The  blood  in  lucaemia  and  pernicious  ana?mia 796 

XVII.     The  diphtheritic  membrane 966 

XVIII.    Diphtheria  bacilli  and  their  associates 977 

XIX,    Tuberculosis  of  the  tracheo-bronchial  lymph  nodes 1028 


ILLUSTRATIONS  IN  THE  TEXT. 

FIGURE  PAGE 

1.  Incubator 12 

2.  Incubator,  section  view .13 

3.  4.  Scales 15 

5.  Weight  curve  for  the  first  twenty  days 16 

6.  Weight  curve  for  the  first  year 18 

7.  Skull,  showing  premature  ossification 23 

8.  Apparatus  for  albolene  spray      .        .     ^ 55 

9.  Nasal  syringe 56 

10.  Position  for  nasal  syringing 57 

11.  Croup  kettle 58 

12.  Vapourizer 59 

xiii 


xiv  LIST  OF  ILLUSTRATIONS. 


PAGE 


FIGURE 

13.  Steam  atomizer ^'^^ 

14.  Oiled-silk  jacket 59 

15.  Apparatus  for  stomach-washing 60 

16.  Position  for  stomach-washing 61 

17.  Colon  of  a  child  six  months  old 64 

18.  Ribemont's  tube ''^ 

19.  Erb's  paralysis 11^ 

20.  Umbilical  tumours ^^'-' 

21.  Temperature  chart  in  inanition  fever 1~0 

22.  Human  milk,  colostrum  period l-"? 

23.  Human  milk,  later  period 127 

24.  Apparatus  for  examination  of  human  milk 132 

25.  Feser's  lactoscope 1"*^ 

26.  Cow's  milk,  showing  creamy  layer 142 

27.  Cooley  creamer,  cans l^^* 

28.  Arnold  sterilizer 1^14 

29.  Freeman  Pasteurizer I'l^ 

30.  Weight  chart,  showing  effect  of  pregnancy 168 

31.  Case  of  marasmus 2*^6 

32.  Normal  bone 220 

33.  Rachitic  bone 221 

34.  Rachitic  skull,  inside  view 224 

35.  Rachitic  head 225 

36.  Rachitic  skull,  external  view 226 

37.  Rachitic  thorax  in  outline 226 

38.  Rachitic  bow-legs 227 

39.  Rachitic  knock-knees 228 

40.  Rachitic  deformity  of  legs 229 

41.  Rachitic  bow-legs  in  outline 236 

42.  Epithelial  desquamation  of  the  tongue 241 

43.  Thrush 251 

44.  Cancrum  oris 255 

45.  Chest  deformity  from  adenoid  vegetations  of  the  pharynx        ....  265 

46.  47.  Child  with  adenoid  vegetations,  before  and  after  operation        .        .        .  267 

48.  Dilatation  of  the  stomach 303 

49.  Malformations  of  the  rectum 307 

50.  Chart  showing  mortality  from  diarrhoeal  diseases  in  New  York        .        .        .  309 

51.  Chart  showing  frequency  of  diarrhceal  diseases 309 

52.  Acute  catarrhal  ileo-colitis,  superficial  type 339 

53.  Acute  catarrhal  ileo-colitis,  severe  form 340 

54.  Follicular  ulceration  of  the  colon,  early  stage 342 

55.  Follicular  ulceration  of  the  colon,  later  stage 343 

56.  Membranous  colitis 345 

57.  Temperature  chart  in  ileo-colitis 348 

58.  Temperature  chart  in  membranous  colitis 349 

59.  Chronic  catarrhal  inflammation  of  the  ileum 355 

60.  Ileo-coecal  intussusception 379 

61.  62.  Mechanism  of  intussusception 380 

63.  Taenia  saginata 396 

64.  Taenia  solium 396 

65.  Taenia  cucumerina 397 


LIST  OF   ILLUSTRATIONS. 


XV 


FIOITRE 

GG.  Bothriocephalus  latus 

67.  Acaris  luinbricoides 

68.  Oxyuris  vermioularis 

69.  Prolapsus  ani 

70.  Apparatus  for  calomel  fumigation    . 

71.  O'Dwyer's  intubation  set 

72.  An  air  vesicle  in  broncho-pneumonia 

73.  An  air  vesicle  in  lobar  pneumonia    . 

74.  Broncho-pneumonia  with  thickened  bronchus  . 

75.  Broncho-pneumonia,  ha?morrhagic  form  . 

76.  Broncho  pneumonia,  early  stage  of  . 

77.  Broncho-pneumonia  with  emphysema 

78.  Broncho-pneumonia  with  thickened  bronchus  . 

79.  Broncho-pneumonia,  diffuse  purulent  infiltration 

80.  Broncho-pneumonia,  diffuse  purulent  infiltration 
8L  Persistent  broncho-pneumonia  .... 

82.  Temperature  chart  in  mild  uncomplicated  broncho-pneumoni 

83.  Temperature  chart,  prolonged  course,  broncho-pneumonia 

84.  Temperature  chart,  relapsing  broncho-pneumonia  . 

85.  Temperature  chart,  rapidly  fatal  broncho-pneumonia 
86-89.  Physical  signs  in  broncho-pneumonia  . 

90.  Temperature  chart,  persistent  broncho-pneumonia  . 

91.  Temperature  chart,  broncho-pneumonia  following  pertus; 

92.  Temperature  chart,  typical  lobar  pneumonia   . 

93.  Temperature  chart,  remittent  type,  lobar  pneumonia 

94.  Temperature  chart,  lobar  pneumonia,  subnormal  temperature 

95.  Temperature  chart,  abortive  pneumonia  . 
96-98.  Physical  signs,  lobar  pneumonia  .... 
99.  Section  of  lung,  showing  distribution  of  fluid  in  chest 

100.  Deformity  after  old  empyema 

101.  Apparatus  for  inducing  lung  expansion  after  empyema 

102.  Showing  normal  areas  of  cardiac  dulness . 

103.  Congenital  cardiac  disease 

104.  Clubbing  of  fingers  in  congenital  cardiac  disease     . 

105.  Congenital  malformations  of  the  kidney  and  ureters 

106.  107.  Sarcoma  of  the  kidney  before  and  after  operation 

108.  Tetany 

109.  Spasmodic  torticollis 

110.  Meningocele 

111.  Encephalocele 

112.  Ilydrencephalocele 

113.  Naso-frontal  meningocele 

114.  Tracing  of  respiration  in  tuberculous  meninjritis     . 

115.  Temperature  chart  in  tuberculous  meningitis  . 

116.  Chronic  basilar  meningitis 

117.  Section  of  the  brain  in  hydrocephalus 

118.  Head  in  chronic  hydrocephalus,  globular  form 

119.  Head  in  chronic  hydrocephalus,  pyramidal  form 

120.  Brain,  showing  results  of  old  meningeal  h;rmorrhage.  1 

121.  Brain,  showing  results  of  old  meningeal  hannorrhage,  superior  view 

122.  Convulsions  in  infantile  cerebral  paralysis 


afte 


teral  view 


PAGE 

397 
398 
400 
403 
448 
451 
478 
479 
484 
486 
487 
488 
489 
400 
491 
492 
497 
498 
498 
498 
500 
503 
504 
520 
520 
521 
521 
525 
550 
555 
556 
561 
563 
566 
609 
626 
670 
683 
699 
699 
699 
700 
718 
719 
722 
736 
737 
738 
742 
743 
744 


xvi  LIST  OF  ILLUSTRATIONS. 


PAGK 


FiarRK 

123.  Contractures  following  infantile  cerebral  paralysis 74S 

124.  Brain  in  idiocy '^'- 

125.  A  typical  cretin "^^^ 

126-128.  Cretin,  showing  effect  of  thyroid  treatment 753 

129.  Spina  bifida,  meningocele  (partially  diagrammatic) 760 

130.  Spina  bifida,  meningocele,  case  of 760 

131.  Spina  bifida,  meningo-myelocele  (partially  diagrammatic)       ....  761 

132.  Spina  bifida,  syringo-myelocele 762 

133.  Spina  bifida,  sacral '''62 

134.  Spina  bifida,  section  of  cord  in 763 

135.  Infantile  spinal  paralysis  of  lower  extremity 774 

136.  Infantile  spinal  paralysis  of  shoulder 775 

137.  Pseudo-muscular  hypertrophy 784 

1.38.  Alcoholic  neuritis "^"^ 

139.  Diphtheritic  paralysis ''^^ 

140.  Facial  paralysis "^^'^ 

141.  Acute  suppurative  adenitis,  cervical 821 

142.  Acute  suppurative  adenitis,  inguinal        . 821 

143.  Cicatrices  following  tuberculous  adenitis 828 

144.  Section  of  the  spine  in  Pott's  disease 839 

145.  Hip-joint  disease 845 

146.  Tuberculous  dactylitis 850 

147.  Syphilitic  disease  of  the  radius  and  ulna 852 

148.  Syphilitic  disease  of  the  tibia 854 

149.  Syphilitic  disease  of  both  tibiiB 855 

150.  Syphilitic  necrosis  of  the  tibia 856 

151.  Syphilitic  dactylitis 857 

152.  Congenital  ichthyosis 859 

153.  Mastoid  abscess 883 

154.  Temperature  chart  in  scarlet  fever,  typical  curve 893 

155.  Temperature  chart  in  scarlet  fever,  prolonged  course 894 

156.  Temperature  chart  in  complicated  scarlet  fever 896 

157.  Temperature  chart  in  fatal  septic  scarlet  fever 897 

158.  159.  Temperature  charts  in  measles,  typical  curve 916 

160.  Temperature  chart  in  measles,  occasional  course 917 

161.  Temperature  chart  in  measles,  prolonged  course 917 

162.  163.  Temperature  charts  in  measles  complicated  by  pneumonia     .        .        .  918 

164.  Vaccination  vesicles,  normal 934 

165.  Vaccination  vesicles,  severe  course 934 

166.  Chart  showing  mortality  from  diphtheria  with  and  without  antitoxine  .         .  994 

167.  Chart  showing  mortality  from  diphtheria  and  croup  in  Berlin,  Paris,  and 

New  York 996 

168.  Chart  showing  mortality  from  diphtheria  in  Chicago 997 

169.  Temperature  chart  in  pseudo-diphtheria 1005 

170.  Temperature  chart  in  typhoid  fever,  short  course 1011 

171.  Temperature  chart  in  typhoid  fever  with  relapse 1012 

172.  Tuberculous  broncho-pneumonia,  diffuse  consolidation 1025 

173.  Cavity  from  tuberculous  broncho-pneumonia 1025 

174.  A  tuberculous  nodule 1026 

175.  Tuberculous  broncho-pneumonia,  early  stage 1027 

176.  Tuberculous  bronchial  lymph  nodes 1029 


LIST  OF  ILLUSTRATIONS.  xvii 

nOURE  PAGE 

177.  Temperature  chart  of  tuberculosis  following  measles 1038 

178.  Temperature  chart  of  tuberculous  broncho-pneumonia,  general  tuberculosis  .  10.39 

179.  Temperature  chart  of  tuberculous  broncho-pneumonia  with  softening  .        .  1040 

180.  Syphilitic  notched  teeth 10G2 

181.  Syphilitic  screw-driver  teeth 10G3 

182.  Temperature  chart  of  acute  broncho-pneumonia  complicating  influenza        .  1072 

183.  Temperature  chart,  quotidian  intermittent  fever 1077 

184.  Temperature  chart,  tertian  intermittent  fever 1078 

185.  Temperature  chart  in  malaria,  irregular  type 1080 


THE  DISEASES  OF  INFANCY  AND  CHILDHOOD. 

PART  L 


CHAPTER  I. 

HYGIENE  AND  GENERAL  CARE  OF  INFANTS  AND   YOUNG 

CHILDREN. 

The  physical  development  of  the  child  is  essentially  the  product  of 
the  three  factors — inheritance,  surroundings,  and  food.  The  first  of  these 
it  is  beyond  the  physician's  power  to  alter ;  the  second  is  largely  and  the 
third  almost  entirely  within  his  control,  at  least  in  the  more  intelligent 
classes  of  society.  These  two  subjects,  infant  hygiene  and  infant  feeding, 
are  the  most  imj^ortant  departments  of  pediatrics. 

The  Care  of  the  Newly-Born  Child. — After  the  ligature  of  the  cord  tlie 
child  should  be  wrapped  in  a  thick  blanket  and  jilaced  in  a  warm  room. 
In  hospital  practice  the  eyes  should  be  cleansed  with  absorbent  cotton 
and  water  which  has  been  boiled,  and  then  two  or  three  drops  of  a  two- 
per-cent  solution  of  nitrate  of  silver,  after  Crede's  method,  instilled  into 
each  eye  by  means  of  a  glass  rod  or  eye-dropper.  In  private  practice  a 
saturated  solution  of  boric  acid  may  be  substituted,  unless  the  mother  has 
had  a  purulent  vaginal  discharge,  in  which  case  the  silver  solution  should 
always  be  used.  The  bath  should  now  be  given  in  a  warm  room;  the 
body  being  first  oiled  thoroughly  in  order  to  remove  the  vernix  caseosa 
and  then  washed  in  water  at  a  temperature  of  10C°  F.  The  mouth  should 
be  cleansed  with  plain  tepid  water  and  a  soft  cloth,  and  no  violence  em- 
ployed. The  cord  may  be  covered  with  salicylic  acid  one  ])art  and  starch 
nineteen  parts,  or  simply  with  subnitrate  of  bismuth,  and  wrapped  in  ab- 
sorbent cotton  or  surgeon's  lint.  The  abdomen  sliould  now  be  enveloped 
in  a  flannel  band,  eight  or  ten  inches  wide,  and  pinned  rather  snugly. 
Before  dressing  is  completed,  the  child  should  be  submitted  to  a  thorough 
examination  for  iiljuries  received  during  delivery,  congenital  deformities, 
also  as  to  the  condition  of  the  respiration,  circulation,  etc. 

After  dressing,  the  child  should  be  placed  in  its  crib  and  covered  with 
blankets,  and  if  the  feet  are«old,  or  the  fingers  and  lips  a  little  blue,  it 


2  HYGIENE   AND   GENERAL  CARE  OF  INFANTS. 

should  be  surroimded  by  hot-water  bottles  covered  with  flannels,  and 
placed  near,  but  not  in  contact  with,  the  body.  The  crib  should  be  placed 
in  a  quiet,  darkened  room.  The  young  infant  should  not  occupy  the 
same  bed  as  the  mother,  unless  it  greatly  needs  the  warmth  of  her  body, 
other  means  of  artificial  heat  not  being  at  hand. 

The  cord  should  be  kept  dry  and  disturbed  as  little  as  possible  until 
it  falls  off.  Under  ordinary  circumstances  the  cord  separates  from  the 
fourth  to  the  seventh  day,  the  average  being  the  fifth  day.  The  stump 
should  then  be  covered  with  the  salicylic  acid  and  starch  powder,  and  a 
pad  of  muslin  about  one  fourth  of  an  inch  thick  and  two  inches  square 
applied  and  secured  in  position  by  means  of  the  abdominal  band.  The 
purpose  of  this  is  to  prevent  umbilical  hernia.  The  pad  should  be  con- 
tinued for  the  first  month.  The  use  of  stronger  antiseptic  dressings  than 
that  recommended  is  somewhat  objectionable,  since  it  preserves  the  cord 
too  long  and  delays  separation.  The  full  bath  should  not  be  given  until 
the  cord  has  separated. 

The  physician  should  always  see  to  it  that  the  infant  cries  enough  to 
keep  the  lungs  properly  expanded. 

The  question  of  food  for  the  newly-born  infant  is  considered  in  the 
chapter  upon  infant  feeding. 

Bathing. — For  the  first  few  months  the  bath  should  be  given  at  98° 
F.  The  room  should  be  warm,  preferably  there  should  be  an  open  fire. 
The  bath  should  be  short  and  the  body  dried  quickly,  without  too  vigor- 
ous rubbing.  The  addition  of  salt  to  the  bath  is  an  advantage  where  the 
skin  is  unusually  delicate  or  excoriations  are  present.  One  large  handful 
should  be  used  to  a  gallon  of  water.  By  the  sixth  month  the  temperature 
of  the  bath  for  healthy  infants  may  be  lowered  to  95°  F.,  and  by  the  end 
of  the  first  year  to  90°  F.  Older  children  who  are  healthy  should  be  sponged 
or  douched  for  a  moment  at  the  close  of  the  tepid  bath  with  Avater  at  65° 
or  70°  F.  During  childhood  the  warm  bath  is  preferably  given  at  night. 
In  the  morning  a  cold  sponge  bath  is  desirable.  This  should  be  given  in 
a  warm  room  and  while  the  child  stands  in  a  tub  partly  filled  with  warm 
water.  This  cold  sponge  should  last  but  half  a  minute,  and  be  followed 
by  a  brisk  rubbing  of  the  entire  body. 

In  some  young  infants  and  even  older  children  there  is  no  proper 
reaction  after  the  bath,  even  when  given  at  the  temperatures  mentioned ; 
children  being  pale,  slightly  blue  about  the  lips  and  under  the  eyes.  All 
tub  bathing,  and  especially  all  cold  bathing,  should  then  be  stopped,  since 
a  continuance  can  only  be  a  drain  upon  the  child's  vitality. 

Clothing. — The  clothing  of  infants  should  be  light,  warm,  non-irri- 
tating to  the  skin,  and  loose  enough  to  allow  free  motion  of  the  extremi- 
ties ;  nor  should  bands  be  pinned  so  tightly  about  the  trunk  as  to  em- 
barrass the  movements  either  of  the  chest  or  of  the  abdomen.  The  chest 
should  be  covered  with  a  woollen  shirt,  hi^  in  the  neck  and  with  long 


BATHING— CLOTHING.  3 

sleeves.  All  petticoats  should  be  supported  from  the  shoulders  and  not 
from  waistbands.  Canton  flannel  and  stockinet  are  both  superior  as 
absorbents  to  the  more  commonly  used  linen  diapers.  Stockinet  has  the 
advantage  of  being  very  soft  and  pliable.  Care  should  be  given  that  in  in- 
fants the  feet  be  kept  warm.  If  the  circulation  is  very  poor,  a  bag  of  hot 
water  should  always  be  in  the  crib.  Cold  feet  are  responsible  for  many 
attacks  of  colic  and  indigestion. 

The  abdominal  band  is  usually  worn  during  infancy.  It  cannot  be 
considered  in  any  sense  a  necessity  after  the  first  few  months,  excepting 
in  cases  of  very  thin  infants  whose  supply  of  fat  in  the  abdominal  walls  is 
an  insufficient  protection  to  the  viscera.  For  the  first  few  weeks  a  band  of 
plain  flannel  is  to  be  preferred ;  later,  a  knitted  band  with  shoulder-straps. 
The  fashion  of  low  neck  and  short  sleeves  for  infants  and  very  young 
children  has  fortunately  passed  away — let  us  hope,  never  to  return. 

During  the  summer  the  outer  clothing  should  be  light  and  the  under 
clothing  of  the  thinnest  flannel  or  gauze.  The  changes  in  the  tempera- 
ture of  morning  and  evening  may  be  met  by  extra  wraps.  The  custom  of 
allowing  young  children  to  go  with  legs  bare  has  many  enthusiastic  advo- 
cates ;  while  it  may  not  be  objectionable  during  the  heat  of  summer,  its 
advantages  at  any  season  are  very  questionable  in  a  changeable  climate 
like  that  of  Xew  York  or  the  Atlantic  coast.  Many  delicate  children  are 
certainly  injured  by  such  ill-advised  attempts  at  hardening. 

The  night  clothing  of  infants  should  be  similar  to  that  worn  during 
the  day,  but  should  be  loose,  the  material  being  of  the  lightest  flannel. 
The  night  clothing  for  older  children  should  consist  of  a  thin  woollen 
shirt  and  a  union  suit  with  waist  and  trousers,  and  in  some  cases  with 
feet,  if  there  is  a  tendency  to  get  outside  the  coverings.  The  common 
mistake  is  to  overload  all  children,  but  especially  infants,  with  covering  at 
night.  This  is  an  explanation  of  much  of  the  restless  sleep  which  is  seen 
particularly  in  delicate  children. 

Care  of  the  Eyes. — During  the  first  few  days  at  the  daily  bath,  the 
eyes  should  be  cleansed  with  a  saturated  solution  of  boric  acid.  They 
should  be  carefully  protected  from  too  strong  light  during  early  infancy. 
It  is  desirable  that  a  cliild  should  always  sleep  in  a  darkened  room. 

Care  of  the  Mouth  and  Teeth. — The  mouth  of  the  newly-born  infant 
should  be  gently  cleansed  at  each  morning  bath  with  boiled  water  and 
a  soft  cloth.  On  the  first  appearance  of  thrush  the  mouth  should  be 
washed  after  every  feeding  with  a  solution  of  bicarbonate  of  soda  or  borax 
(twenty  grains  to  the  ounce).  Harm  is  often  done  by  the  use  of  too  much 
force  in  cleansing  the  mouth  of  a  young  infant. 

The  primary  teeth  as  well  as  those  of  the  permanent  set  should  receive 
daily  attention.  Too  often  they  are  neglected  altogether.  Dirty  teeth 
are  likely  sooner  or  later  to  become  carious ;  and  carious  teeth,  besides 
being  a  cause  of  bad  breath  and  neuralgia,  are  a  constant  menace  to  the 


4:  HYGIENE   AND   GENERAL  CARE  OF   INFANTS. 

health  of  the  child,  since  they  may  harbour  infections  germs  of  all  varie- 
ties.    Such  teeth  should  either  be  filled  or  removed. 

Care  of  the  Skin. — The  skin  of  a  young  infant  is  exceedingly  deli- 
cate, and  excoriations,  intertrigo,  and  eczema  are  of  very  common  occur- 
rence. These  conditions  are  much  easier  of  prevention  than  of  cure. 
The  first  essential  in  the  care  of  the  skin  is  cleanliness,  and  this  must  be 
secured  without  the  use  of  strong  soaps  or  too  much  rubbing.  Napkins 
must  be  removed  as  soon  as  soiled  or  wet.  Some  bland  absorbent  powder, 
like  starch,  talcum,  or  the  stearate  of  zinc,  shquld  be  used  in  all  the  folds 
of  the  skin,  in  the  neck,  in  the  axillae,  groins,  and  about  the  genitals,  and 
in  the  folds  of  the  thighs,  particularly  in  very  fat  infants.  If  plain  water 
produces  an  undue  amount  of  irritation,  the  salt  or  bran  bath  should  be 
employed. 

Care  of  the  Genital  Organs. — The  female  genitals  need  but  little 
attention  in  young  children,  excepting  as  to  cleanliness.  This  is  more 
often  neglected  in  older  children  than  in  infants.  Yulvo-vaginitis  is  very 
common  among  the  children  of  the  poorer  classes  where  cleanliness  is 
neglected. 

In  males  the  prepuce  should  receive  attention  during  the  first  few 
weeks  of  life.  If  the  foreskin  is  long  and  the  preputial  orifice  small, 
circumcision  should  invariably  be  done.  If  it  is  not  long,  but  is  only 
adherent,  these  adhesions  should  be  broken  up,  the  parts  thoroughly 
cleansed  and  the  foreskin  retracted  daily  until  there  is  no  disposition  to  a 
recurrence  of  the  adhesions.  These  operations  will  be  discussed  more  at 
length  in  a  subsequent  chapter.  The  only  thing  to  be  emphasised  in 
the  present  connection  is  that  the  prepuce  should  receive  proper  atten- 
tion in  early  infancy,  since  this  can  now  be  done  with  less  pain  and  dis- 
comfort to  the  child,  and  at  the  same  time  better  results  are  obtained. 
If  this  matter  is  neglected  during  infancy,  it  is  apt  to  be  overlooked  until 
harm  has  been  produced  by  local  or  reflex  irritation  which  phimosis  or 
adherent  prepuce  may  have  excited. 

Vaccination. — This,  although  considered  elsewhere,  should  be  men- 
tioned in  this  connection  as  among  the  things  requiring  the  physician's 
attention  during  the  first  months  of  life. 

Training  to  Proper  Control  of  Rectum  and  Bladder.— It  is  surpris- 
ing to  see  what  can  be  accomplished  by  intelligent  efforts  at  training 
in  these  particulars.  An  infant  can  often  be  trained  at  three  months  to 
have  its  movements  from  the  bowels  when  placed  upon  a  small  cham- 
ber. This  not  only  saves  a  great  amount  of  washing  of  napkins,  but 
there  is  soon  formed  a  habit  of  having  the  bowels  move  at  a  regular  time 
or  times  each  day.  The  infant  must  be  put  upon  the  chamber  soon  after 
its  feeding.  The  importance  of  training  young  children  to  regular  habits 
regarding  evacuations  from  the  bowels  can  hardly  be  overestimated.  It 
should  be  impressed  upon  every  mother  and  nurse  by  the  physician,  and 


SLEEP.  5 

especially  the  necessity  of  beginning  training  during  infancy.  Much  of 
course  will  depend  upon  the  food  and  the  digestion ;  but  habit  is  a  very 
large  factor  in  the  case. 

The  training  of  the  bladder  is  not  quite  so  important,  but  the  proper 
education  of  this  organ  adds  much  to  the  comfort  of  the  child  and  the  ease 
with  which  it  is  cared  for.  Before  the  end  of  the  first  year  most  intelli- 
gent children  can  be  trained  to  indicate  a  desire  to  empty  the  bladder. 
Many  mothers  and  nurses  succeed  in  training  children  so  well  that  by  the 
tenth  or  eleventh  month  napkins  are  dispensed  with  during  the  day. 
On  the  other  hand,  it  is  very  common  to  see  children  of  two  and  even  two 
and  a  half  years  still  wearing  napkins  because  of  the  lack  of  j^roper  train- 
ing. Before  it  has  reached  the  latter  age  a  healthy  child  should  go  from 
10  p.  M.  until  morning  without  emptying  the  bladder.  The  annoyance 
and  discomfort  from  the  neglect  of  early  training  in  this  particular  are 
very  great.  Night  feeding  is  responsible  for  much  of  the  difficulty  expe- 
rienced in  training  children  to  hold  the  water  during  the  night. 

General  Hygiene  of  the  Nervous  System. — Great  injury  is  done  to 
the  nervous  system  of  children  by  the  influences  with  which  they  are 
surrounded  during  infancy,  especially  during  the  first  year.  The  brain 
grows  more  during  the  first  two  years  than  in  all  the  rest  of  life.  Xormal 
healthy  development  of  the  nervous  centres  demands  quiet,  rest,  peaceful 
surroundings,  and  freedom  from  everything  which  causes  excitement  or 
undue  stimulation. 

The  steadily  increasing  frequency  of  functional  nervous  diseases  among 
young  children  is  one  of  the  most  powerful  arguments  for  greater  atten> 
tion  by  physicians  to  the  subject  of  the  hygiene  of  the  nervous  sys- 
tem during  infancy.  Most  parents  err  through  ignorance.  Playing  with 
young  children,  stimulating  to  laughter  and  exciting  them  by  sights, 
sounds,  or  movements  until  they  shriek  with  apparent  delight,  may  be  a 
source  of  amusement  to  fond  parents  and  admiring  spectators,  but  it  is 
almost  invariably  an  injury  to  the  child.  This  is  especially  harmful  when 
done  in  the  evening.  It  is  the  plain  duty  of  the  physician  to  enlighten 
parents  upon  this  point,  and  insist  that  the  infant  shall  be  kept  quiet,  and 
that  all  such  playing  and  romping  as  has  been  referred  to  shall,  during 
the  first  year  at  least,  be  absolutely  prohibited. 

Sleep. — The  sleep  of  the  newly-born  infant  is  profound  for  the  first 
two  or  three  days  and  under  normal  conditions  almost  continuous.  In 
the  case  of  prolonged  or  tedious  labor,  or  where  from  any  cause  undue 
compression  has  been  exerted  upon  the  head,  it  may  approach  the  con- 
dition of  semi-coma  for  twenty-four  or  forty-eight  hours.  This  may  be  so 
deep  as  to  excite  apprehensions  of  serious  brain  lesions.  If,  however,  there 
are  associated  with  it  no  convulsions  and  no  rigidity,  this  early  stupor 
usually  passes  away  on  the  second  or  third  day. 

The  sleep  of  early  infancy  is  quiet  and  peaceful,  but  not  very  deep  after 


6  HYGIENE   AND   GENERAL   CARE   OF  INFANTS. 

the  first  month.  After  the  third  year  the  heavy  sleep  of  childhood  is 
commonly  seen.  A  healthy  infant  during  the  first  few  weeks  sleeps  from 
twenty  to  twenty-two  hours  out  of  the  twenty-four,  waking  only  from 
hunger,  discomfort,  or  pain.  During  the  first  six  months  a  healthy  infant 
will  usually  sleep  from  sixteen  to  eighteen  hours  a  day,  the  waking  pe- 
riods being  only  from  half  an  hour  to  two  hours  long.  At  the  age  of  one 
year  most  infants  sleep  from  fourteen  to  fifteen  hours,  viz.,  from  eleven 
to  twelve  hours  at  night,  and  two  or  three  hours  during  the  day,  .usually 
in  two  naps.  When  two  years  old  usually  thirteen  to  fourteen  hours' 
sleep  are  taken  ;  eleven  or  twelve  hours  at  night  and  one  or  two  hours 
during  the  day,  generally  in  a  single  nap.  At  the  age  of  four  j^ars  chil- 
dren require  from  eleven  to  twelve  hours'  sleep.  It  is  always  desirable, 
and  in  most  cases  with  regularity  it  is  possible,  to  keep  up  the  daily  nap 
until  children  are  four  years  old.  From  six  to  ten  years  the  amount  of 
sleep  required  is  ten  or  eleven  hours,  and  from  ten  to  sixteen  years  nine 
hours  should  be  the  minimum. 

Training  in  proper  habits  of  sleep  should  be  begun  at  birth.  From 
the  outset  an  infant  should  be  accustomed  to  being  put  into  its  crib  while 
awake  and  to  go  to  sleep  of  its  own  accord.  Eocking  and  all  other  habits 
of  this  sort  are  useless  and  may  even  be  harmful.  An  infant  should  not 
be  allowed  to  sleep  on  the  breast  of  the  nurse,  nor  with  the  nipple  of  the 
bottle  in  its  mouth.  Other  devices  for  putting  infants  to  sleep,  such  as 
allowing  the  child  to  suck  a  rubber  nipple  or  anything  else,  are  positively 
injurious.  If  such  means  of  inducing  sleep  are  resorted  to  the  infant  soon 
acquires  the  habit  of  2iot  sleeping  without  them."  I  have  known  of  one 
instance  where  the  habit  of  rocking  during  sleep  was  continued  until  the 
child  was  two  years  old ;  the  moment  the  rocking  was  stopped  the  infant 
would  wake,  and  in  consequence  this  practice  was  continued  by  the  de- 
voted but  misguided  parents.  A  quiet,  darkened  room,  a  warm  and  com- 
fortable bed,  an  appetite  satisfied,  and  dry  napkins  are  all  that  are  needed 
to  induce  sleep  in  a  healthy  child. 

The  periods  of  sleep  in  young  infants  are  usually  from  two  to  three 
hours  long,  Avith  the  exception  of  once  or  twice  in  the  twenty-four  hours, 
when  a  long  sleep  of  five  or  six  hours  occurs.  The  purpose  of  training 
is  to  have  the  child  take  this  long  sleep  at  night.  The  habit  of  regular 
sleep  is  best  established  by  wakening  the  infant  regularly  every  two  or 
two  and  a  half  hours  during  the  day  for  feeding,  and  allowing  it  to  sleep 
as  long  as  possible  during  the  night.  This  training  goes  hand-in-hand 
with  regular  habits  of  feeding.  Such  habits  are  easily  formed  if  the  plan 
be  systematically  followed  from  the  outset. 

By  the  fifth  month  all  feeding  between  10  p.  m.  and  7  A.  m.  should  be 
discontinued.  If  this  is  done  most  infants  can  be  trained  by  this  time  to 
sleep  all  night.  If  the  room  is  lighted,  and  the  child  taken  from  the  crib 
or  rocked  or  fed  as  soon  as  it  wakens  at  night,  there  is  no  such  thing  as 


EXERCISE.  7 

the  formation  of  good  habits  of  sleep.  Regularity  in  sleep  and  feeding 
not  only  make  the  care  of  young  infants  very  much  easier,  but  they  are  of 
a  good  deal  of  importance  for  the  health  of  the  child. 

The  causes  of  disturbed  or  irregular  sleep  in  young  infants  are  mainly 
two — hunger  and  indigestion.  In  nursing  infants  it  is  usually  the  for- 
mer ;  in  those  artificially  fed  usually  the  latter.  Sleeplessness  from  hun- 
ger is  often  seen  in  children  who  are  nursed  thirty  or  forty  minutes  and 
then  fall  asleep,  but  wake  in  fifteen  or  twenty  minutes  crying  and  fretful. 
After  being  quieted  they  may  fall  asleep  again  for  half  an  hour,  but  wake 
at  short  intervals.  The  peaceful  sleep  of  two  or  three  hours  which  should 
follow  a  proper  feeding  is  never  seen.  With  this  restlessness  other  signs 
of  indigestion  are  usually  present,  such  as  bad  stools,  stationary  weight, 
etc.  The  disturbed  sleep  due  to  overfeeding  shows  itself  by  much  the 
same  symptoms,  excepting  that  the  first  sleep  after  the  meal  is  usually 
longer. 

Exercise. — This  is  no  less  important  in  infancy  than  in  later  child- 
hood. An  infant  gets  its  exercise  in  the  lusty  cry  which  follows  the  cool 
sponge  of  the  bath,  in  kicking  its  legs  about,  waving  its  arms,  etc.  By 
these  means  pulmonary  expansion  and  muscular  development  are  in- 
creased and  the  general  nutrition  promoted.  An  infant's  clothing  should 
be  such  as  not  to  interfere  with  its  exercise.  Confinement  of  the  legs 
should  not  be  permitted.  In  hospital  practice  I  have  often  had  a  chance 
to  observe  the  bad  results  which  follow  when  very  young  infants  are 
allowed  to  lie  in  the  cribs  nearly  all  the  time.  Little  by  little  the  vital 
processes  flag,  the  cry  becomes  feeble,  the  weight  is  first  stationary,  then 
there  is  a  steady  loss.  The  appetite  fails  so  that  food  is  at  first  taken 
without  relish,  then  at  times  altogether  refused ;  later,  vomiting  ensues 
and  other  symptoms  of  indigestion.  This,  in  many  cases,  is  the  begin- 
ning of  a  steady  downward  course  which  goes  on  until  a  condition  of  hope- 
less marasmus  is  reached.  Such  infants  must  be  taken  up  every  few 
hours  and  carried  about  the  wards ;  the  position  should  be  frequently 
changed,  and  general  friction  of  the  entire  body  employed  at  least  twice  a 
day.  Every  means  must  be  made  use  of  to  stimulate  the  vital  activity. 
The  value  of  systematic  attention  to  these  matters  cannot  be  overestimated 
in  hospitals  for  infants.  Infants  who  are  old  enough  to  creep  or  stand 
usually  take  sufficient  exercise  unless  they  are  restrained.  At  this  age 
they  should  be  allowed  to  do  what  they  are  eager  to  do.  Every  facility 
should  be  afforded  for  using  their  muscles.  Exercise  may  be  encouraged 
by  placing  upon  the  floor  in  a  warm  room  a  mattress  or  a  thick  "  com- 
fortable," and  allowing  the  infant  to  roll  and  tumble  upon  it  at  will.  A 
large  bed  may  answer  the  same  purpose. 

In  older  children  every  form  of  out-of-door  exercise  should  be  encour- 
aged— ball,  tennis,  and  all  running  games,  horseback  riding,  the  bicycle, 
tricycle,  swimming,  coasting,  and  skating.     Up  to  the  eleventh  year  no 


8  HYGIENE   AND   GENERAL   CARE  OF   INFANTS. 

difference  need  be  made  in  the  exercise  of  the  two  sexes.  Companion- 
ship is  a  necessity.  Children  brouglit  np  alone  are  at  a  great  disadvantage 
in  this  respect,  and  are  not  likely  to  get  as  much  exercise  as  they  require. 
The  amount  of  exercise  allowed  delicate  children  should  be  regulated 
with  some  degree  of  care.  It  may  be  carried  to  the  point  of  moderate 
muscular  fatigue,  but  never  to  muscular  exhaustion.  The  latter  is  partic- 
ularly likely  to  be  the  case  in  competitive  games. 

Exercise  should  have  reference  to  the  symmetrical  development  of  the 
whole  body.  In  prescribing  it  the  specific  needs  of  the  individual  child 
should  be  considered.  By  careftilly  regulated  exercises  very  much  may  be 
done  to  check  such  deformities  as  round  shoulders  and  slight  lateral  cur- 
vature of  the  spine,  and  also  to  develop  narrow  chests  and  feeble  thoracic 
muscles.  For  purposes  like  these,  gymnastics  are  exceedingly  valuable  to 
supplement  out-of-door  exercise,  but  they  can  never  take  their  place. 

There  are  two  important  points  with  reference  to  exercise  indoors : 
First,  the  playroom  should  be  cool — from  60°  to  65°  F. ;  never  above 
this  point.  Secondly,  during  all  active  exercise  the  clothing  should  be 
loose  and  light,  so  as  to  allow  the  freest  possible  motion  of  the  body. 

Airing. — In  summer  there  can  be  no  possible  objection  to  a  young 
infant  being  allowed  out  of  doors  at  the  end  of  the  first  week.  It  should 
be  kept  in  the  open  air  as  much  as  possible  during  the  day.  In  the  fall 
and  spring  this  should  not  be  permitted  until  the  child  is  at  least  a  month 
old,  and  then  only  when  the  out-of-door  temperature  is  above  60°  F. 
During  its  outing  the  head  should  be  protected  from  the  wind  and  the 
eyes  from  the  sun.  The  duration  of  the  outing  at  first  should  be  only  fif- 
teen or  twenty  minutes,  the  time  being  gradually  lengthened  to  two  or 
three  hours.  The  child  should  be  gradually  accustomed  to  changes  of 
temperature  in  the  room  by  opening  wide  the  windows  for  a  few  min- 
utes each  day  even  before  it  is  taken  out  of  doors,  the  child  being  dressed 
meanwhile  as  for  an  outing.  In  the  case  of  children  born  late  in  the 
fall  or  in  the  winter  this  means  of  giving  fresh  air  may  be  advantageously 
begun  at  one  month  and  followed  throughout  the  first  winter.  It  is  only 
necessary  in  all  such  cases  that  the  changes  be  made  very  gradually 
both  as  to  the  length  of  the  airing  and  to  the  temperature.  The  great 
advantage  of  this  plan  over  that  more  commonly  followed  of  keeping 
young  infants  closely  housed  for  the  first  six  months  in  case  they  are  born 
in  the  fall  or  early  winter,  I  can  positively  affirm  from  quite  a  wide  obser-^ 
vation  of  both  methods.  It  is  a  matter  of  very  serious  importance  that 
every  infant  be  furnished  an  abundance  of  pure  fresh  air  in  winter  as  well 
as  in  summer.  When  the  plan  above  outlined  is  carefully  and  judiciously 
followed,  the  tendency  to  catarrhal  affections  instead  of  being  increased  is 
thereby  greatly  lessened. 

When  four  or  five  months  old,  there  is  no  reason  why  a  healthy  child 
should  not  go  out  of  doors  on  pleasant  days  if  the  temperature  is  not 


NURSERY.  9 

below  20°  F.  "While  there  is  a  prejudice  on  the  part  of  many  mothers 
and  some  physicians  against  a  child's  sleeping  out  of  doors  in  cold 
weather,  it  is  a  practice  which  I  have  always  urged  upon  mothers,  and 
have  never  seen  followed  by  any  but  the  most  beneficial  results.  The 
days  of  all  others  when  infants  and  very  young  children  should  not  be 
out  of  doors  are  when  there  are  high  winds,  especially  those  from  the 
northeast,  an  atmosphere  of  melting  snow,  and  during  severe  storms. 
Delicate  infants  must  of  course  be  more  carefully  guarded  during  the 
cold  season.  With  most  of  these  the  plan  of  house-airing  is  all  that 
should  be  attempted. 

Nursery. — This  should  be  the  sunniest  and  best- ventilated  room  in 
the  house.  It  is  the  physician's  duty  to  see  that  proper  attention  is  paid 
to  the  hygiene  of  the  room  in  which  the  child  spends  at  least  four  fifths  of 
its  time  during  the  first  year,  and  two  thirds  of  its  time  during  the  first 
two  or  three  years  of  life.  Sunlight  is  absolutely  indispensable.  Sunny 
rooms  always  contain  less  organic  matter  and  less  humidity,  and  hence  a 
room  upon  the  north  side  of  the  house  should  always  be  avoided,  prefera- 
bly one  in  the  second  story  should  be  chosen.  Nothing  which  can  in  any 
way  contaminate  the  air  of  the  room  should  be  allowed.  There  should  be 
no  drying  of  clothes  or  of  napkins,  and  no  plumbing.  No  food  should  be 
allowed  to  stand  about  the  room.  The  gas  should  not  be  allowed  to  burn 
at  night ;  a  small  wax  night-light  furnishes  all  that  is  needed  in  the 
nursery.  If  possible  the  heat  should  be  from  an  open  fire ;  the  next  best 
thing  is  the  Franklin  radiator.  Nothing  in  the  room  is  worse  than  steam 
heat  from  a  radiator  unless  it  be  a  gas  stove  which  under  no  circumstances 
should  be  allowed,  excepting  possibly  for  a  few  minutes  each  morning  dur- 
ing the  bath. 

The  temperature  of  the  room  during  the  day  should  be  70°  F.,  but 
better  68°  than  72°  F.  It  is  important  that  every  nursery  should  have  a 
thermometer,  and  that  this  and  not  the  sensations  of  the  nurse  should  be 
the  guide.  It  is  almost  invariably  true  that  the  nursery  is  overheated. 
Often  no  other  explanation  can  be  found  for  chronic  indigestion  and  fail- 
ing weight  excepting  a  nursery  whose  habitual  temperature  ranges  from 
75°  to  80°  F.  At  night  for  the  first  few  months  the  temperature  should 
not  be  allowed  to  fall  below  65°  F.  After  the  first  year  the  night  tem- 
perature may  fall  to  60°  or  even  55°  F. 

Free  ventilation  without  draughts  is  an  absolute  necessity.  This  is  best 
accomplished  by  ventilators  in  the  windows,  of  which  there  are  many  ex- 
cellent devices  sold  in  the  shops.  While  the  child  is  absent  from  the  room 
the  windows  should  be  widely  opened  and  free  airing  of  the  nursery  ac- 
complished. The  room  should  always  be  thoroughly  aired  at  night  before 
the  child  is  put  to  bed.  The  window  may  be  kept  open  even  in  the  first 
year,  unless  the  temperature  out  of  doors  is  below  40°  F.  After  the  first 
year  the  window  may  be  open,  unless  the  outside  temperature  is  as  low  as 


10  HYGIENE  AND   GENERAL   CARE   OF   INFANTS. 

20"  F.  If  the  window  is  open  the  door  of  the  nursery  should  be  closed, 
that  currents  of  air  may  be  avoided.  The  ventilation  by  means  of  an  open 
fire  is  the  most  efficient. 

The  furniture  of  the  nursery  should  be  as  simple  as  possible,  heavy 
hangings  should  be  positively  forbidden,  and  upholstered  furniture  used 
only  to  a  small  extent.  Floors  covered  by  large  rugs  are  much  more  clean- 
ly than  carpets,  and  hence  are  to  be  preferred. 

The  child,  whenever  it  is  possible,  should  have  a  separate  bed ;  and 
so  should  the  newly-born  infant,  in  order  to  prevent  the  danger  of  over- 
lying by  the  mother,  which  among  the  lower  claisses  is  a  frequent  cause  of 
death,  and  also  to  avoid  the  danger  of  too  frequent  night  nursing,  which  is 
injurious  alike  to  mother  and  child.  Separate  beds  for  older  children  will 
prevent  the  spread  of  many  forms  of  infection  from  the  diseased  child  to 
the  healthy.  The  cradle  for  infants  should  be  one  which  does  not  rock,  in 
order  that  this  unnecessary  and  vicious  practice  should  not  be  carried  on. 
The  mattress  should  be  of  hair  and  quite  firm.  The  pillow  should  be 
small ;  in  the  summer,  hair  pillows  are  an  advantage  but  not  a  neces- 
sity. The  position  of  the  child  during  sleep  should  be  changed  from 
time  to  time  from  one  side  to  the  other  and  then  to  the  back.  Atten- 
tion to  all  these  details  should  not  be  beneath  the  physician's  notice,  since 
the  violation  of  these  plain  rules  of  hygiene  is  at  the  bottom  of  many 
of  the  milder  disorders  and  even  of  some  of  the  more  serious  diseases  seen 
in  infancy. 

The  Nurse. — The  nurse  of  a  young  child  should  be  healthy,  young 
or  in  middle  life,  free  from  tuberculous  or  syphilitic  taint,  and  from  ca- 
tarrhal affections  of  the  nose  and  throat.  She  should  be  neat  in  habit, 
of  quiet  disposition,  and,  most  of  all,  she  should  be  a  person  of  intelli- 
gence. 

The  Amount  of  Air  Space  required  by  Infants. — The  nursery  should 
always  be  as  large  a  room  as  possible.  One  of  the  reasons  why  young 
infants  do  so  badly  in  institutions  is  because  of  overcrowding.  In  a 
well-ventilated  ward  there  should  be  allowed  to  each  infant  at  least  1,000 
cubic  feet  for  the  best  results.  Children  over  two  years  old  are  not  so 
sensitive  to  their  surroundings,  and  may  thrive  in  wards  where  only  700 
or  800  cubic  feet  are  allowed  to  each  child. 


THE   CARE  OP   PREMATURE   AND   DELICATE   INFANTS. 

Infants  born  before  term,  and  some  exceedingly  delicate  ones  which  are 
born  at  full  term,  require  very  special  and  particular  care.  The  vitality  is 
so  feeble  in  these  children  that  if  they  are  handled  in  the  ordinary  way 
they  survive  at  most  but  a  few  weeks.  The  symptom  which  indicates  that 
such  special  care  is  necessary  is  most  of  all  the  weight  of  the  child.  Either 
congenital  feebleness  or  prematurity  may  be  assumed  in  most  of  the  chil- 


THE   CARE   OF   PREMATURE   AND   DELICATE  INFANTS.  H 

dren  weighing  less  than  four  pounds.  Tliis  is  certainly  true  of  those 
weighing  less  than  three  pounds;  also  if  the  length  of  the  body  is  less  than 
nineteen  inches.  In  these  children  all  the  organs  are  likely  to  be  imper- 
fectly developed  and  they  are  not  ready  for  their  work.  Especially  is  this 
true  of  the  lungs  and  of  the  organs  of  digestion. 

The  clinical  picture  presented  by  these  cases  is  quite  characteristic. 
The  body  is  limp  ;  the  skin  very  soft  and  delicate  and  almost  transparent; 
the  cry,  a  low  feeble  whine  not  unlike  the  mew  of  a  kitten  ;  the  respira- 
tory movements,  extremely  irregular,  sometimes  scarcely  perceptible  for 
several  seconds ;  the  movements  of  the  extremities  infrequent  and  never 
vigorous.  The  general  appearance  is  one  of  torpor.  The  muscles  of  the 
mouth  and  cheek  and  tongue  may  lack  the  requisite  force  for  sucking, 
so  that  this  is  practically  impossible,  and  even  deglutition  is  slow,  diffi- 
cult, and  prolonged.  Unless  very  carefully  protected  the  temperature  of 
the  body  quickly  falls  to  a  subnormal  point,  and  it  is  difficult  to  maintain 
the  normal  body  heat.  These  symptoms  vary  much  in  degree  according 
as  the  infants  are  born  at  six  and  a  half,  seven  months,  or  only  shortly  be- 
fore term. 

In  the  management  of  these  cases  there  are  two  problems  to  be  solved  : 
the  first  to  maintain  the  animal  heat,  the  second  to  nourish  the  infant. 
Difficult  as  it  always  is  to  rear  a  premature  infant,  these  difficulties  are 
much  increased  in  cases  where  proper  means  are  not  adopted  immediately 
after  birth.  The  loss  which  these  children  sustain  during  the  first  few 
days  is  in  very  many  cases  so  great  that  subsequent  measures,  however 
well  carried  out,  are  futile.  The  heat-producing  power  is  so  feeble  that 
the  body  temperature  quickly  falls  below  normal  unless  artificial  heat  is 
constantly  used.  The  effect  of  cold  upon  these  delicate  infants  is  very 
serious,  and  not  only  growth  but  even  life  depends  upon  maintaining  the 
body  temperature  steadily  and  uniformly.  Their  extreme  susceptibility 
is  something  which  it  is  difficult  for  one  to  appreciate  who  has  not  had 
experience  in  these  cases. 

One  of  the  simplest  means  of  maintaining  the  temperature  is  to  oil 
the  skin  and  then  roll  the  entire  body  in  cotton  batting,  no  clothing  ex- 
cepting the  diaper  being  used.  The  body  should  then  be  wrapped  in 
two  or  three  blankets  and  surrounded  by  bottles  or  rubber  bags  con- 
taining hot  water.  These  means  are  usually  sufficient  in  infants  of  three 
and  a  half  pounds  or  over,  but  in  those  much  under  this  weight  this 
is  not  enough.  Where  cotton  is  used  it  should  be  changed  only  once  in 
two  or  three  days,  excepting  about  the  buttocks.  If  absorbent  cotton 
be  used  in  this  region  instead  of  cotton  batting,  the  napkin  may  be 
dispensed  with  altogether.  This  cotton  may  be  changed  as  often  as  it  is 
soiled  by  the  discharges.  These  children  should  not  be  bathed,  but  the 
skin  should  be  kept  in  a  healthy  condition  by  rubbing  with  sweet  oil  once 
in  two  or  three  days. 


12 


HYGIENE  AND  GENERAL  CARE  OF  INFANTS. 


Incubators. — In  the  case  of  infants  born  in  the  seventh  month,  and 
in  some  even  later  than  this,  the  animal  heat  which  can  be  maintained 
by  the  means  described  is  inadequate  to  the  child's  needs.  For  such 
cases  an  incubator  must  be  employed.  The  following  statistics  are  pub- 
lished by  Taruier,  showing  the  results  obtained  in  his  hospital  in  Paris 
during  five  years  with  the  incubator  and  for  the  five  years  before  its  in- 
troduction : 


Age. 

Percentage  saved 
with  incubator. 

Percentage  saved 
without  incubator. 

Infants  born  at  6 

months 

160 
36-6 

49-8 
77-0 
88-8 
96-0 

"      "   7 

21-5 

39-0 

«               a        .4     g 

54-0 

78-0 

"        "    8J 

88-0 

The  essential  thing  to  be  secured  in  an  incubator  is  a  uniform  temper- 
ature, which  in  the  most  delicate  infants  should  be  maintained  at  96°  to 
98°  F.  In  those  a  little  more  robust,  from  80°  to  95°.  The  air  must  at 
the  same  time  be  moistened,  and  there  must  be  sufficient  ventilation  to 
keep  it  pure. 

A  modification  of  Tarnier's  incubator  is  shown  in  the  accompanying 
illustrations.      (Figs.   1   and  2).     This  consists  of  a  wooden  box  thirty 


III!™' ''':!i;il!l!|!|||!l|llilil|  J 

Fig.  1. — Incubator. 


inches  long,  fifteen  inches  wide,  and  twenty  inches  high.  It  is  composed 
of  an  outer  and  inner  box,  each  one  half  inch  in  thickness,  with  an  air 
chamber  one  fourth  of  an  inch  in  thickness  separating  them,  excepting 


INCUBATORS. 


13 


at  the  bottom,  which  is  solid.  It  may  be  made  solid  throughout.  The 
temperature  is  maintained  by  a  large  tank  of  warm  water  four  inches  in 
height  which  completely  fills  the  bottom  of  the  incubator.  Tliis  is  so 
arranged  that  it  can  be  emptied  and  filled  without  opening  the  box.     Con- 


Glass  Cover 


Air  Exit 


Bed 


Hot-Water  Tank 


'■f^^yy^yy^.-y^. 


yi-iyyyyyyyyyyyyyy>yyyyyyyyyyyyyy/y/^^^^^ 


Fig.  2.— Section  of  incubator,  showing  construction. 


±X 


nected  with  one  end  of  the  tank  is  a  loop  of  brass 
pipe.  To  this  is  attached  a  funnel  for  filling  and  a 
faucet  for  emptying  the  tank.  Beneath  this  pipe  the  heat  is  applied. 
The  tank,  which  holds  five  or  six  gallons,  is  filled  with  hot  water,  and  the 
heat  is  then  maintained  by  the  flame  of  a  Bunsen  burner  or  an  'alcohol 
lamp.  The  lamp  stands  upon  a  hanging  shelf  made  of  tin.  Fresh  air  is 
admitted  at  four  openings,  three  inches  in  diameter,  two  being  on  each 
side.  A  slide  is  so  arranged  that  one  or  all  of  these  can  be  opened  as  de- 
sired. The  air  passes  over  the  upper  surface  of  the  tank,  is  moistened  by 
a  wet  sponge,  and  finds  its  exit  at  the  top.  A  thermometer  is  placed  on 
the  inside  of  the  box  just  over  the  bed,  so  that  the  exact  temperature 
can  be  seen.  A  portion  of  the  cover  consists  of  a  sliding  plate  of  glass, 
through  which  the  child  can  be  observed,  and  by  partly  opening  which 
it  can  be  fed.  The  infant  lies  upon  a  bed  of  cotton,  in  some  cases  naked, 
in  others  enveloped  in  the  cotton.  The  discharges  are  received  in  the 
cotton  upon  which  it  lies.  The  infant  is  kept  clean  by  the  use  of  oil 
and  cotton.  It  is  not  to  be  removed  for  feeding,  since  the  food  is  usually 
given  by  gavage,  and  this  can  be  done  by  sliding  the  cover.  Every  day 
the  child  should  be  taken  out  long  enough  to  allow  thorough  cleansing 
and  airing  of  the  incubator,  introduction  of  fresh  cotton,  etc. 

This  apparatus,  which  was  devised  by  Dr.  E.  J.  Sherow  and  myself, 
can  be  made  by  any  carpenter  and  tinsmith  at  a  very  moderate  expense. 
The  only  difficulty  is  with  the  ventilation.  This  is  quite  easy  provided 
the  temperature  of  the  room  in  which  the  incubator  stands  is  not  over 


14  HYGIENE  AND  GENERAL   CARE   OP   INFANTS. 

65°  or  68°  F.,  but  much  more  difficult  when  it  is  at  75°  or  over,  as  in 
warm  weather.  At  such  times  all  the  doors  for  the  entrance  of  air  should 
be  opened  to  the  full  extent  and  the  glass  cover  opened  from  one  half  to 
two  inches. 

Kotch,*  of  Boston,  has  devised  a  very  elaborate  incubator  which  con- 
tains a  very  perfect  heating  and  ventilating  apparatus  and  also  scales,  so 
that  the  weight  of  the  infant  can  be  ascertained  every  day  without  remov- 
ing it.  This  apparatus,  which  is  without  doubt  the  best  that  has  been 
devised,  is  made  of  metal,  principally  of  copper.  The  only  objection  is 
its  cost.  The  apparatus  which  I  have  described  above  is  one  with  which 
excellent  results  can  be  obtained,  but  it  requires  a  little  more  care  and 
attention.  The  essential  thing  in  all  cases  is  a  constant  temperature  and 
free  ventilation. 

The  child  is  kept  in  the  incubator  until  it  is  nearly  full  term,  or  has 
become,  judging  by  its  activity,  sufficiently  strong  to  withstand  the  varia- 
tions in  temperature  of  an  ordinary  room.  Before  it  is  taken  out  perma- 
nently the  temperature  of  the  incubator  should  be  gradually  lowered  by 
opening  the  cover  more  and  more  until  it  is  only  a  little  higher  than  the 
temperature  of  the  room,  clothing  being  of  course  added  at  the  same 
time. 

TJie  feeding  of  the  premature  infant  is  not  less  important  than  the 
use  of  the  incubator.  Very  few  infants  before  eight  months  can  be  de- 
pended upon  to  take  a  proper  amount  of  food  from  the  breast  or  bottle. 
Forced  feeding  by  means  of  gavage  is  indispensable  in  order  to  save  these 
very  young  and  very  delicate  children.  This  method  of  feeding  is  de- 
scribed elsewhere.  The  amount  of  food  will  depend  upon  the  age  of  the 
child.  At  seven  months  one  half  ounce  may  be  given  every  hour  and  a 
half,  and  at  eight  months  three  fourths  of  an  ounce  at  the  same  interval. 
The  food  employed  should  if  possible  be  breast  milk.  If  artificially  fed 
the  feeding  should  be  carried  on  as  described  in  the  chapter  on  the  feed- 
ing of  delicate  children  during  the  first  year.  With  careful  attention  to 
details  and  intelligent  co-operation  on  the  part  of  a  good  nurse  very  many 
of  these  cases  may  be  saved  that  otherwise  would  be  absolutely  hopeless. 

The  incubator  thus  far  has  not  been  so  much  employed  in  America  as 
in  Europe,  where  the  most  gratifying  results  have  followed  its  use,  par- 
ticularly in  Paris,  St.  Petersburg,  and  Moscow. 


*  Archives  of  Pediatrics,  August,  1893. 


CHAPTER   II. 
GROWTH  AND  DEVELOPMENT  OF  THE  BODY. 

Observation's  upon  growth  and  development  are  of  the  utmost  im- 
portance during  infancy  and  childhood.  Only  by  this  means  are  very 
many  diseases  detected  in  their  incipiency.  Early  recognition  carries 
with  it  in  most  cases  the  possibility  of  checking  such  pathological  pro- 
cesses, as,  if  allowed  to  go  on,  may  affect  the  health  not  only  in  infancy 
but  even  throughout  life. 

By  familiarity  with  what  is  normal,  detection  of  the  abnormal  soon 
becomes  easy.  Investigation  in  regard  to  these  subjects  should  be  made  a 
part  of  the  physical  examination  of  every  child. 

WEIGHT. 

The  weight  of  the  infant  is  the  best  means  we  have  to  measure  its 
nutrition.  It  is  as  valuable  a  guide  to  the  physician  in  infant  feeding  as 
is  the  temperature  in  a  case  of  continued  fever.  Although  the  weight  is 
not  to  be  taken  as  the  only  guide  to  the  child's  condition,  it  is  of  such 


Fig.  3. 

importance  that  we  cannot  afford  to  dispense  with  it  during  the  first  two 
years.  It  is  a  great  advantage  to  keep  up  regular  observations  during 
childhood. 

Weekly  weighings  should  be  made  for  the  first  six  months,  bi-weekly 
for  the  rest  of  the  first  year,  and  monthly  during  the  second  year.  Deli- 
cate children  should  be  weighed  even  more  frequently.  Satisfactory  scales 
of  moderate  price  for  domestic  use  are  those  known  in  the  shops  as  the 
*' Universal  Family  Scales."  (Fig.  3).  These  weigh  up  to  twenty-four 
B  15 


16 


GROWTH  AND  DEVELOPMENT. 


pounds  and  indicate  ounces.  For  hospital  use  and  for  very  fine  observa- 
tions more  accurate  scales  are  needed.  In  Fig.  4  are  shown  the  scales  I 
employ ;  they  weigh  up  to  sixty-one  pounds  and  indicate  half  ounces.* 

Weight  at  Birth. — The  following  figures  are  taken  consecutively  in 
nearly  equal  proportion  from  the  records  of  the  Nursery  and  Child's 
Hospital,  the  Sloane  Maternity,  and  the  New  York  Infant  Asylum,  and 
include  only  full-term  children  : 

Average  weight  of  568  females 7*16  lbs.  (3,260  grammes). 

590  males 7-55    "   (3,400        "        ), 


1,158  infants 735    "  (3,330 


). 


Weight  Curve  during  the  First  Few  Weeks.  —  The  accompanying 
chart  represents  the  variations  in  weight  for  the  first  twenty  days.  These 
observations  were  made  upon  one  hundred  healthy,  nursing  infants,  fifty 

males  and  fifty  fe- 
males, at  the  Xu  rsery 
and  Child's  Hospi- 
tal. The  children 
were  weighed  daily 
during  the  period 
of  observation.  The 
average  weight  at 
birth  was  7'1  pounds. 
The  curve  shows  a 
very  marked  loss  of 
weight  on  the  first 
day  and  a  slight  loss 
on  the  second  day, 
the  lowest  point  be- 
ing touched  at  the 
beginning  of  the 
third  day;  but  from 
this  time  there  was 
a  steady  gain.  The 
average  initial  loss 
in  these  cases  was 
ten  ounces,  being  in  each  sex  exactly  eleven  per  cent  of  the  body  weight. 
In  eight  hundred  and  thirty-five  cases,  however,  including  those  above 
mentioned,  the  average  loss  was  nine  and  a  half  ounces.  The  loss  of  the 
first  days  is  chiefly  due  to  the  discharge  of  the  meconium  and  urine,  but  is 
in  part  from  the  excess  of  tissue  waste  over  the  nutriment  derived  from 
the  breasts.     After  the  third  day,  coincident  with  an  abundant  secretion 


Name,- Date  of  Birth, 1S9 

Gms. 

Lbs. 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

4420 
4310 
4200 
4080 
3970 
3850 
3740 
3630 
3510 
3400 
3290 
3180 
3060 
2940 
2S30 
2720 
2610 
2490 
2380 

9 

8^ 
8K 
8M 

8 
7^ 
7H 
7X 

T 
6% 
6ii 
6Ji 

6 
5U 
5X 

5M 

^ 

r" 

K-^ 

<^ 

r^ 

V 

,— ' 

-^ 

^ 

\ 

^ 

^ 

\ 

^ 

^ 

^ 

\ 

r^ 

^' 

Fig.  5. — Weight  curve  of  the  first  twenty  days. 


*  These  are  made  by  the  Howe  Scale  Company. 


WEIGHT   CURVE   OF   THE   FIRST   YEAR.  17 

of  milk,  there  is  a  steady,  daily  increase  in  weight.  If  the  milk  is  very 
scanty  or  is  wanting  altogether,  the  loss  in  weight  continues. 

The  hirth-weight  of  nursing  children  who  thrive  normally  is  regained 
on  the  average  on  the  tenth  day.  The  most  frequent  deviation  from  the 
normal  curve  consists  in  a  continued  loss  or  stationary  weight  after  the 
third  day.  This  may  be  due  to  acute  illness,  such  as  bronchitis,  diarrhoea, 
pyaemia,  or  haemorrhage,  but  in  the  majority  of  cases  there  is  a  disturbance 
of  nutrition  from  improper  or  insufficient  food.  This  is  quite  as  likely  to 
be  the  case  in  nursing  infants  as  in  those  who  are  artificially  fed.  Under 
these  circumstances  the  loss  may  continue  indefinitely,  and  it  may  be  slow 
or  rapid  according  to  the  character  of  the  nursing  or  feeding. 

The  weight  curve  in  strong  infants  who  are  artificially  fed  in  the 
proper  way  from  the  beginning,  follows  in  some  cases  the  same  course  as 
in  nursing  infants.  There  are  many  infants  who,  though  properly  fed, 
gain  very  little  or  not  at  all  for  two  or  three  weeks,  often  not  regaining 
the  birth-weight  until  the  end  of  the  third  or  fourth  week.  Such  infants 
should  be  closely  watched  and  weighed  twice  a  week,  and  if  the  weight 
is  stationary,  one  should  not  be  too  ready  to  make  a  change  in  the  food. 
A  continued  loss  in  weight,  however,  is  an  invariable  indication  that  this 
should  be  done.  It  should  be  expected  that  most  artificially  fed  infants 
will  be  slower  in  getting  started,  but  in  my  experience  their  subsequent 
gain  under  favourable  circumstances  has  been  quite  as  regular  and  as 
rapid  as  that  of  average,  breast-fed  children. 

There  are  cases  in  which  an  excessive  loss  of  weight  during  the  first 
three  or  four  days  is  associated  with  an  elevation  of  temperature,  but 
without  any  other  evident  signs  of  disease.  Both  the  fever  and  the  rapid 
loss  in  weight  are  to  be  looked  upon  as  due  to  the  same  cause — inani- 
tion. This  will  be  more  fully  considered  in  the  chapter  devoted  to  that 
subject. 

Excessive  loss  in  weight  during  the  first  few  days  from  any  cause 
whatsoever,  seriously  handicaps  an  infant  during  the  first  weeks  of  its 
life.  The  great  importance  of  this  has  not  been  sufficiently  appreciated. 
Loss  in  weight  after  the  second  day  is  an  indication  for  food  in  addition 
to  that  derived  from  the  breast. 

Weight  Curve  of  the  First  Year. — The  curve  of  the  accompanying 
chart  is  made  up  from  complete  weight  charts  of  one  hundred  healthy 
nursing  infants  who  were  thriving  and  weighed  every  week,  and  the  in- 
complete charts  of  about  three  hundred  others.  There  are  represented 
in  round  numbers  about  ten  thousand  observations  on  children  under 
one  year.  The  period  of  most  rapid  increase  is  during  the  first  three 
months.  It  is  slowest  from  the  sixth  to  the  ninth  month.  This  curve  is 
not  to  be  regarded  as  a  normal  line,  like  the  normal  line  of  the  tempera- 
ture chart,  but  as  an  average  line.  An  infant  who  is  at  birth  a  pound 
above  the  average  may  keep  this  distance  above  the  line  for  the  whole 


18 


GROWTH   AND  DEVELOPMENT. 


year ;  another  weighing  one  pound  less  than  the  average  may  be  as  far 
below  it.  Girls  throughout  the  year  are  on  the  average  half  a  pound 
lighter  than  boys.  No  single  child  exactly  follows  the  line  all  the  way, 
but  it  is  surprising  to  see  how  close  to  it  a  very  large  number  of  the  cases 
come. 

In  artificially-fed  infants — provided  the  feeding  is  properly  done — the 
curve  does  not  differ  essentially  from  that  of  breast-fed  infants,  excepting 


WEIGHT  CHART. 
Name, Date  of  Birth, rSg 

i 

J3 

_J 

MONTH  OF  AGE. 

123456          78          9        10        11      12 

10890 
10130 
9980 

24 

23 
22 

] 

" 

■ 

1 

9070  20 

y 

LJ 

^ 

81G0 
7710 
7260 

18 
17 
16 

-^ 

- 

J^ 

- 

- 

- 

- 

^ 

— 

1 

f^ 

6350  U 
5900  13 

" 

^ 

^ 

y 

5140 
4990 
4540 
4080 
3630 

12 

/ 

/ 

11 

10 
9 
8 

y 

/^' 

/ 

- 

/ 

\ 

V 

- 

1 

-i 

. 

V 

/ 

2720 
2270 

6 
5 

V 

- 

- 

1 

- 

"1  1" 

_j 

'~~ 

Fig.  6. — The  weight  curve  of  the  first  year. 

in  the  slower  gain  of  the  first  one  or  two  months,  although  this  difference 
is  usually  made  up  before  the  sixth  month  is  reached. 

At  the  end  of  the  first  year  the  average  child  weighs  nearly  three  times 
as  much  as  at  birth.  Perfect  health  during  the  first  year  is  consistent 
only  with  a  steady  gain  in  weight.  A  child  may  not  always  gain  rapidly, 
but  it  should  gain  steadily,  and  if  it  does  not,  something  is  wrong.  All 
the  conditions  surrounding  the  infant  should  be  investigated,  but  espe- 
cially the  food.  One  should  not  be  satisfied  unless  the  average  weekly 
gain  during  the  first  six  months  is  at  least  four  ounces.  In  the  second 
six  months  it  may  be  slightly  less.  It  may  be  taken  as  a  rule  that  a 
child  who  gains  regularly  in  weight  is  thriving;  an  exception  must,  how- 
ever, be  made  in  the  case  of  some  infants  who  are  fed  chiefly  upon  carbo- 
hydrate foods. 


TUK  wp:ight  of  older  children. 


19 


Weight  from  the  Second  to  the  Fifth  Year. — Comparatively  few  obser- 
vations luive  been  publislied  upon  the  weight  during  this  period.  P'rom 
three  hundred  and  seventy-two  personal  observations  it  appears  that  the 
gain  is  about  six  pounds  during  the  second  year,  about  four  and  a  half 
during  the  third  year,  and  about  four  pounds  during  the  fourth  year :  the 
actual  \veights  are  given  in  the  large  table  (page  20).  During  this  period 
the  gain  is  rarely  steady  even  in  the  second  year.  With  most  children  it 
is  slowest  or  the  weight  is  stationary  in  the  summer  months,  while  the 
most  rapid  increase  is  usually  seen  in  autumn.  Throughout  this  period 
the  girls  gain  in  about  the  same  ratio  as  boys,  but  remain  on  the  average 
nearly  one  pound  lighter.  During  almost  every  illness,  no  matter  of  what 
character,  the  gain  in  weight  ceases,  and  usually  there  is  a  loss,  the  rapid- 
ity and  extent  of  which  are  somewhat  proportionate  to  the  severity  of  the 
attack ;  but  it  is  always  much  more  rapid  in  diseases  of  the  digestive  tract 
than  in  any  other  form  of  illness. 

Weight  of  Older  Children. — The  Aveights  given  in  the  table  of  children 
from  tive  to  fourteen  years  are  from  Bowditch.  Observations  were  made 
upon  children  of  American  parentage  in  the  public  schools  of  Boston — 
upon  4,327  boys  and  3,681  girls.*  It  is  to  be  remembered  that  these 
weights  include  the  ordinary  clothing,  while  those  below  five  years  are 
without  clothing,  f 

The  slowest  gain  is  from  the  fifth  to  the  eighth  year,  when  it  is  about 
four  pounds  a  year.  From  the  eighth  to  the  eleventh  year  it  rises  to  about 
six  pounds  a  year.  Up  to  the  eleventh  year  the  two  sexes  gain  in  about 
the  same  ratio.     From  the  eleventh  to  the  thirteenth  year  the  girls  gain 


*  W.  T.  Porter  has  published  (1894)  observations  made  upon  14,744  children  of  Amer- 
ican parentage  in  the  public  schools  of  St.  Louis.  His  figures  show  quite  a  variation 
from  those  of  Bowditch,  and  are  as  follows : 


boys'  weight. 

girls'  weight. 

Age. 

Kilos. 

Pounds. 

Kilos. 

Pounds. 

6  years  

19-66 

21-67 

23-91 

20-08  ■ 

28-49 

31-20 

33-45 

35-96 

40-34 

47-25 

52-10 

43-2 

47-7 
52-6 
57-4 
62-7 
68-8 
73-6 
79-1 
88-7 
103-9 
114-6 

18-76 
20-82 
22-71 
25-07 
27-43 
29-93 
33-17 
38-29 
43-12 
46-90 
50-06 

41-8 

7     "       

45-8 

8     "     

50-0 

9     "     

55-1 

10     "                   

60-3 

11     "           

65-8 

12     "         

73-0 

13     "     

84-2 

14     "                 

94-9 

15     "            

103-2 

16     "       

110-1 

f  The  average  weight  of  the  ordinary  house  clothing  of  school  children,  according 
to  Bowditch,  is  at  five  years  2-8  pounds  for  both  sexes ;  at  seven  years.  3-5  for  both 
sexes  ;  at  ten  years.  5-7  pounds  for  boys  and  4-5  pounds  for  girls  ;  at  thirteen  years.  7-4 
pounds  for  boys  and  5-6  pounds  for  girls;  at  sixteen  years.  9-7  pounds  for  boys  and  8-1 
pounds  for  girls.     This  must  be  deducted  from  weights  given  to  obtain  the  net  weight. 


20 


GROWTH   AND   DEVELOPMENT. 


much  more  rapidly,  passing  the  boys  for  the  first  time  and  maintaining 
this  lead  until  the  fifteenth  year,  when  again  the  boys  pass  them. 

Table   shoiving    Weight,   Height,   and   Circumference   of   the   Head  and 
Chest  from  Birth  to  the  Sixteenth  Year* 


Birth 

6  months  . . 
12  months.. 
18  months.. 
2  years 


4  years. 

5  years. 

6  years. 

7  years. 

8  years. 


10  years. 

11  years. 

12  years. 

13  years. 

14  years. 

15  years. 

16  years. 


Sex. 

■WEIGHT. 

HEIGHT. 

CHEST. 

Pounds. 

Kilos. 

Inches. 

Cm. 

Inches. 

Cm. 

Boys. 

Girls. 

7- 
7 

55 

16 

3-43 

3  26 

20 

20 

6 

5 

52 

52 

5 

2 

13 

13 

4 

0 

34 

33 

2 

2 

Boys. 

Girls. 

16 

15 

0 

5 

7 
7 

26 

03 

25 

25 

4 

0 

64 

63 

8 
6 

16 

16 

5 

1 

42 

41 

0 

0 

Boys. 

Girls. 

20- 

19 

5 

8 

9 

8 

29 

84 

29 

28 

0 

7 

73 

73 

8 
2 

18 

17 

0 

4 

45 

44 

9 

4 

Boys. 

Girls. 

22 

22 

8 
0 

10 

9 

35 

98 

30 

29 

0 

7 

76 

75 

3 

6 

18 
18 

5 

0 

47 

45 

1 
9 

Boys. 

Girls. 

26 

25 

5 

5 

12 

11 

02 

56 

32 

32 

5 

5 

82 
82 

8 

8 

19 

18 

0 

5 

48 
47 

4 

0 

Boys. 

j  Girls. 

31 

30 

2 

0 

14 

13 

14 

60 

35 

35 

0 

0 

89 
89 

1 
1 

20 

19 

1 
8 

51 

50 

1 
5 

Boys. 

Girls. 

35 

34 

0 

0 

15 

15 

87 
41 

38 

38 

0 

0 

96 

96 

7 
7 

20 

20 

7 
5 

52 

52 

8 
2 

Boys. 

Girls. 

41 

39 

2 

8 

18 

18 

71 

06 

41 

41 

7 
4 

106 

105 

0 

3 

21 

21 

5 

0 

54 

53 

8 
5 

Boys. 

Girls. 

45 

43 

1 
8 

20 

19 

48 
87 

44 

43 

1 
6 

112 

110 

0 

9 

23 

22 

2 

8 

59 

58 

1 

3 

Boys. 

Girls. 

49 

48 

5 

0 

22 

21 

44 

78 

46 

45 

2 

9 

117 

116 

4 

7 

23 

23 

7 
3 

60 

59 

6 

5 

Boys. 

Girls. 

54 

52 

5 

9 

24 

24 

70 

01 

48 
48 

2 

0 

122 

122 

3 

1 

24 

23 

4 

8 

62 

60 

2 

8 

Boys. 

Girls. 

60 

57 

0 

5 

26 

26 

58 
10 

50 

49 

1 
6 

127 

126 

2 

0 

25 

24 

1 
5 

63 

62 

9 

5 

Boys. 

Girls. 

66- 

64 

6 

1 

30 

29 

22 

07 

52 

51 

2 

8 

132 

131 

6 
5 

25 

24 

8 

7 

65 

63 

6 

0 

Boys. 

Girls. 

72 

70 

4 

3 

32 

31 

83 
87 

54 

53 

0 

8 

137 

136 

2 

6 

26 

25 

4 

8 

67 

65 

2 
8 

Boys. 

Girls. 

79- 

81 

8 
4 

36 

36 

21 

90 

55 

57 

8 
1 

141 

145 

7 
2 

27 

26 

0 

8 

68 
68 

8 
3 

Boys. 

Girls. 

88 
91 

3 

2 

40 

41 

04 

36 

58 
58 

2 

•7 

147 

149 

7 
2 

27 

28 

7 
0 

70 

71 

6 

3 

Boys. 

Girls. 

99 

100 

3 

3 

45 

45 

03 

50 

61 

60 

0 

3 

155 

153 

1 

2 

28 
29 

8 
2 

73 

74 

3 

1 

Boys. 

Girls. 

110 

108 

8 
4 

50 

49 

26 

17 

63 

61 

0 

4 

159 

155 

•9 

9 

30 

30 

•0 

3 

76 

76 

6 

8 

Boys. 

Girls. 

123 

113 

•7 
0 

56 

51 

09 

24 

65 

61 

6 

•7 

166 

156 

•5 

7 

31 

30 

2 

8 

79 

78 

2 

8 

Inches.       Cm 


13-9 

13-5 

170 

16-6 

180 

17-6 

18-5 

18-0 

18-9 

18-6 

19-3 

19-0 


19 

19' 

20 

20' 


21  0 

20-7 


21-8 

21-5 


*  The  recently  published  observations  of  Boas  (Science,  April  12,  1895)  upon  4,319 
children  over  six  years  old  show  that  first  born  exceed  later  children  both  in  height 
and  wei<rht. 


GROWTH   OF  THE  EXTREMITIES.  21 

HEIGHT. 

The  figures  showing  the  height  at  different  ages  are  given  in  the  fore- 
going table.  The  measurements  of  infants  at  birth  are  taken  in  about 
equal  numbers  from  the  records  of  the  New  York  Infant  Asylum  and 
the  Sloane  Maternity  Hospital.     They  were  made  upon  full-term  infants. 

Average  length  of  231  males 20 -Gl  inches  (o2-5  cm.) ; 

211  females 20-47      "       (52-2     "); 

442  infants 20-54      "       (52-35"). 

The  most  rapid  gain  in  length  is  in  the  first  year.  During  this  period 
the  child  grows  on  an  average  a  little  over  eight  inches  {21  cm.).  This 
gain  is  usually,  but  not  always,  proportionate  to  the  increase  in  weight. 
During  the  second  year  the  average  increase  is  three  and  a  half  inches  (9 
cm.).  From  this  time  on  the  rate  of  increase  is  quite  uniform  in  both 
sexes  until  the  eleventh  year,  it  being  between  two  and  three  inches  a 
year. 

After  the  eleventh  year  in  girls  and  the  twelfth  in  boys  the  growth  is 
much  more  rapid.  In  height  the  girls  exceed  the  boys  at  the  twelfth  and 
thirteenth  years  for  the  only  time  in  their  growth. 

In  the  figures  given  in  the  preceding  table  those  of  five  years  and  over 
are  taken  from  Bowditch,*  the  observations  being  made  upon  the  same 
children  as  those  whose  weights  were  taken.  The  observations  from  six 
months  to  four  years  inclusive  are  from  original  sources,  and  are  drawn 
from  about  five  hundred  cases.  The  height  much  more  than  the  weight 
of  childreii  is  modified  by  hereditary  influences. 

Rachitic  children  during  infancy  and  early  childhood  are,  as  a  rule, 
shorter  than  others.  I  have  frequently  measured  such  children  during 
the  third  year  who  were  six  inches  below  the  average  for  that  age.  The 
effect  of  malnutrition  upon  the  length  of  the  body  is  much  less  than  on 
the  weight. 

GROWTH  OF  THE  EXTREMITIES  AS  COMPARED  WITH  THE  TRUNK. 

At  birth  the  trunk  is  relatively  long  and  the  extremities  short.  Sub- 
sequently the  growth  of  the  extremities  is  much  more  rapid  than  that  of 
the  trunk.  Thus  I  have  found  at  birth  the  length  of  the  lower  ex- 
tremities (measuring  from  the  anterior  superior  spine  of  the  ilium  to  the 
sole  of  the  foot)  to  be  forty-three  per  cent  of  the  length  of  the  body ;  at 
five  years,  fifty-four  per  cent,  and  at  sixteen  years  sixty  per  cent.  The 
above  figures  are  from  one  hundred  and  fifty  observations,  which,  although 
not  numerous  enough  for  exact  percentages,  are  still  suflRcient  to  give  a 

*  According  to  the  observations  of  Porter,  the  St.  Louis  children  reach  a  given 

height  on  the  average  about  one  year  later  than  Boston  school  children. 


22  GROWTH  AND   DEVELOPMENT. 

very  good  idea  of  the  general  relation  of  the  length  of  the  extremities  to 
that  of  the  body  as  a  whole. 

THE   HEAD. 

Circumference. — The  average  circumference  of  the  head  at  birth  in 
four  hundred  and  forty-six  full-term  infants  taken  in  about  equal  num- 
bers from  the  Sloane  Maternity  Hospital  and  Xew  York  Infant  Asylum 
was  as  follows  : 

Average  circumference  of  the  head,  231  males. .   13-90  inches  (35-5  cm.) ; 

"      215  females.  13-53      "       (34-5     "  ); 

Total 446  infants.  13-71      "       (35-0     "  ). 

The  occipito-frontal  measurement  has  been  the  one  taken. 

The  growth  of  the  head  is  most  rapid  during  the  first  year,  the  in- 
crease being  about  four  inches  (10  cm.).  During  the  second  year  the  in- 
crease is  about  one  inch  (2-5  cm.).  From  the  second  to  the  fifth  year  the 
growth  is  slower,  being  only  about  one  and  a  half  inches  (4  cm.)  for  the 
three  years.  After  the  fifth  year  the  increase  in  the  circumference  of  the 
head  is  very  slow,  as  shown  by  the  preceding  table. 

Closure  of  the  Sutures. — The  main  sutures  of  the  cranium  are  not 
commonly  ossified  before  the  end  of  the  sixth  month,  and  very  frequently 
some  mobility  may  be  detected  at  the  end  of  the  ninth  month.  Distinct 
separation  of  the  cranial  bones  after  birth  is  abnormal.  It  is  most  fre- 
quently seen  in  premature  and  in  syphilitic  infants,  but  rarely  in  this 
country  as  the  result  of  congenital  rickets. 

Closure  of  the  Fontanels. — The  posterior  fontanel  is  usually  obliterated 
by  the  end  of  the  second  month.  The  anterior  fontanel  under  normal 
conditions  closes  on  an  average  at  about  the  eighteenth  month.  The 
usual  variations  are  between  the  fourteenth  and  the  twenty-second  months. 
At  the  end  of  the  first  year  the  fontanel  should  be  about  one  inch  in 
diameter.  An  open  fontanel  at  the  end  of  the  second  year  may  always 
be  considered  abnormal.     Eickets  is  the  usual  explanation. 

The  closure  of  the  fontanel  is  not  always  early  in  well-nourished  chil- 
dren, nor  is  it  always  delayed  in  those  suffering  from  malnutrition.  It 
often  happens  that  in  a  child  with  marked  evidences  of  malnutrition  the 
fontanel  at  ten  or  twelve  months  is  nearly  or  quite  closed  and  the  sutures 
firmly  ossified.  In  such  children  the  head  is  usually  small,  and  the  early 
closure  is  partly  due  to  the  slow  growth  of  the  brain.  On  the  other  hand, 
it  is  sometimes  the  case  that  in  stout,  well-nourished  children  the  fontanel 
may  remain  open  until  nearly  the  end  of  the  second  year,  although  the 
child  presents  every  evidence  of  perfect  nutrition  and  no  signs  of  rickets. 
This  may  be  due  to  the  fact  that  the  brain  has  grown  with  more  than 
usual  rapidity.  When,  however,  there  is  any  great  disproportion  between 
the  size  of  the  head  and  the  development  of  the  rest  of  the  body,  or  when 


SHAPE   OF   THE   HEAD.  23 

the  circumference  of  the  head  exceeds  very  much  the  figures  given  in  the 
table  above,  either  rickets  or  hydrocephalus  sliould  be  suspected. 

Shape  of  the  Head. — The  deformity  which  results  from  compression 
during  labour  usually  disappears  by  the  end  of  the  first  month.  During 
the  first  year  the  head  often  becomes  flattened  at  the  occiput  in  conse- 
quence of  the  child's  lying  too  much  upon  the  back.  This  is  easily 
remedied  by  changing  its  position.     A  slight  obliquity  of  the  head  may 


FiG.  7  — Premature  ossification  of  the  sagittal  suture.     Death  at  ^ix  weeks. 

be  produced  by  the  child's  being  habitually  held  in  one  position,  as  in 
some  cases  where  it  is  nursed  only  at  one  breast,  or  where  it  is  always 
laid  upon  the  same  side  during  sleep. 

The  other  abnormities  in  the  shape  of  the  head  are  chiefly  due  to 
rickets  and  hydrocephalus,  more  rarely  to  congenital  malformations  of 
the  brain.    They  will  be  considered  in  the  chapter  devoted  to  these  topics. 

Premature  ossification  of  the  sutures  of  the  cranium  occasionally  gives 
rise  to  a  very  striking  deformity  of  the  head.  I  have  recently  seen  two 
cases  of  such  deformity  from  premature  ossification  of  the  sagittal  suture. 
The  heads  in  both  cases  were  very  narrow  and  long  in  the  antero-poste- 
rior  diameter.     The  forehead  was  narrow,  prominent,  and  slightly  pro- 


24  GROWTH   AND   DEVELOPMENT. 

jecting.  The  accompanying  illustration  shows  the  skull  of  one  of  these 
cases.  There  is  a  complete  obliteration  of  the  sagittal  suture.  In  this 
case  there  was  a  wide  separation  of  the  sutures  at  the  junction  of  the 
parietal  and  temporal  bones.     (See  Fig.  7.) 

THE   CHEST. 

The  figures  showing  the  circumference  of  the  chest  at  the  different 
periods  of  childhood  are  given  on  page  20.  The  measurements  up  to 
and  including  five  years  are  from  original  sources,  those  from  the  sixth 
to  the  sixteenth  are  taken  from  Porter,  and  are  drawn  from  observations 
on  31,371  school  children.  The  measurement  of  the  chest  is  that  taken 
midway  between  full  inspiration  and  expiration,  and  at  the  level  of  the 
nipples. 

In  the  newly-born  child  the  antero-posterior  and  the  transverse  diame- 
ters of  the  chest  ai-e  nearly  the  same.  As  age  advances,  the  transverse 
diameter  increases  very  much  more  rapidly,  so  that  the  outline  of  the 
chest  gradually  assumes  an  elliptical  shape,  which  it  maintains  during 
childhood. 

At  birth,  the  circumference  of  the  chest  is  about  one  half  inch  less 
than  that  of  the  head,  but  throughout  infancy  the  two  measurements 
are  nearly  the  same.  It  is  not  until  the  third  year  that  the  circum- 
ference of  the  chest  exceeds  that  of  the  head.  According  to  Uffel- 
mann,  the  circumference  of  the  head  and  the  chest  are  the  same  until 
the  twenty-first  month  in  a  robust  child,  and  until  two  and  a  half  years 
in  an  average  child.  If  at  three  years  the  chest  continues  smaller  than 
the  head,  the  child  is  likely  to  be  a  weak  one.  If  the  chest  is  below 
the  average  at  birth,  it  is  likely  to  remain  so  throughout  infancy. 
The  chest  measurement  in  infants  is  always  much  modified  by  the 
amount  of  fat ;  but,  after  making  due  allowance  for  this,  a  large  chest 
always  indicates  a  robust  child  and  a  small  chest  a  delicate  one.  If  at 
any  age  the  circumference  of  the  child's  chest  is  found  to  be  below  the 
average,  measures  should  be  taken,  by  gymnastics  and  otherwise,  to 
develop  it. 

Deformities  of  the  thorax  result  chiefly  from  rickets,  sometimes  from 
empyema,  emphysema,  and  cardiac  disease  ;  in  older  children,  from  lateral 
curvature  of  the  spine,  or  from  Pott's  disease. 

THE   ABDOMEN. 

Throughout  infancy  the  circumference  of  the  abdomen  is,  as  a  rule, 
about  the  same  as  that  of  the  chest.  At  the  end  of  the  second  year 
the  measurements  of  the  head,  chest,  and  abdomen  are  very  often  identi- 
cal ;  after  this  time  the  chest  measurement  increases  much  more  rapidly 
than  the  other  two.      ]\Iarked  enlargement  of  the  abdomen  is  seen  in 


DEVELOPMENT   OF  THE   SPECIAL  SENSES.  25 

many  varieties   of   chronic   intestinal   disorders.      It   is,   however,   most 
marked  in  the  tympanites  which  so  constantly  accompanies  rickets. 

MUSCULAR   DEVELOPMENT. 

The  first  voluntary  movements  are  usually  in  the  fourth  month,  when 
the  infant  deliberately  attempts  to  grasp  some  object  placed  before  it. 
During  the  fourth  mouth,  as  a  rule,  the  head  can  be  held  erect  when  the 
trunk  is  supported.  In  many  infants  this  is  possible  in  the  early  part 
of  the  third  month.  At  seven  months  a  healthy  child  is  usually  able  to 
sit  erect  and  support  the  trunk  for  several  minutes. 

In  the  ninth  or  tenth  month  are  usually  seen  the  first  attempts  to  bear 
the  weight  upon  the  feet.  At  ten  or  eleven  months  a  child  stands  with 
slight  assistance.  The  first  attempts  at  walking  are  commonly  seen  in 
the  twelfth  "or  thirteenth  month.  The  average  age  at  which  children 
walk  freely  alone  has  been,  in  my  experience,  the  fourteenth  or  fifteenth 
month.  Quite  wide  variations  are  seen  in  healthy  children.  Very  much 
depends  upon  the  surroundings.  I  have  known  infants  to  walk  at  ten 
months  and  many  others  not  until  seventeen  or  eighteen  months,  although 
showing  no  evidences  of  disease,  and  although  their  development  had  not 
been  retarded  by  previous  illness.  A  very  marked  difference  is  seen  in 
different  families  of  children  with  respect  to  the  time  of  walking. 

The  physician  is  often  consulted  because  of  backward  muscular  devel- 
opment, most  frequently  because  the  child  is  late  in  walking.  General 
malnutrition,  or  any  other  severe  or  prolonged  illness,  may  postpone  for 
several  months  this  or  any  of  the  other  functions  mentioned.  When 
there  is  no  such  explanation  of  the  backwardness,  a  child  who  does  not 
hold  up  its  head,  sit  alone,  or  make  efforts  to  stand  or  walk  at  tlie  proper 
time,  should  be  submitted  to  a  careful  examination  for  a  cerebral  or  spinal 
paralysis,  but  especially  for  rickets  which  is  the  most  frequent  explanation 
of  the  symptoms. 

Contrivances  for  teaching  infants  to  walk  are  unnecessary,  and  their 
effect  may  even  be  injurious.  An  infant  should  be  allowed  the  greatest 
possible  freedom  in  the  use  of  its  limbs.  It  should  not  be  restrained 
from  walking  when  inclined  to  do  so,  nor  continually  urged  to  w^alk  when 
no  voluntary  attempts  are  made.  Nothing  short  of  mechanical  restraint 
will  prevent  a  healthy  eliild  from  walking  or  standing  when  it  is  strong 
enough  to  do  so. 

DEVELOPMENT   OF    THE   SPECL\L   SENSES.* 

Sight. — The  newly-born  infant  avoids  the  light.  Its  pupils  contract 
in  a  light  room,  and  if  a  bright  light  is  brought  before  the  eyes  they 

*  For  many  of  the  facts  in  this  paragraph  T  am  indebted  to  Preyer's  The  Senses 

and  the  Will,  American  edition,  1888,  D.  Appleton  &  Co. 


26  GROWTH   AND   DEVELOPMENT. 

close.  During  the  first  few  weeks  the  infant  indicates  by  every  sign  that 
excessive  light  is  unpleasant.  As  early  as  the  sixth  day  the  eyes  will 
sometimes  follow  a  light  in  the  room,  and  the  child  may  even  turn  the 
head  for  this  purpose.  The  muscles  of  the  eyes  of  the  newly-born  infant 
act  irregularly  and  not  in  harmony.  Co-ordinate  action  for  general  pur- 
poses is  not  established  until  about  the  end  of  the  third  month.  Even 
after  this  time  inco-ordinate  action  is  occasionally  seen.  The  eyelids  also 
move  irregularly,  and  are  often  partly  separated  during  sleep.  The  cornea 
is  but  slightly  sensitive  during  the  first  weeks.  In  Preyer's  child  it  was 
not  until  the  third  month  that  the  lids  closed  when  the  water  in  the  bath 
touched  the  lashes  or  the  cornea.  The  recognition  of  objects  seen  is  usu- 
ally evident  in  the  sixth  month. 

It  is  important  that  the  room  in  which  the  newly-born  child  is  placed 
should  be  darkened,  and  that  for  the  first  few  weeks  the  eyes  should  be 
protected  against  strong  light. 

Hearing. — For  the  first  twenty-four  hours  after  birth  infants  are 
deaf.  This  deafness  sometimes  persists  for  several  days.  It  is  believed 
to  be  due  to  absence  of  air  from  the  middle  ear  and  to  swelling  of  the 
mucous  membrane  which  lines  the  tympanum.  With  the  movements  of 
respiration,  air  gradually  finds  its  way  into  the  middle  ear,  and  the  swell- 
ing subsides  during  the  first  few  days.  After  this  the  hearing  gradually 
improves,  and  during  the  early  months  of  life  it  is  very  acute.  The  child 
starts  at  the  slamming  of  a  door,  and  even  moderately  loud  noises  will 
waken  it  from  sleep.  By  the  end  of  the  second  month  it  will  sometimes 
turn  its  head  in  the  direction  from  which  the  sound  comes,  and  by  the 
end  of  the  third  month  this  will  usually  be  done.  Demme  found,  in 
observations  upon  one  hundred  and  fifty  infants,  that  the  voices  of  parents 
were  recognised  on  an  average  at  three  and  a  half  months. 

Not  only  are  the  ears  unusually  sensitive  to  sound  in  infancy,  but 
the  impression  produced  upon  the  brain  is  often  marked — very  loud 
sounds  causing  great  fright,  and  sometimes  even,  it  is  reported,  convul- 
sions. 

Touch. — Tactile  sensibility  is  present  at  birth,  but  is  not  highly  devel- 
oped except  in  the  lips  and  tongue,  where  it  is  very  acute  for  the  obvious 
necessity  of  sucking.  After  the  third  month  it  is  fairly  acute  over  the 
surface  of  the  body  generally.  Two  especially  sensitive  areas,  according 
to  Preyer,  are  the  forehead  and  external  auditory  meatus. 

Sensibility  to  painful  impressions  is  present  in  early  infancy,  but  very 
dull  as  compared  with  later  childhood. 

Temperature  is  also  distinguished.  This  recognition  is  especially 
acute  in  the  tongue.  A  young  infant  is  often  seen  to  refuse  to  take 
the  bottle  because  the  milk  is  only  a  few  degrees  too  cold  or  too 
warm. 

The  localization  of  sensory  impressions  comes  later,  probably  not  much 


DENTITION.  27 

before  the  middle  of  the  sixth  month,  and  is  very  imperfect  throughout 
the  first  year. 

Taste. — This  is  highly  developed,  even  from  birth.  According  to  the 
experiments  of  Kussnianl,  the  ability  to  distinguish  sweet,  sour  and  bit- 
ter, exists  in  the  newly-born  child — sweet  exciting  sucking  movements, 
and  bitter,  grimaces.  A  young  infant  detects  with  surprising  accuracy 
the  slightest  variation  in  the  taste  of  its  food,  and  the  smallest  difference 
is  often  enough  to  cause  it  to  refuse  its  bottle  altogether.  Sweet  sub- 
stances are  always  easily  administered,  and  in  combination  with  sirups 
even  very  bitter  substances  can  be  given ;  but  to  aromatic  powders  and 
elixirs  it  usually  objects. 

Smell. — Observations  upon  the  sense  of  smell  in  newly-born  infants 
are  few  and  not  altogether  conclusive.  Kroner's  experiments  appear  to 
show  that  smell  is  present  in  the  newly  born.  It  has  been  noted  to  be 
especially  acute  in  infants  born  blind.  The  sense  of  smell  is  developed 
much  later  than  the  other  senses.  Detection  of  fine  differences  in  odours 
is  not  acquired  until  quite  late  in  childhood. 

SPEECH. 

There  is  a  very  wide  variation  in  children  with  reference  to  the  time 
of  development  of  the  function  of  speech.  Girls,  as  a  rule,  talk  from  two 
to  four  months  earlier  than  boys.  Towards  the  end  of  the  first  year  the 
average  child  begins  with  the  words  "  papa,"  "  mamma."  By  the  end  of 
the  second  year  it  is  able  to  put  words  together  in  short  sentences  of  two 
or  three  words.  Progress  in  speech  from  this  time  is  very  rapid,  each 
month  showing  great  improvement.  Xames  of  persons  are  commonly  first 
acquired,  then  the  names  of  objects.  Xext  to  this  the  verbs  are  learned, 
and  then  adverbs  and  adjectives.  Conjunctions,  prepositions,  and  articles 
follow  in  order,  and  last  of  all  the  personal  pronouns. 

If  a  child  of  tw^o  years  makes  no  attempt  to  speak,  some  mental  defect 
may  usually  be  inferred. 

DENTITION. 

The  teeth  are  enclosed  at  birth  in  dental  sacs  which  are  situated  in  the 
gums.  Above,  they  are  covered  by  the  submucous  connective  tissue  and 
the  mucous  membrane ;  below,  the  dental  sacs  rest  in  depressions  in  the 
alveolar  process  of  the  jaw.  The  tooth  grows  in  length  mainly  as  the 
result  of  the  calcification  of  its  roots,  and  being  thus  fixed  below,  it  pushes 
upward  towards  the  mucous  membrane.  This  growth  undoubtedly  goes 
on  steadily  from  birth  until  the  tooth  pierces  the  gum. 

The  deciduous  or  milk  teeth  are  twenty  in  number.  The  time  at 
which  they  appear  is  subject  to  considerable  variation  even  under  normal 
conditions.  The  following  is  the  order  and  the  average  time  of  appearance 
of  the  different  teeth  : 


28  GROWTH   AND  DEVELOPMENT. 

(1)  Two  lower  central  incisors 6  to    9  months. 

(2)  Four  upper  incisors 8  "  12        " 

(3)  Two  lower  lateral  incisors  and  four  anterior  molars.  12  "  15        " 

(4)  Four  canines 18  "  24        " 

(5)  Four  posterior  molars 24  "  30        " 

At  1    year  a  child  should  have 6  teeth. 

At  U     "  '     12     '• 

At  2    years       "  "'  "     16     " 

At  2i  "  "  "  •'  •'     20     " 

Qtiite  wide  variations  on  both  sides  of  the  average  are  common,  and 
are  not  always  easy  of  explanation.  In  many  cases  it  seems  to  be  a  family 
idiosyncrasy,  since  in  the  different  members  of  a  family  the  teeth  are 
apt  to  appear  at  about  the  same  time.  I  know  one  family  in  which  no 
less  than  three  members  of  three  successive  generations  were  born  with 
teeth,  and  in  most  of  the  other  members  the  first  teeth  appeared  in  the 
third  or  fourth  month.  The  order  in  which  the  teeth  appear  is  much 
more  regular  than  the  time  of  their  appearance.  The  order  given  above 
corresponds  with  that  stated  by  most  observers,  although  some  writers 
have  made  different  statements,  jDlacing  the  lower  before  the  upper  lateral 
incisors. 

The  teeth  may  pierce  the  gum  without  any  local  manifestations.  Very 
frequently,  however,  just  before  a  tooth  conies  through  there  is  noticed  a 
moderate  swelling  and  redness  of  the  mucous  membrane  of  the  gum  over- 
lying it,  and  to  a  slight  degree  this  may  affect  the  general  mucous  mem- 
brane of  the  mouth.  This  condition  may  be  accompanied  by  a  little  fret- 
fulness  and  increased  salivation,  or  both  of  these  may  be  entirely  wanting. 
These  symptoms  usually  disappear  when  the  tooth  has  pierced  the  gum. 
The  symptoms  of  difficult  dentition  will  be  discussed  in  connection  with 
Diseases  of  the  Mouth. 

Infants  may  be  born  with  teeth ;  this  is,  however,  an  exceedingly  rare 
occurrence.  It  is  almost  invariably  one  of  the  lower  central  incisors  that 
is  present.  In  case  this  interferes  with  nursing,  or  if  it  is  very  loosely 
attached  to  the  gum,  it  should  be  extracted,  but  under  other  circumstances 
it  should  be  allowed  to  remain,  since,  if  it  is  removed,  a  second  tooth  is 
not  likely  to  appear  in  its  place  in  the  first  set.  It  is  not  at  all  uncommon 
for  the  first  teeth  to  appear  in  the  fourth  month.  Such  teeth,  in  my 
experience,  do  not  usually  differ  in  character  from  those  appearing  later, 
unless  they  are  in  children  who  are  syphilitic.  Syphilitic  children  are 
rather  prone  to  early  dentition,  and  under  such  circumstances  rapid  and 
early  decay  is  likely  to  take  place.  Nursing  infants  are,  as  a  rule,  a  little 
earlier  i:i  their  dentition  than  those  artificially  fed. 

Delayed  dentition  is  much  more  frequently  due  to  rickets  than  to  all 
other  causes  combined.  It  is  to  be  remembered,  however,  that  the  first 
teeth  may  not  appear  until  the  tenth  month  in  healthy,  well-nourished 
children  and  in  those  who  present  no  signs  whatever  of  rickets.     On  the 


DENTITION.  29 

other  hand,  it  is  by  no  means  invariable  that  dentition  is  late  in  rachitic 
children.  The  latest  dentition  is  seen  in  cases  of  cretinism.  In  such 
children  it  is  not  rare  for  the  first  teeth  to  appear  as  late  as  the  eighteenth 
month.  I  have  seen  one  child  two  years  old  with  but  two  teeth.  As  a 
rule,  dentition  and  ossification  of  the  bones  of  the  head  go  on  in  a  cor- 
responding manner;  where  one  is  early  the  other  is  likely  to  be  rapid, 
and  conversely. 

Provided  an  infant  is  well  nourished  and  thrives  properly  for  the  first 
six  or  eight  months,  the  eruption  of  the  teeth  is  likely  to  go  on  steadily 
after  this  time,  even  though  the  child  may  later  have  chronic  indigestion 
or  suffer  from  extreme  malnutrition  from  any  cause  excepting  rickets. 
If,  however,  the  symptoms  of  malnutrition  date  from  birth,  dentition  is 
almost  invariably  delayed.  It  is  often  a  matter  of  very  great  surprise  to 
see  children  who  are  markedly  emaciated  as  a  result  of  chronic  indiges- 
tion or  ileo-colitis  and  yet  go  on  cutting  their  teeth  regularly.  I  have 
under  observation  at  the  present  time  a  delicate  infant  of  sixteen  months, 
whose  body  length  is  twenty-eight  inches  and  whose  weight  is  less  than 
nineteen  pounds — almost  exactly  what  they  were  eight  months  ago — and 
yet  he  has  now  thirteen  good  teeth. 

Eruption  of  the  Permanent  Teeth. — The  first  to  appear  are  the  first 
molars,  which  usually  come  in  the  sixth  year,  and  hence  the  name  six- 
year-old  molars,  which  is  applied  to  them.  These  appear  posterior  to  the 
second  molars  of  the  first  set.  The  following  table  from  Forchheimer 
gives  the  average  time  of  the  appearance  of  the  second  teeth  : 

First  molars 6  years. 

Incisors 7  to    8 

Bicuspids 9  "  10 

Canines 12  "  14      " 

Se(!ond  molars 12  "  15 

Third  molars 17  "  25      " 

The  order  of  appearance,  therefore,  leaving  out  the  first  molars,  is 
essentially  the  same  as  that  of  the  first  set.  The  permanent  teeth,  with 
the  exception  of  the  molars,  take  the  place  of  the  corresponding  deciduous 
teeth.  As  they  grow  and  push  upward  they  cause  atrophy  of  the  roots  of 
the  first  teeth,  and  gradually  cut  off  their  blood  supply,  so  that  they 
loosen  and  fall  out. 

The  place  of  dentition  as  an  etiological  factor  in  the  diseases  of  in- 
fancy will  be  considered  in  the  chapter  on  Difficult  Dentition. 


CHAPTER   III. 

PECULIARITIES  OF  DISEASE  IN  CHILDREN. 

In  many  particulars  disease  in  children  differs  from  that  of  later  life. 
These  differences  relate  to  etiology,  pathology,  symptomatology,  diagno- 
sis, and  prognosis.  The  greatest  contrast  to  adult  life  is  presented  by  in- 
fancy and  early  childhood.  After  seven  years,  children  in  their  diseases 
resemble  adults  more  than  they  do  infants. 

ETIOLOGY. 

1.  Inheritance  is  an  important  factor.  The  disease  most  frequently 
transmitted  directly  is  syphilis.  Occasionally  tuberculosis  and  other  in- 
fectious diseases  have  been  conveyed  directly  from  the  mother  to  the 
child.  In  cases  where  no  distinct  disease  is  transmitted,  children  may 
inherit  from  parents  constitutional  tendencies,  or  a  diathesis  which  may 
manifest  itself  in  infancy,  or  in  some  cases  not  until  later  childhood. 
Under  this  head  we  may  place  the  influence  of  rheumatism,  gout,  the 
various  neuroses,  and  possibly  alcoholism  and  insanity.  In  consequence 
of  these  conditions  in  parents,  the  child  may  inherit  no  definite  disease, 
but  simply  a  vitiated  constitution. 

2.  Malformations  must  be  considered,  particularly  in  the  first  two 
years  of  life.  The  most  important  of  these,  from  a  medical  standpoint, 
are  those  of  the  heart,  brain,  and  kidney.  The  various  malformations  of 
the  mouth,  nose,  bladder,  rectum,  and  genital  organs  belong  more  particu- 
larly to  the  domain  of  surgery. 

3.  The  Diseases  or  Accidents  Connected  with  Birth. — Some  of  these  are 
distinctly  traumatic,  like  the  meningeal  hemorrhages.  A  very  large  class 
are  the  infectious  processes  in  the  newly  born.  Infection  usually  takes 
place  through  the  umbilical  wound,  more  rarely  through  the  skin  or 
mucous  membranes.  This  class  includes  pyaemia,  with  its  varied  lesions 
in  the  brain,  lungs,  and  serous  membranes,  erysipelas,  ophthalmia,  and 
tetanus.  In  the  class  of  infectious  diseases  may  also  be  included  many  of 
the  varieties  of  pulmonary  and  intestinal  diseases  in  the  newly  born,  and 
probably  also  some  of  t'no  hcvmnrrhagic  affections. 

4.  Conditions  Interfering  with  Proper  Growth  and  Development. — 
These  are  among  the  largest  etiological  factors  in  the  diseases  of  infancy. 
They  are  improper  food  or  feeding,  unhygienic  surroundings,  and  neglect. 

30 

{ 


SYMPTOMATOLOGY  AND   DIAGNOSIS.  31 

These  may  cause  specific  diseases,  like  rickets  or  scurvy,  or  may  lead  to  a 
condition  of  general  malnutrition  or  marasmus.  In  this  way  they  become 
most  important  predisposing  factors,  in  infancy,  to  the  acute  diseases  of 
the  gastro-enteric  tract,  and  later  in  childhood,  to  functional  nervous  dis- 
eases. 

5.  Infection.— This  has  already  been  mentioned  as  an  important  factor 
in  diseases  of  the  newly  born.  The  number  of  diseases  in  later  life  di- 
rectly traceable  to  this  is  very  large,  and  is  constantly  increasing.  Under 
this  head  should  be  included  not  only  the  well-known  classes  of  infectious 
and  contagious  diseases,  but  filso  a  very  large  number  of  varieties  of  infec- 
tion which  as  yet  have  not  been  differentiated,  and  the  nature  of  which 
is  but  imperfectly  understood. 

SYMPTOMATOLOGY   AND  DIAGNOSIS. 

In  older  children  the  symptoms  of  disease  are  very  much  the  same  as 
in  adults,  and  similar  methods  of  examination  may  be  employed.  What 
is  really  peculiar  to  children  belongs  especially  to  the  first  three  years  of 
life,  before  speech  has  developed.  During  this  period  the  chief  and  al- 
most the  sole  reliance  of  the  physician  must  be  upon  the  objective  signs 
of  the  disease.  It  is  not  so  much  that  diseases  in  early  life  are  peculiar, 
as  that  the  patients  themselves  are  peculiar. 

Two  fundamental  facts  are  always  to  be  kept  in  mind  :  First,  that  the 
common  pathological  processes  are  comparatively  few,  being  chiefly  of 
the  gastro-enteric  tract,  the  lungs,  and  the  brain,  but  that  the  variations 
in  clinical  types  are  almost  endless ;  the  second  is,  that  in  infants,  on 
account  of  the  susceptibility  of  the  nervous  system,  functional  derange- 
ments are  often  accompanied  by  very  grave  symptoms,  and  may  even 
prove  fatal  in  twelve  or  twenty-four  hours,  or  there  may  be  speedy  and 
complete  recovery  after  very  alarming  symptoms.  In  many  of  these 
cases  the  symptoms  are  so  indefinite  that  an  exact  diagnosis  is  impossible 
during  life,  and  even  the  autopsy  may  throw  but  little  light  upon  them. 

At  the  bedside,  it  is  of  great  assistance  to  the  physician  if  he  can  keep 
in  mind  the  most  frequent  forms  of  acute  disease  that  are  likely  to  be 
met  with.  In  the  first  group,  including  those  which  are  very  common, 
may  be  placed  acute  indigestion  and  ileo-colitis,  bronchitis,  pneumonia, 
pharyngitis,  and  tonsilitis;  in  the  second  group,  including  those  which 
are  not  quite  so  common,  may  be  placed  otitis  and  the  acute  infectious 
diseases — measles,  scarlet  fever,  diphtheria,  influenza,  and  malaria ;  in  the 
third  group,  including  the  rarer  forms  of  acute  disease — meningitis, 
tuberculosis,  rheumatism,  and  diseases  of  the  kidneys.  Under  all  circum- 
stances, the  season,  and  the  nature  of  the  prevailing  epidemic,  if  one 
exists,  are  to  be  considered. 

In  the  examination  of  a  sick  infant  quite  a  different  method  is  to  be 
followed  from  that  pursued  in  adults.  Much  information  is  to  be  gained 
4 


32  PECULIARITIES  OF   DISEASE   IN   CHILDREN". 

from  a  history  carefully  taken  from  an  intelligent  mother  or  nurse,  and 
much  more  from  a  close  observation  of  the  child,  whether  asleep  or 
awake,  quiet  or  crying. 

The  History. — The  points  to  be  most  carefully  investigated  will  vary 
somewhat  with  the  nature  of  the  illness.  If  the  disturbance  is  one  of 
nutrition,  the  minutest  details  relating  to  the  character  and  preparation 
of  the  food  from  birth  up  to  the  present  illness  must  be  considered ;  also 
the  progress  of  dentition,  and  whether  this  has  been  easy  or  difficult.  All 
facts  relating  to  the  child's  growth  and  development  are  significant — the 
period  when  it  was  able  to  sit  alone,  stand  and  walk,  and  its  weight. 
Every  previous  illness  should  be  investigated  as  to  its  nature,  duration, 
and  severity,  especially  the  eruptive  fevers,  the  diseases  of  the  lungs 
and  the  digestive  tract.  All  the  facts  relating  to  the  present  illness 
should  then  be  brought  out — the  exact  time  and  mode  of  onset,  the 
presence  or  absence  of  fever,  the  amount  of  food  taken,  the  existence  of 
cough  or  hoarseness,  the  evidences  of  pain,  such  as  restlessness  or  scream- 
ing, the  character  of  the  sleep,  the  condition  of  the  bowels,  the  amount 
of  urine  passed,  and  the  frequency  of  micturition.  In  every  case  the  phy- 
sician should  inspect  for  himself  the  child's  napkins,  and  never  trust  to 
the  statements  of  the  mother  or  nurse  with  regard  to  the  character  of  the 
fgecal  discharges  or  the  urine.  The  question  of  exposure  to  any  conta- 
gious disease  should  also  be  considered. 

In  chronic  diseases  it  is  of  special  importance  to  investigate  the  sub- 
ject of  heredity,  from  manifestations  of  disease  both  in  the  parents  and  in 
other  children  of  the  family.  This  is  most  important  with  reference  to 
syphilis  and  tuberculosis.  The  character  of  the  labour  should  be  in- 
quired into,  whether  it  Avas  difficult,  prolonged,  or  instrumental. 

Inspection. — What  is  learned  by  the  inspection  of  a  sick  child  will 
depend  almost  entirely  upon  the  powers  of  observation  of  the  physician. 
One  accustomed  to  bring  out  the  patient's  symptoms  by  questions  is  de- 
decidly  at  a  loss  to  know  how  to  proceed  in  the  case  of  a  sick  infant. 
With  time,  patience  and  method  very  much  that  is  important  and  exact 
can  be  determined.  In  fact,  the  diagnosis  of  disease  in  infancy,  instead 
of  being,  as  is  often  supposed,  a  matter  of  extreme  difficulty  or  impossi- 
bility, becomes  with  experience  quite  as  easy  as  among  adults. 

In  acute  disease  when  the  child  is  asleep  or  quiet  the  following 
points  should  be  noted  : 

1.  Posture — whether  the  child  lies  upon  the  back',  the  side,  or  the 
face ;  whether  there  is  opisthotonos,  or  a  general  flexion  of  all  the  limbs. 

2.  Character  of  the  sleep — whether  it  is  quiet  and  peaceful  or  dis- 
turbed ;  whether  there  is  constant  tossing  about,  grinding  of  the  teeth, 
etc. 

3.  Respiration — whether  it  is  regular,  or  irregular.  This  can  be  deter- 
mined only  by  careful  observation  for  some  minutes.     It  should  be  noted 


INSPECTION.  30 

whether  it  is  rapid,  or  slow,  easy,  natural,  and  quiet,  or  whether  there  is 
nasal  obstruction  with  snoring  and  mouth-breathing  due  to  tonsillitis, 
diphtheria,  scarlet  fever,  or  adenoid  vegetations  of  the  pharynx.  The 
best  evidence  of  dyspnoea  is  the  recession  of  the  supraclavicular  and 
suprasternal  regions,  the  sinking  in  of  the  intercostal  spaces,  sometimes 
with  lateral  recession  of  the  chest  walls.  There  is  usually  present  active 
(lihitation  of  the  nostrils. 

4.  Pulse — whether  it  is  rapid  or  slow,  full  and  strong  or  soft  and  com- 
pressible. The  frequency  of  the  pulse  in  infancy  is  of  much  less  impor- 
tance than  the  force  and  rhythm.  A  slow,  irregular  pulse  is  always  sig- 
nificant, and  should  suggest  meningitis ;  an  irregular  pulse,  when  rapid, 
has  no  special  significance. 

5.  Ski7i — whether  it  is  dry  and  hot,  or  covered  with  perspiration.  The 
existence  of  pallor,  general  cyanosis,  or  blueness  of  the  lips  and  finger 
nails  should  be  noted ;  also  the  circulation  in  the  extremities,  whether 
they  are  warm,  or  cold  and  clammy. 

6.  Facial  exjrression — whether  this  is  calm  and  peaceful,  drawn  and 
anxious,  intelligent  or  stupid,  and  whether  the  features  are  contracted 
from  time  to  time  as  if  from  paiu. 

7.  Cough — whether  this  is  frequent,  difficult,  or  severe. 

8.  Cry :  Since  this  is  the  chief  means  by  which  the  infant  expresses 
discomfort  or  displeasure,  it  becomes  exceedingly  important  but  not  always 
easy  to  determine  whether  an  infant  cries  from  paiu,  discomfort,  hunger, 
temper,  or  from  habit.  In  very  many  instances  the  cry  under  these  con- 
ditions is  so  characteristic  that  one  who  is  familiar  with  the  child's 
language  readily  divines  what  is  wrong.  It  is  something  which  should 
never  be  disregarded,  even  though  it  may  be  the  only  obvious  symptom. 
Tears  are  not  seen  until  the  second  month,  so  that  their  absence  before 
that  time  is  not  to  be  taken  as  an  evidence  that  the  cry  is  not  from  pain. 

The  cry  of  hunger  is  apt  to  be  interrupted  by  vigorous  sucking  of  the 
fingers.  It  is  not  usually  sharp  and  piercing,  like  the  cry  of  pain,  but  it 
is  a  worrying,  fretful  cry.  It  ceases  immediately  when  the  hunger  has 
been  satisfied. 

The  cry  of  indigestion  is  often  mistaken  for  that  of  hunger,  but  in 
such  cases,  although  crying  may  cease  for  a  few  minutes  after  taking  food, 
from  the  temporary  relief  which  this  gives,  it  is  likely  soon  to  return  with 
unabated  vigour.  Under  such  circumstances  a  frequent  repetition  of 
feeding  or  nursing  should  never  be  allowed,  although  very  often  this  is 
just  what  is  done. 

The  character  of  the  cry  of  pain  will  depend  somewhat  upon  the  se- 
verity of  the  pain.  "When  it  is  acute  like  that  of  colic  or  earache,  it  may 
be  sharp  and  piercing,  and  accompanied  by  contraction  of  the  features, 
drawing  up  of  the  legs,  and  other  evident  signs  of  distress.  The  child 
falls  asleep  only  when  exhausted,  and  soon  wakes,  often  with  a  scream.     In 


34  PECULIARITIES   OF   DISEASE   IN  CHILDREN. 

pain  of  less  seventy  there  is  usually  moaning,  but  rarely  a  sharp  cry.  In- 
fants cry  not  only  from  pain  but  from  every  sort  of  discomfort — wet 
diapers,  cold  feet,  a  cramped  position,  uncomfortable  clothing,  also  if  they 
are  tired  or  sleepy,  and  from  a  great  many  other  minor  causes.  The  more 
delicate  a  child  the  more  readily  it  cries  from  any  cause. 

The  cry  of  weakness  and  exhaustion  is  quite  characteristic.  It  may  be 
noticed  in  a  great  variety  of  conditions.  It  is  usually  a  low,  feeble  whine 
or  moan,  often  nearly  constant,  except  when  the  child  is  asleep. 

The  cry  of  temper  is  not  generally  heard  befo"pe  the  fifth  month.  It 
is  usually  accompanied  by  stiffening  of  the  body,  throwing  back  of  the 
head,  and  sometimes  by  vigorous  kicking.  It  is  loud,  violent,  and  often 
prolonged. 

The  cry  of  habit  is  one  of  the  most  difficult  to  recognise.  These  habits 
are  formed  by  indulging  infants  in  various  ways.  Some  children  cry  to 
be  held,  some  to  be  carried,  some  to  be  rocked,  some  for  a  light  in  the 
nursery,  some  for  a  rubber  nipple  or  some  other  thing  to  suck.  The 
extent  to  which  this  kind  of  crying  may  be  indulged  in,  even  by  very 
young  infants,  is  surprising,  and  it  explains  much  of  the  crying  of  early 
childhood.*  The  fact  that  the  cry  ceases  immediately  when  the  child 
gets  what  it  wants  is  diagnostic  of  the  cry  from  habit.  The  only  success- 
ful treatment  of  such  cases  is  to  allow  the  child  to  "  cry  it  out "  once  or 
twice,  and  then  the  habit  is  broken.  Of  course,  before  such  a  procedure 
is  allowed  to  go  on,  one  must  be  well  assured  that  the  cry  is  from  this 
cause  and  no  other. 

There  are  some  diseases  in  which  the  cry  is  sufficiently  characteristic 
to  be  of  diagnostic  importance.  Thus  we  hear  the  short,  catchy,  sup- 
pressed cry  of  pneumonia,  the  sharp  nocturnal  cry  of  tuberculous  menin- 
gitis and  of  chronic  bone  disease,  the  moan  of  chronic  indigestion  and 
acute  intestinal  diseases,  the  hoarse  nasal  cry  of  hereditai-y  syphilis,  and 
the  feeble  whine  of  marasmus  and  of  atelectasis. 

9.  The  mental  condition  may  be  one  of  undue  excitement,  and  it  may 
be  difficult  to  tell  whether  this  is  from  fright  at  the  approach  of  a  stranger 

*  On  admission  to  the  Babies'  Hospital  very  young  infants  almost  Invariably  cry  a 
great  deal  for  the  first  two  days.  It  being  against  the  rules  to  take  such  children  from 
their  cribs  and  hold  them  to  quiet  their  crying,  they  soon  cease  the  habit,  and  give  no 
further  trouble,  crying  subsequently  only  from  the  usual  causes. 

Dr.  J.  S.  Thacher  relates  an  experience  which  illustrates  to  what  extent  this  habit 
may  be  formed  in  infants  of  only  a  few  weeks.  In  a  hospital  ward  under  his  care, 
containing  fifteen  or  twenty  mothers  and  newly-born  infants,  one  of  the  women  was 
seriously  ill,  and  was  so  annoyed  by  the  crying  of  the  infants  that  they  were  allowed  to 
be  taken  from  their  cribs  and  held  or  carried  as  soon  as  crying  from  any  cause  began. 
After  several  days  the  patient  was  removed  from  the  ward,  and  for  the  next  two  or 
three  days  the  crying  in  the  ward  was  enough  to  drive  one  distracted  ;  but  the  mothers 
were  forbidden  to  quiet  the  infants  by  taking  them  up,  and  after  two  or  three  days' 
discipline  the  crying  ceased  and  peace  and  order  were  again  restored. 


THE    PHYSICAL   EXAxMINATION.  35 

or  from  disease.  More  significant  is  a  condition  of  apathy  and  dulness 
and  general  relaxation  in  which  no  resistance  whatever  is  made  to  the  ex- 
amination. Such  symptoms  always  indicate  either  extreme  prostration 
or  brain  disease.  A  child  may  cry  from  pain  or  from  fright.  General 
hypersesthesia  is  common  in  meningitis.  Soreness  of  the  legs  only,  sug- 
gests scurvy,  rheumatism,  or  joint  disease. 

10.  The  condition  of  the  pupils  should  be  observed,  whether  con- 
tracted or  dilated,  and  the  nature  of  the  response  to  light ;  also  the  pres- 
ence of  corneal  ulcers  and  the  interstitial  keratitis  so  frequent  in  heredi- 
tary syphilis.  The  thin  mucous  film  seen  over  the  cornea  always  indicates 
grave  prostration,  and  often  approaching  death. 

11.  The  lymph  glands  of  the  neck  should  be  noted:  as  when  swollen 
they  may  indicate  scarlet  fever,  diphtheria,  or  simple  acute  inflammation. 

12.  The  presence  or  absence  of  7iasal  discharge  should  be  determined, 
and  also,  if  possible,  its  character.  In  acute  disease  this  suggests  diph- 
theria, scarlet  fever,  or  influenza;  if  it  is  chronic,  adenoid  growths  of 
the  pharynx,  or  syphilis. 

13.  The  appearance  of  the  mucous  memlrane  of  the  mouth,  teeth,  and 
gums  may  often  be  ascertained  by  watching  the  child  while  it  is  crying. 
It  should  be  noted  whether  the  tongue  is  dry  or  moist,  also  whether  thrush 
is  present,  or  any  other  form  of  stomatitis.  The  condition  of  the  gums 
may  be  observed,  whether  congested  or  swollen  or  haemorrhagic  as  in 
scurvy,  and  also  the  number,  position,  and  character  of  the  teeth.  The 
general  colour  of  the  mucous  membrane  may  be  significant,  as-  in  cases  of 
cyanosis. 

Very  much  can  be  learned  in  acute  illness  by  simply  watching  atten- 
tively a  sick  child  for  a  few  minutes,  studying  the  foregoing  points  in 
order.  By  such  observation  and  a  carefully  obtained  history  of  the  ill- 
ness an  experienced  physician  can  often  make  a  very  probable  diag- 
nosis without  further  examination  ;  the  latter,  however,  should  never  be 
omitted. 

The  Physical  Examination. —  Temperature.  The  first  step  should  gen- 
erally be  to  ascertain  whether  or  not  there  is  fever.  For  this  one  should 
never  fall  into  the  habit  of  trusting  to  his  sense  of  touch,  for  it  is  often 
very  misleading.  Only  the  rectal  temperature  in  infants  is  to  be  de- 
pended upon,  since  axillary  temperatures  are  untrustworthy,  and  those  in 
the  mouth  difficult  to  obtain. 

Immediately  after  birth  the  temperature  of  the  child  is  about  the  same 
as  that  of  the  mother,  or  a  little  higher.  It  falls  from  1°  to  3°  F.  in  the 
course  of  the  first  few  hours,  under  the  influence  of  the  bath  and  radiation 
from  the  skin  during  dressing.  Very  soon  it  again  rises  to  98-5°  or  99°  F., 
near  which  point,  under  normal  conditions,  it  remains  during  the  first 
months  of  life,  and  in  fact  throughout  childhood. 

From  a  large  number  of  personal  observations  upon  healthy  infants  I 


36  PECULIARITIES   OF   DISEASE   IN   CHILDREN. 

have  found  the  rectal  temperature  to  vary,  under  normal  conditions, 
between  98°  and  99-5°  F.  Within  these  limits  the  temperature  may  be 
considered  normal.  The  heat-regulating  center  in  the  brain  acts  only 
imperfectly  in  the  young  infant,  and  very  slight  causes  are  enough  to  dis- 
turb the  temperature.  When  the  heat  equilibrium  has  once  been  dis- 
turbed, slight  fluctuations  may  continue  for  some  time  after  the  cause  has 
been  removed. 

The  temperature  in  infants  is  always  higher  than  from  corresponding 
causes  in  adults.  Moreover,  very  high  temperatures  may  be  met  with  in 
cases  not  at  all  serious,  and  not  infrequently  when  no  explanation  can  be 
found  even  after  the  most  thorough  examination.  In  such  cases  the  tem- 
perature very  often  does  not  remain  at  a  high  i^oiut  for  more  than  a  few 
hours.  It  is  a  continuous  high  temperature  rather  than  a  single  rise 
which  is  significant  of  disease  in  infancy.  Notliing  is  more  perplexing  to 
the  young  practitioner  than  the  frequency  with  which  a  high  tempera- 
ture is  seen  in  infants  in  cases  of  comparatively  mild  illness.  While  a 
valuable  guide  in  diagnosis,  the  temperature  alone  must  not  be  depended 
upon  in  early  life,  nor  should  its  significance  be  measured  by  the  adult 
standards. 

It  is  very  common  in  chronic  wasting  diseases,  in  delicate  infants  and 
in  those  prematurely  born,  to  find  the  temperature  one  or  two  degrees 
below  the  normal ;  95°  and  9G°  F.  are  of  almost  daily  occurrence  in  hos- 
pitals. In  one  premature  infant  the  temperature  on  admission  was  93° 
F.  The  feeble  heat-producing  power  of  these  infants,  and  the  rapid  ra- 
diation from  their  bodies  because  of  the  absence  of  subcutaneous  fat,  make 
the  temperature  a  very  important  matter  in  their  nutrition.  Daily  ob- 
servations should  be  made  with  the  thermometer,  just  as  in  cases  of  high 
temperature. 

Some  of  the  most  puzzling  elevations  of  temperature  met  with  in  in- 
fancy are  the  result  of  the  application  of  artificial  heat.  Eross  has  shown 
by  very  careful  experiments  that  the  body  temperature  can  be  raised  by 
means  of  hot  bottles  or  water  bags  from  1°  to  5°  F.  This  is  accomplished 
much  more  readily  in  the  case  of  feeble  or  delicate  infants  than  in  those 
who  are  stronger.  The  truth  of  his  observations  I  have  had  abundant 
opportunity  to  verify  in  my  own  experience.  This  cause  must  be  care- 
fully eliminated  in  cases  where  unusually  high  temperatures  apj)ear  after 
surgical  operations  or  unexpectedly  under  other  conditions. 

For  the  purpose  of  making  a  S3"stematic  routine  examination  of  the 
entire  body,  the  child's  clothing,  with  the  exception  of  the  napkin,  should 
be  removed,  and  the  child  laid  upon  the  nurse's  laja  on  a  blanket.  The 
skin  may  now  be  inspected  for  eruptions,  and  it  is  important  that  the 
entire  body  be  examined.  Next  the  general  nutrition  of  the  patient 
should  be  observed — whether  it  is  emaciated  or  well  nourished. 

The  head  should  be  examined  to  see  whether  the  sutures  are  ossified 


THE   PHYSICAL  EXAMINATION.  37 

or  unnaturally  open  ;  whether  the  fontanel  has  closed,  or,  if  open,  whether 
it  is  depressed  or  bulging. 

The  details  regarding  physical  examination  of  the  lungs  are  discussed 
in  the  introductory  chapter  of  the  section  devoted  to  pulmonary  diseases. 

In  the  auscultation  of  the  hearty  it  should  be  remembered  that  under 
two  years  of  age  loud  murmurs  are  almost  invariably  of  congenital  ori- 
gin, that  soft  murmurs  are  frequently  functional,  and  that  acquired  or- 
ganic heart  disease  is  extremely  rare  until  after  the  third  year. 

In  the  examination  of  the  abdomen  there  should  be  noted  the  pres- 
ence or  absence  of  tympanites  or  abdominal  tenderness,  whether  general 
or  localized,  and  the  existence  of  retraction  of  the  abdominal  walls  as  in 
meningitis.  The  size  and  position  of  the  liver  and  spleen  are  best  de- 
termined by  palpation.  The  lower  border  of  the  liver  is  usually  slightly 
below  the  free  border  of  the  ribs.  If  the  spleen  can  be  easily  felt  below 
the  ribs,  it  is  as  a  rule  enlarged.  If  it  can  not  be  felt  in  a  satisfactory  ex- 
amination, it  is  not  sufficiently  enlarged  to  be  of  any  diagnostic  impor- 
tance. It  should  be  remembered  that  both  liver  and  spleen  may  be  dis- 
placed downward  in  rickets  from  contraction  of  the  chest,  giving  the 
appearance  of  slight  enlargement  when  they  are  normal  in  size.  In  acute 
disease  a  large, spleen  suggests .  malaria,  t3'phoid,  or  tuberculosis;  in 
chronic  disease,  malaria,  syphilis,  leucoemia,  or  ansemia. 

Examination  of  the  tirijie  should  not  be  forgotten.  The  staining  of 
the  napkin  may  give  information  regarding  the  discharge  of  crystalline 
uric  acid  or  of  concentrated  urine.  For  other  purposes  the  urine  must  be 
collected.  This  is  often  difficult.  The  most  satisfactory  method  I  have 
found  is,  in  male  infants,  to  tie  a  condom  over  the  penis;  in  female  in- 
fants, to  put  a  small  cup  over  the  vulva  inside  the  napkin.  In  those  who 
are  a  year  old  the  urine  may  readily  be  collected  by  putting  the  child 
upon  the  chamber  every  few  minutes.  It  is  important  not  to  overlook 
phimosis  or  balanitis  in  the  male  or  vulvo-vaginitis  in  the  female,  since 
these  conditions  may  not  only  give  rise  to  local  but  even  to  general 
symptoms. 

A  careful  inspection  of  the  throat  should  never  be  omitted  in  any 
acute  illness,  no  matter  what  the  other  symptoms  are ;  but  usually  this 
had  better  be  deferred  until  tiie  last.  For  this  are  required  a  good  light 
and  a  quick  glance.  Upon  the  hard  palate  one  may  look  for  the  first 
signs  of  the  eruption  in  measles  and  scarlet  fever,  and  the  condition  of 
the  throat  may  be  the  first  and  one  of  the  most  important  signs  of  both 
the  diseases.  Diphtheria  may  exist  without  pseudo-membrane,  and 
marked  general  redness  may  be  due  to  scarlet  fever,  influenza,  or  simple 
pharyngitis. 

In  chronic  disease  a  somewhat  different  method  of  examination  may 
be  followed.  The  most  important  diseases  because  most  often  met  with 
in  infancy  are,  in  the  first  place,  those  which  are  connected  with  nutri- 


38  PECULIARITIES   OF   DISEASE   IN  CHILDREN. 

tion,  chronic  disturbances  of  the  gastro-enteric  tract,  rickets,  and  scurvy; 
secondly,  syphilis,  tuberculosis,  chronic  diseases  of  the  lungs,  diseases  of 
the  blood,  the  bones,  the  kidney,  and  the  heart. 

In  the  examination,  the  general  development  of  the  child  should  be 
considered.  Its  height,  weight,  circumference  of  head,  chest,  and  ab- 
domen should  be  taken  and  these  compared  with  the  average  for  the 
child's  age.  The  condition  of  the  tissues  should  be  noted,  whether  firm, 
soft,  or  flabby ;  the  ligaments,  whether  relaxed  or  not ;  the  presence  of 
bony  deformities ;  also  the  existence  of  pallor,  cyanosis,  and  cachexia,  and 
the  general  nutrition.  It  should  then  be  determined  whether  the  child 
has  for  its  age  a  suflRcient  muscular  development,  as  shown  by  sitting, 
standing  or  walking.  Its  speech,  hearing,  sight,  general  intelligence  and, 
finally,  its  mental  disposition  should  be  investigated. 

In  the  local  examination  special  attention  should  be  given  to  the  shape 
of  the  skull,  the  condition  of  the  sutures,  the  size  and  shape  of  the  fon- 
tanel, and  the  progress  of  dentition.  It  should  be  noted  whether  there 
are  glandular  swellings  in  the  neck  or  in  different  parts  of  the  body ;  also 
hypertrophied  tonsils  or  adenoids.  Finally,  there  should  follow  a  thor- 
ough examination  of  the  heart,  lungs,  liver,  spleen,  blood,  urine,  bones, 
spine,  and  joints.  The  same  order  need  not  be  followed  in  every  case, 
but  the  examination  should  always  be  thorough,  and  with  the  body 
stripped.  Unless  this  is  done,  serious  deformities  are  often  entirely  over- 
looked, and  an  erroneous  diagnosis  made. 

In  children  who  are  old  enough  to  answer  questions  the  same  method 
may  be  pursued  as  in  an  adult  examination.  An  important  thing  in 
dealing  with  children  is  a  gradual  approach,  first  winning  the  confidence 
of  the  child  and  diverting  its  attention  from  the  real  purpose  in  view ) 
secondly,  the  avoidance  of  every  rough  examination  which  might  by  any 
chance  produce  pain ;  and,  finally,  deferring  until  the  end  of  the  ex- 
amination the  inspection  of  the  throat,  which  must  frequently  be  done 
forcibly,  and  is  sure  to  interrupt  any  further  chance  of  intimacy.  With 
time  and  patience  almost  everything  mentioned  in  the  above  category 
can  be  satisfactorily  investigated. 

PATHOLOGY. 

The  pathological  processes  which  result  from  intra-uterine  disease  and 
those  which  are  connected  with  delivery  are  peculiar  to  early  life.  They 
have  already  been  referred  to  in  the  section  on  etiology.  Of  the  processes 
of  early  life  which  begin  after  birth,  the  first  in  frequency  are  those  of 
the  mucous  membranes  resulting  from  the  various  forms  of  infection. 
In  summer,  it  is  the  stomach  and  intestines  which  suffer  chiefly ;  in 
winter,  the  respiratory  tract. 

The  serous  membranes  are  rarely  the  seat  of  primary  inflammation. 
The  pleura  is   seldom  the  seat   of  primary  disease,  but  very  often    in- 


PATHOLOaY.  39 

volved  secondarily  to  disease  of  the  lung  itself.  Affections  of  the  peri- 
cardium and  peritonaiuin  are  quite  rare.  Meningitis  is  fairly  common 
both  Id  the  simple  and  the  tuberculous  form. 

Diseases  of  the  lymph  nodes  (lymphatic  glands)  play  an  important 
part  in  connection  with  the  acute  diseases  of  the  mucous  membranes,  with 
many  affections  of  the  skin  and  even  of  the  viscera.  Acute  infection  tends 
to  excite  suppurative  inflammation,  particularly  in  infants ;  a  less  active 
process  leads  to  chronic  hyperplasia  in  the  mesenteric,  mediastinal,  and 
cervical  glands,  in  the  tonsils,  adenoid  tissue  of  the  pharynx,  etc.  The 
lymph  nodes  in  the  neck  and  thorax  are  frequently  the  earliest  seat  of 
tuberculous  deposits,  and  in  very  many  cases  they  are  the  foci  from  which 
secondary  infection  of  the  lungs,  brain,  or  joints  may  occur. 

Of  the  visceral  inflammations  *  those  of  the  lungs  are  the  most  com- 

*  The  following  table  gives  in  a  general  way  a  very  good  idea  of  the  relative  fre- 
quency of  diseases  of  the  different  organs  in  infancy.  It  is  based  upon  seven  hundred 
and  twenty-six  consecutive  autopsies  in  the  New  York  Infant  Asylum,  extending  over 
a  period  of  eight  years  during  my  connection  with  that  institution.  More  than  one  half 
of  the  autopsies  I  made  personally.  Of  these  children  seventy-two  per  cent  were 
under  one  year,  twenty-five  per  cent  between  one  and  two  years,  and  only  three  per 
cent  were  over  two  years.  The  institution  does  not  receive  infants  under  one  month, 
hence  the  absence  of  lesions  peculiar  to  the  newly  born : 

Table  showing  principal  lesions  in  seven  hundred  and  twenty-six 
consecutive  autopsies  in  the  New  York  Infant  Asylum. 
Lungs : 

Pneumonia — Primary 1,39 

Complicating  other  acute  infectious  diseases 112 

Complicating  other  conditions 71 

Noted  to  be  present  in 322 

Pleurisy —      No  case  uncomplicated  with  disease  of  lungs. 

Empyema 5 

Serous  pleurisy 1 

Dry  pleurisy  in  nearly  all  the  severe  cases  of  pneu- 
monia. 

Atelectasis  (congenital) 6 

Pulmonary  abscess  (always  with  pneumonia) 7 

Pulmonary  gangrene  (always  with  pneumonia) 2 

Pulmonary  tuberculosis 5G 

Mouth : 

Noma 1 

Peritoncpum  : 

Acute  peritonitis  (localized  2,  with  acute  pneumonia  and  pleurisy  2)..       4 
Kidneys : 

Acute  nephritis  (complicating  scarlet  fever  4,  diphtheria  l.inieumouia 
4,  measles  1,  pertussis  1,  ileo-colitis  2,  pyonephrosis  1,  apparently 

primary  .5) 19 

Malformations  of  the  kidnev 7 


40  PECULIARITIES   OF  DISEASE   IN   CHILDREN. 

mon,  it  being  rare  to  find  the  lungs  normal  at  autopsy  after  any  acute 
infectious  disease  which  has  lasted  a  week.  Up  to  the  third  or  fourth 
year  of  life  the  heart  usually  escapes.  In  older  children  it  may  be 
involved,  as  in  adults,  in  the  rheumatic  diseases.  The  liver  and  spleen 
are  not  often  the  seat  of  organic  disease  in  early  life,  nor  is  serious  disease 
of  the  kidney  likely  to  be  met  with  excepting  in  connection  with  scarlet 
fever.  Organic  disease  of  the  brain  itself  is  rare,  as  is  also  organic  dis- 
ease of  the  spinal  cord,  with  the  exception  of  poliomyelitis.  Chronic  dis- 
eases of  the  different  viscera  are  decidedly  rare,  except  when  resulting 
from  acute  processes.  Diseases  of  the  bones  and  joints  are  common,  and 
of  extreme  importance.  They  are  usually  of  tuberculous,  less  frequently  of 
syphilitic,  origin.  Diseases  of  the  blood  are  quite  common,  but  as  yet 
but  little  understood.  New  growths  are  rare.  The  parts  most  frequently 
the  seat  are  the  kidney  and  the  bones.  Disorders  of  nutrition  are  ex- 
tremely common  and  of  great  importance,  particularly  rickets  and  scurvy. 

PROGNOSIS  AND  INFANT  MORTALITY. 

The  younger  the  patient  the  worse  the  prognosis  in  all  the  diseases  of 
childhood.  This  is  in  consequence  of  the  feeble  resistance  of  the  infan- 
tile organism  to  all  diseases,  particularly  those  which  are  of  an  acute 
nature.  On  the  other  hand,  the  rapid  metabolism  of  childhood  makes 
it  possible  for  many  conditions  of  an  organic  nature  to  disappear  with 
time,  or,  as  the  phrase  is,  to  be  "  outgrown,"  provided  the  patient  can 
be  so  placed  that  the  general  nutrition  can  be  carried  to  the  highest 
point. 

The  accompanying  chart  (Plate  I)  shows  the  mortality  of  New  York 
city    by    months  during  the  three  years  from    1890    to    1893,  inclusive, 

Stomach  and  Intestines : 

Acute  ileo-colitis,  with  or  without  gastritis   116 

Acute  gastritis  (without  intestinal  lesions) None 

Acute  diarrhoeal  disease  (without  gross  lesions) 72 

Intussusception 1 

Heart  : 

Pericarditis  (all  with  acute  pneumonia) 3 

Congenital  malformations 3 

Acute  or  chronic  endocarditis None 

Brain  : 

Acute,  simple,  or  purulent  meningitis  (7  with  pneumonia,  2  cerebro- 
spinal)    14 

Tuberculous  meningitis 11 

Acute  encephalitis 1 

Chronic  pachymeningitis 5 

Chronic  simple  meningitis 1 

Chronic  hydrocephalus 3 

There  were  twenty-six  deaths  from  marasmus  without  gross  lesions. 


PLATE    r. 


■ 

I 

DHILOREN   under    1    VEAR 
"            1    TO  2  YEARS. 
"            2  TO  5  YEARS 

5  TO   15  YEARS. 

Over   15  years. 

U                        I 

Jan. 

Feb. 

Mar. 

APR. 

May 

June 

July 

Aug. 

Sept. 

Oct. 

Nov. 

Dec. 

Chart  showing  by  months  the  mortality  of  New  YorK  city  for  the  different  ages 
for  three  years.     (Scale,  1  in.  =  2,200  deaths.) 


THE  MOST  FREQUENT  CAUSES  OF  DEATH.         41 

representing  a  total  mortality  of  128, 13G.     This  is  distributed  among  the 
different  ages  as  follows  : 

Under  1  year 33,916  =  20  per  cent. 

1  to    2  years 10,r)47  =  8       " 

2  to    T)      "      9,794  =       7       " 

5  to  15      " 5,470  =       5 

Over  15    "      '. 69,409  =  54 

128,136 

Thus  over  one  fourth  of  all  the  deaths  occurred  during  the  first  year 
of  life,  and  over  one  tliird  in  the  first  two  years.  The  graphic  chart 
gives  a  better  idea  of  this  than  the  figures.  It  will  be  noticed  that  the 
only  age  in  which  the  mortality  is  much  increased  in  the  summer  months 
is  in  the  first  year. 

According  to  Eross,  who  collected  statistics  from  sixteen  cities  of  con- 
tinental Europe,  of  1,4.39,056  infants  born,  there  died  in  the  first  four 
weeks  of  life  130,010,  or  nearly  ten  per  cent. 

The  Most  Frequent  Causes  of  Death  at  the  Different  Periods  of  Child- 
hood.— According  to  Eross,  of  94,400  deaths  occurring  during  the  first 
four  weeks,  fifty-six  per  cent  were  due  to  congenital  debility.  The  other 
causes  which  raise  the  mortality  in  this  period  are  asphyxia,  infection, 
congenital  malformations  of  the  heart,  intestine,  or  genito-urinary  tract, 
haemorrhages,  convulsions,  acute  attacks  of  diarrha>al  diseases,  and  pneu- 
monia. Pneumonia  is  exceedingly  common  in  very  young  infants,  both  as 
a  primary  and  secondary  lesion. 

Statistics  from  America  and  Europe  show  that  in  all  large  cities  infant 
mortality  has  been  steadily  increasing  for  the  past  twenty-five  years. 
This  is  due  to  many  causes — Overcrowding,  neglect,  and  unhygienic  sur- 
roundings. But  more  important  than  all  is  artificial  feeding  as  at  pres- 
ent ignorantly  practised.  In  my  experience  it  is  exceedingly  rare  to  find 
a  healthy  child  who  has  been  reared  in  a  tenement  house,  and  who  has 
been  artificially  fed  from  birth.  "While  among  the  poor  the  capacity  for 
maternal  nursing  seems  to  be  diminishing  year  by  year,  among  the  better 
classes  it  has  come  to  be  the  exception  and  not  the  rule.  In  my  private 
practice  not  one  third  of  the  mothers  have  been  able,  even  though  willing, 
to  nurse  their  infants.  But  as  ignorant  and  improper  feeding  are  not  con- 
fined to  the  poor,  we  find  among  rich  and  poor  alike  the  largest  number 
of  deaths  in  the  first  year  due  to  disease  of  the  gastro-enteric  tract  and 
marasmus,  cither  alone  or  associated.  In  the  second  rank  come  acute 
diseases  of  the  respiratory  tract,  especially  acute  broncho-pneumonia. 
All  other  causes  of  mortality  fall  far  below  these  two.  Of  the  nervous 
diseases,  convulsions  and  tuberculous  meningitis  are  the  only  ones  that 
are  common.  Of  the  acute  infectious  diseases  pertussis  takes  the  first  place, 
with  measles  second,  while  tuberculosis  ranks  first  of  the  chronic  infec- 


42  PECULIARITIES  OF  DISEASE  IN  CHILDREN. 

tious.  Although  rarely  the  cause  of  death,  rickets  is  a  very  important 
factor  in  increasing  the  mortality  of  other  diseases. 

During  the  second  year  the  deaths  from  marasmus  are  few.  The  dis- 
eases of  the  gastro-enteric  tract  are  still  a  large  factor  in  the  death  rate, 
but  by  no  means  to  so  great  a  degree  as  in  the  first  year  of  life.  Nearly 
if  not  quite  as  important  during  this  period  are  the  acute  diseases  of  the 
lungs  and  the  acute  infectious  diseases,  especially  measles,  diphtheria, 
and  jDcrtussis.  Deaths  from  scarlet  fever  are  much  less  numerous.  Gen- 
eral tuberculosis  and  tuberculous  meningitis  are  frequent. 

From  the  second  to  the  fifth  year  the  deaths  are  mainly  from  acute 
infectious  diseases — chiefly  diphtheria  and  scarlet  fever — much  less  fre- 
quently from  measles  or  pertussis.  In  the  next  group  come  the  acute  dis- 
eases of  the  lungs,  general  tuberculosis,  and  tuberculous  meningitis. 

From  the  fifth  to  the  fifteenth  year  the  mortality  in  childhood  is  re- 
markably small,  diphtheria  and  scarlet  fever  being  still  in  the  front  rank 
in  point  of  frequency.  Next  come  the  acute  diseases  of  the  lungs,  simple 
as  well  as  tuberculous  meningitis,  diseases  of  the  bones,  appendicitis,  rheu- 
matism, and  cardiac  disease. 

Sudden  Death. — This  is  not  a  very  uncommon  occurrence  in  infants 
who  are  apparently  healthy.  They  are  sometimes  found  dead  in  bed 
under  circumstances  in  which  grave  suspicions  may  unjustly  rest  upon 
the  attendants.  The  causes  are  often  very  puzzling.  While  sudden  death 
sometimes  occurs  in  children  who  are  apparently  in  perfect  health,  it  is 
very  much  more  frequent  in  those  who  are  delicate  or  suffering  from  mal- 
nutrition. Among  this  latter  class,  such  as  are  seen  especially  in  institu- 
tions, sudden  death  is  by  no  means  rare. 

The ,  most  frequent  causes  of  sudden  death  in  infants  are  the  fol- 
lowing : 

1.  Malformations. — While  in  most  cases,  to  be  sure,  malformations  of 
a  serious  nature  give  rise  to  symptoms,  they  may  be  absent,  or  may  be  so 
slight  as  to  be  overlooked.  Infants  may  succumb  during  the  first  few 
days  of  life  from  malformations  of  the  heart,  lungs,  kidneys,  stomach  or 
intestines,  and  sometimes  from  diaphragmatic  and  umbilical  hernia. 

3.  Internal  hceniorrhage.-^This  is  chiefly  limited  to  the  first  two 
weeks  of  life.  In  the  cases  that  have  come  to  my  notice  the  cause  has 
been  rupture  of  some  subperitoneal  haemorrhage  into  the  general  abdomi- 
nal cavity.  The  primary  haemorrhage  is  most  frequently  into  the  supra- 
renal capsiile.  It  maybe  beiieath  the  capsule  of  the  liver.  Such  cases  are 
reported  in  the  chapter  upon  Visceral  Haemorrhages  in  the  Newly  Born. 
Under  these  circumstances  no  symptoms  may  exist  until  the  occurrence 
of  collapse,  with  death  in  a  few  hours. 

3.  Asj)hyxia  from  overlying. — This  is  not  very  common,  excepting 
among  the  lower  classes,  and  is  most  frequently  due  to  intoxication  on  the 
part  of  the  mother.     Such  children  after  death  present  the  usual  lesions 


SUDDEN  DEATH.  43 

of  death  from  asphyxia,  but  without  any  evidence  of  violence.  This  form 
of  asphyxia  is  most  frequently  seen  in  infants  a  few  weeks  old.  A  recent 
writer  in  the  British  Medical  Journal  states  that  one  thousand  infants 
die  every  year  from  this  cause  in  the  city  of  London  alone. 

4.  Asphyxia  from  aspiration  of  food  into  the  larynx  and  trachea. — 
This  may  be  due  to  vomiting  or  to  the  regurgitation  of  food  during  sleep ; 
in  a  very  weak  infant  it  may  occur  while  awake.  This  is  usually  seen  in 
infants  who  are  less  than  a  year  old,  and  most  of  the  reported  cases  have 
been  under  six  months.  Such  children  are  usually  delicate.  There  seems 
to  be  vomiting  with  an  attempt  at  crying,  during  which  the  food  is  drawn 
into  the  air  passages.  In  some  cases,  as  that  reported  by  Demme,  a  single 
large  clot  of  milk  has  been  found  in  the  larynx.  In  others,  food  is  found 
in  the  larynx,  trachea,  and  large  bronchi.  Cases  have  also  been  reported 
by  Partridge  and  Parrot,  and  I  have  myself  met  with  at  least  three.  The 
infants  have  generally  been  found  dead  in  bed  within  a  few  hours  after 
feeding.  This  accident  is  more  likely  to  happen  when  an  infant  lies 
upon  its  back. 

5.  Asphyxia  associated  with  enlargement  of  the  thymiis  gland. — I 
have  notes  of  three  such  cases.  Two  of  them  occurred  in  the  New  York 
Infant  Asylum  and  one  at  the  Nursery  and  Child's  Hospital.  The  chil- 
dren were  aged  respectively  three,  four,  and  ten  months.  The  symptoms 
were  asphyxia,  followed  by  convulsions  and  death  in  a  few  hours.  The 
thymus  was  in  all  the  cases  very  greatly  enlarged,  the  weight  being  over  one 
ounce.  Only  one  of  these  children  was  markedly  rachitic.  I  have  found 
in  literature  records  of  fifteen  other  cases  of  a  similar  nature  in  children 
A-arying  from  three  to  sixteen  months.  The  symptoms  in  all  have  been 
similar  to  those  in  my  own  cases.  The  asphyxia  is  apparently  due  to 
pressure  upon  the  pneumogastric.  Eickets  was  present  in  about  one 
half  of  the  recorded  cases. 

6.  Atelectasis. — In  very  young  infants  there  may  be  no  symptoms  ex- 
cepting malnutrition  until  sudden  death  occurs,  sometimes  with  convul- 
sions and  sometimes  without  any  such  symptoms.  I  have  in  several 
instances  known  death  to  follow  compression  upon  the  lungs  by  the  over- 
distended  stomach,  the  symptoms  coming  on  very  soon  after  feeding  or 
associated  with  an  attack  of  indigestion.     (See  Atelectasis.) 

7.  Marasmus. — In  this  class  of  cases  sudden  death  is  of  very  common 
occurrence.  These  children  are  often  as  well  two  or  three  hours  before 
death  as  for  several  weeks.  Death  frequently  occurs  at  night,  the  chil- 
dren being  found  dead  in  bed  in  the  morning.  In  some  of  the  cases  the 
exciting  cause  seems  to  be  the  lowering  of  the  temperature,  while  in  many 
no  exciting  cause  can  be  found ;  the  vital  spark  simply  goes  out  after 
burning  for  some  time  with  a  feeble  intensity.  In  some  of  these  cases  the 
autopsy  reveals  atelectasis,  but  in  many  cases  nothing  abnormal  is  found, 
death  apparently  resulting  from  heart  failure. 


44  PECULIARITIES   OF    DISEASE   IN   CHILDREN. 

8.  Convulsions  in  children  j)T^vioiisly  showing  no  sights  of  disease. — 
Most  of  these  cases  are  seen  in  children  who  were  previously  rachitic. 
In  them  the  autopsy  shows  no  lesion  except  those  commonly  associated 
with  death  from  convulsions.  It  is  extremely  rare  for  a  cerebral  lesion 
such  as  hsemorrhage  to  produce  death  in  this  way.  In  some  of  these 
rachitic  cases  death  is  due  to  spasm  of  the  glottis. 

9.  As2)hyxia  in  older  infants  and  young  children. — This  may  result 
from  the  pressure  of  a  retropharyngeal  abscess  upon  the  larynx  or  trachea, 
or  from  the  rupture  of  such  an  abscess  during  sleep  and  the  entrance  of 
pus  into  the  air  passages.  While  in  most  such  cases  other  symptoms 
have  been  present,  they  may  be  latent.  A  rare  cause  of  sudden  asphyxia 
in  children  from  eighteen  months  to  five  years  is  pressure  upon  the 
pneumogastric  by  tubercular  bronchial  glands,  or  by  abscesses  in  the 
posterior  mediastinum  connected  with  caries  of  the  spine.  I  have 
seen  examples  of  both  the  latter.  Gibney  has  reported  a  case  of  sud- 
den death  from  dislocation  of  the  upper  cervical  vertebrge  consequent  upon 
caries. 

Sudden  asphyxia  may  follow  the  ulceration  of  tubercular  lymph  nodes 
and  the  escape  of  cheesy  masses  into  the  trachea  or  primary  bronchi. 
This  usually  occurs  in  children  from  two  to  five  years  old,  and  many  cases 
have  been  reported. 

10.  Death  after  a  few  hours''  illness,  in  which  the  cliief  symptom  is 
high  temperature. — This  is  quite  a  common  occurrence.  Children  who 
are  apparently  well  may  be  taken  with  great  prostration  and  a  high  tem- 
perature, which  may  rise  rapidly  to  106°  or  even  107°  F.,  with  death  in  from 
six  to  twelve  hours,  sometimes  preceded  by  convulsions.  In  my  hospital 
experience  I  have  met  vvith  many  such  cases.  In  infants,  the  most  fre- 
quent explanation  of  these  symptoms,  as  shown  by  autops}',  is  acute  con- 
gestive pneumonia;  in  older  children  it  may  be  due  to  malignant  scarlet 
fever  or  epidemic  meningitis,  although  I  have  never  seen  an  instance  of 
either  of  these  diseases  in  which  death  occurred  in  the  first  twenty-four 
hours. 

It  does  not  fall  within  the  scope  of  this  chapter  to  consider  cases  of 
sudden  death  from  heart  failure  after  diphtheria,  with  pleurisy  with  effu- 
sion, or  with  myocarditis.     These  will  be  discussed  elsewhere. 

PROPHYLAXIS. 

There  is  no  more  promising  field  in  medicine  than  the  prevention  of 
disease  in  childhood.  The  majority  of  the  ailments  from  which  children 
die,  it  is  within  the  power  of  man  in  great  measure  to  prevent.  Prophy- 
laxis should  aim  at  the  solution  of  two  distinct  problems  :  (1)  The  re- 
moval of  the  causes  which  interfere  with  the  proper  growth  and  develop- 
ment of  children  ;  (2)  the  prevention  of  infection.  The  former  can 
come  only  through  the  education  first  of  the  profession  and  then  the 


THERAPEUTICS.  45 

general  public,  ia  the  fundamental  principles  of  infant  feeding  and  hy- 
giene. This  IS  a  department  which  has  received  altogether  too  small  a 
place  in  medical  education.  The  latter  must  come  through  the  profession, 
and  through  legislation,  the  purpose  of  which  shall  be  more  rigid  quaran- 
tine, more  thorough  disinfection,  and  improved  sanitation  in  all  its  depart- 
ments. 

THERAPEUTICS. 

Treatment  in  the  diseases  of  children,  and  particularly  those  of  infants, 
is  a  difficult  subject.  Therapeutics  in  infancy  consists  in  something  more 
than  a  graduated  dosage  of  drugs.  Many  therapeutic  means  which  are 
valuable  in  adults  are  useless  in  children,  and  many  others  which  are  of 
little  value  in  adults  are  extremely  useful  in  children.  There  is  no  doubt 
of  the  truth  of  the  statement  that  children  in  the  past  have  suffei-ed  mucii 
from  overzealous  treatment,  particularly  from  drug-giving.  It  should  be 
a  fundamental  principle  never  to  give  a  dose  of  medicine  without  a  clear 
and  definite  indication.  If  this  rule  is  followed,  it  is  surprising  to  find 
how  often  medication  can  be  dispensed  with,  and  also,  in  many  cases,  how 
much  better  children  do  without  drugs  than  with  them.  A  second  rule 
is  equally  important :  never  to  give  a  nauseous  dose  when  one  that  is 
palatable  will  answer  the  purpose  equally  well.  This  is  no  small  matter, 
and  one  that  is  well  worth  the  physician's  careful  attention,  if  he  would 
succeed  in  the  management  of  sick  children.  The  simpler  prescriptions 
are  made,  the  better.  As  a  rule,  infants  revolt  against  most  of  the  highly 
seasoned  siru^DS  and  elixirs  which  are  used  to  disguise  the  taste  of  unpleas- 
ant doses.  Bitter  medicines  when  mixed  with  water,  are  frequently  ad- 
ministered without  the  slightest  difficulty. 

It  is  a  common  mistake  to  underestimate  the  importance  of  the  hy- 
gienic surroundings  of  the  patient,  the  value  of  good  nursing,  careful 
feeding,  and  judicious  stimulation,  just  as  it  is  to  overestimate  the  bene- 
ficial effects  of  drugs.  In  the  great  majority  of  acute  ailments  not  serious 
in  character  for  which  a  physician  is  called,  the  patient  recovers  quite  as 
promptly  without  drugs  as  with  them.  This  does  not  mean  that  such 
children  require  no  treatment,  but  that  the  least  important  part  of  the 
treatment  is  drug-giving,  while  the  most  important  part  is  attention  to 
the  hygienic  matters  just  referred  to.  In  cases  of  severe  illness,  in  infants 
especially,  we  must  avoid  all  unnecessary  medication,  in  order  that  the 
stomach  may  not  be  disturbed  and  vomiting  excited.  Hence  the  impor- 
tance of  relying  as  far  as  possible  upon  local  measures  of  treatment.  The 
tendency  to  recovery  from  all  acute  processes,  while  seen  in  adults,  is  even 
more  striking  in  children,  where,  if  we  can  but  remove  that  which  hampers 
the  bodily  functions.  Nature  will  conduct  the  case  to  a  satisfactory  termi- 
nation. Thus,  after  an  attack  of  ordinary  bronchitis  of  no  great  severity, 
it  is  often  seen  that  the  disturbance  of  the  stomach  and  intestines,  which 


46  PECULIARITIES  OF   DISEASE   IN   CHILDREN. 

can  be  directly  traced  to  the  drugs  employed,  continues  long  after  the 
original  disease  has  subsided,  and  is  very  much  more  difficult  to  relieve. 
In  diseases  of  the  stomach  and  intestines  especially  there  is  a  great  amount 
of  overmedication,  very  much  to  the  detriment  of  the  patient.  In  all 
chronic  disturbances  of  nutrition — chronic  indigestion,  malnutrition,  and 
anaemia — nothing  is  of  so  much  value  as  change  of  air  and  surroundings. 
This  is  most  striking  in  the  case  of  city  children.  With  them  it  is  a  fre- 
quent experience  that  tonics  of  every  description  are  of  little  or  no  avail, 
and  yet  immediate  and  most  marked  improvement  begins  when  the  chil- 
dren are  sent  to  the  country. 

The  tablet  triturates  have  furnished  us  with  a  convenient  method  of 
administering  many  drugs  to  children.  Those  which  are  especially  useful 
are:  calomel,  from  one  tenth  to  one  half  grain;  gray  powder  in  the  same 
doses ;  antimony  and  ipecac,  one  one-hundredth  of  a  grain  each ;  phena- 
cetine,  one  to  two  grains ;  arsenious  acid,  one  one-hundredth  of  a  grain ; 
paregoric,  lUv ;  Dover's  powder,  one  tenth  of  a  grain ;  atropine,  one  four- 
hundredth  to  one  two-hundredth  of  a  grain.  This  list  might  be  very 
greatly  extended. 

As  to  the  method  of  administration,  it  is  to  be  remembered  that 
several  small  doses  are  more  easily  given  and  less  likely  to  disturb  the 
stomach  than  a  few  larger  ones.  This  method  of  administering  very 
many  drugs  to  children  will  be  found  extremely  satisfactory  —  e.  g., 
sodium  bromide,  one  half  grain  every  fifteen  minutes,  is  often  better 
than  five  grains  every  two  hours ;  phenacetine,  one  half  grain  every  half 
hour,  is  better  than  two  grains  every  two  hours ;  calomel,  one  tenth  of  a 
grain  every  hour,  is  better  for  constipation  than  a  single  dose  of  two 
grains. 

Antipyretics. — The  indications  for  the  employment  of  antipyretics  in 
children  are  somewhat  different  from  those  in  adults.  It  is  to  be  borne 
in  mind  that,  where  the  cause  is  similar,  all  temperatures  in  children  are 
higher  than  in  adults.  Thus  a  simple  pharyngitis,  which  in  an  adult 
causes  a  rise  of  temperature  only  to  100°  or  101°  F.,  is  in  a  child  not  in- 
frequently accompanied  by  a  temperature  of  104°,  or  even  105°  F.  The 
height  of  the  temperature,  as  measured  by  the  thermometer,  is  not  to  be 
taken  as  the  only  guide  for  the  employment  of  antipyretics.  In  many 
cases  the  temperature  is  104°,-  or  even  105°  F.,  and  yet  the  child  exhibits 
no  signs  of  unusual  discomfort.  Such  a  temperature  manifestly  does  not 
call  for  interference.  Again,  a  temperature  of  103°  F.  may  be  accom- 
panied by  very  marked  restlessness  and  other  signs  of  distress  which 
may  be  relieved  by  employing  some  antipyretic  measure.  The  number 
of  cases  seen  in  practice,  of  high  temperature  apparently  from  trivial 
causes,  is  very  great.  One  must  not  be  unduly  alarmed  even  by  a  very 
high  temperature  if  it  is  of  short  duration.  It  is  the  continuously  high 
temperature  which  indicates  serious  illness.     Whenever  the  temperature 


ANTIPYRETICS.  47 

is  found  to  be  much  above  the  normal  it  should  be  carefully  watched, 
but  not  interfered  with  until  a  diagnosis  has  been  made,  unless  the 
symptoms  urgently  demand  it ;  otherwise  the  physician  may  lose  one  of 
the  most  valuable  aids  to  diagnosis,  since  it  is  not  the  height  of  the 
temperature  but  its  course  which  is  significant.  The  routine  practice  of 
ordering  full  doses  of  antipyretic  drugs  whenever  on  the  first  visit  an 
elevation  of  three  or  four  degrees  is  discovered  can  not  be  too  strongly 
deprecated.  In  many  cases  it  is  very  important  to  knovv^  whether  the  tem- 
perature uninfluenced  by  drugs  is  remittent,  intermittent,  or  steadily 
high,  and  hence  the  advantage  of  waiting  until  a  diagnosis  has  been  made 
before  disturbing  the  temperature  curve,  always  provided,  of  course,  that 
the  child  is  in  no  danger  from  the  high  temperature — a  condition  which  is 
certainly  not  common.  Since  the  cause  of  a  great  many  obscure  tempera- 
tures is  found  in  the  stomach  and  intestines,  it  very  often  hapjiens  that  a 
purgative,  stomach-washing,  or  intestinal  irrigation  may  be  the  most  effi- 
cient antipyretic.  In  cases  of  moderate  elevation  of  temperature  we  need 
go  no  further  than  cold  s2)onging. 

The  most  reliable  antipyretic  measure  for  infants  is  the  use  of  cold. 
This  may  be  employed — 

(1)  As  an  ice  cap  to  the  head. — In  many  cases  of  quite  high  tempera- 
ture and  restlessness  in  infants  this  alone  will  reduce  the  temperature  one 
or  two  degrees  and  allay  the  nervous  sym2:)toms.  It  may  be  used  continu- 
ously or  intermittently,  according  to  circumstances. 

(2)  Cold  S2)onging. — For  this  purpose  water  about  80°  to  85°  F.,  equal 
parts  of  alcohol  and  water,  or  equal  parts  of  vinegar  and  water  may  be 
emploved.  In  the  case  of  infants,  all  the  clothing  except  the  diaper 
should  be  removed  and  the  child  laid  upon  a  blanket.  The  body  should 
be  sponged  for  from  ten  to  twenty  minutes,  and  then  wrajiped  in  a 
blanket  without  further  dressing.  Cold  sponging  must  be  very  frequently 
employed  in  order  to  be  efficient  in  reducing  high  temperature.  Its  great 
value  in  allaying  nervous  symptoms,  even  when  the  temperature  is  not 
very  high,  is  not  sufficiently  appreciated.  Its  eflfect  is  often  more  satis- 
factory than  an  anodyne. 

(3)  Cold  pack. — This  is  one  of  the  simplest  and  most  efficient  means 
of  reducing  temperature  which  can  be  employed.  The  child  should  be 
stripped  and  laid  upon  a  blanket.  The  entire  trunk  should  then  be 
enveloped  in  a  small  sheet  wrung  from  water  at  a  temperature  of  100°  F. 
Upon  the  outside  of  this,  ice  may  now  be  rubbed  over  the  entire  trunk, 
first  in  front  and  then  behind.  By  this  method  there  is  no  shock  and 
no  fright,  and  any  ordinary  temperature  can  usually  be  readily  reduced. 
The  rubbing  with  ice  should  be  repeated  in  from  five  to  thirty  minutes, 
according  to  circumstances,  after  which  the  child  may  be  rolled  in  the 
blanket  upon  which  he  is  lying  without  the  removal  of  the  wet  pack. 
The  head  shouM  be  sponged  with  cold  water  while  this  is  being  carried 


48  PECULIARITIES  OF   DISEASE   IX   CHILDREN. 

on,  and  artificial  heat,  if  necessary,  should  be  applied  to  the  feet.  The 
pack  is  continued  from  one  to  twenty-four  hours,  according  to  cir- 
cumstances. 

(4)  The  cold  bath. — This  is  more  easily  employed  in  the  case  of  infants 
than  larger  children.  The  child  is  j)ut  into  a  bath  at  a  temperature  of 
100°  F.,  the  bath  being  gradually  lowered  by  the  addition  of  ice  to  85°  or 
80°  F.  The  body  should  be  well  rubbed  while  the  child  is  in  tlie  batli  and 
water  should  also  be  applied  to  the  head.  On  removal  from  the  bath,  the 
body  should  be  quickly  dried  and  rolled  in  a  warm  blanket.  The  bath  is 
usually  continued  from  five  to  twenty  minutes. 

(5)  Irrigation  of  the  colon  is  an  efficient  means  of  lowering  the  tem- 
perature. The  water  should  be  from  40°  to  50°  F. ;  it  should  be  injected 
through  a  catheter,  and  not  more  than  a  pint  should  be  introduced  at  one 
time.  It  is  not  to  be  advised  except  in  cases  of  colitis,  where  the  doable 
purpose  of  lowering  the  temperature  and  cleansing  the  intestine  may  be 
accomplished  at  the  same  time. 

Antipyretic  Drugs. — Except  in  cases  of  malaria,  quinine  should  not  be 
employed  for  the  reduction  of  temperature  in  children.  The  dose  required 
is  so  large,  the  difficulty  of  administration  is  so  great,  and  the  tendency  to 
upset  the  stomach  is  so  uniform,  that  its  use  should  be  discouraged  alto- 
gether ;  besides,  its  effect  is  extremely  uncertain. 

Of  the  three  antipyretics  more  recently  introduced — phenacetine,  anti- 
pyrine,  and  antifebrine — their  value  in  children  is  in  the  order  named. 
Phenacetine,  has  the  advantage  of  being  tasteless,  but  the  slight  disadvan- 
■  tage  of  being  insoluble.  Antipyrine  is  so  bitter  as  to  make  its  administra- 
tion often  difficult.  The  prostration  attending  the  use  of  antifebrine  is 
rather  greater  than  that  of  either  of  the  others.  None  of  these  drugs  is, 
however,  to  be  employed  in  large  doses  with  the  sole  purpose  of  reducing 
the  temperature.  Their  great  value  in  paediatrics  consists  rather  in  allay- 
ing the  nervous  symptoms  which  accompany  fever,  and  this  purpose  can 
be  accomplished  by  the  use  of  comparatively  small  doses.  To  an  infant 
of  one  year,  phenacetine  or  antipyrine  can  be  given  in  one-grain  doses 
every  hour  or  two  hours  until  the  desired  effect  is  produced.  For  a  child 
of  five  years  a  dose  of  two  grains  may  be  given  in  the  same  manner.  When 
used  as  indicated,  these  drugs  are  of  very  great  value  in  making  the  patient 
more  comfortable,  in  promoting  sleep,  and  in  allaying  headache  and  gen- 
eral pains.  In  cases  of  hyperpyrexia  they  are,  however,  much  less  certain 
and  less  safe  than  the  use  of  cold.  In  many  cases  of  mild  pyrexia  the  symp- 
toms are  relieved  by  the  administration,  either  separately  or  in  combination, 
of  citrate  of  potassium,  spiritus  aetheris  nitrosi,  and  liquor  ammonii  acetatis, 
in  small  frequent  doses. 

Stimulants. — In  spite  of  the  many  statements  to  the  contrary,  alco- 
holic stimulants  are  well  tolerated  even  by  very  young  infants.  Propor- 
tionately larger  doses  of  alcohol  than  of  most  drugs  may  be  administered 


STIMULANTS.  49 

to  infants ;  still,  stimulants,  and  alcohol  in  particular,  are  no  doubt  very 
greatly  abused  in  the  hands  of  many  practitioners. 

The  indications  for  the  employment  of  stimulants  are  much  the  same 
in  young  children  as  in  adults.  They  are  to  be  used  whenever  the  pulse 
is  weak,  soft,  and  compressible,  and  whenever  the  general  powers  of  the 
patient  are  very  greatly  depressed.  In  most  of  the  acute  fevers  they  are 
not  to  be  given  early  in  the  disease,  and  in  many  cases  they  are  not  re- 
quired at  all ;  but  whenever  the  patient's  general  strength  is  greatly 
reduced,  and  what  is  known  as  the  typhoid  condition  develops,  they  are 
to  be  used  freely,  whatever  the  disease  may  be.  They  must  often  be  used 
very  sparingly  while  the  temperature  is  high,  but  given  freely  as  soon  as  it 
falls.  In  many  acute  febrile  diseases  stimulants  are  not  called  for  at  any 
period.  This  is  especially  true  of  most  cases  of  lobar  pneumonia.  The 
time,  however,  when  they  are  most  likely  to  be  needed  is  at  or  just  after 
the  crisis  of  the  disease,  when  for  twenty-four  hours  they  should  be  very 
freely  given.  In  broncho-pneumonia  they  are  more  uniformly  required, 
and  their  use  should  be  begun  earlier.  This  is  particularly  true  of  the 
broncho-pneumonia  which  develops  secondarily  to  the  infectious  diseases. 
In  all  toxic  diseases,  such  as  diphtheria,  alcohol  should  be  begun  as  soon 
as  depressing  symptoms  show  themselves,  and  continued  in  doses  regu- 
lated by  the  degree  of  prostration.  In  the  acute  gastro-enteric  diseases 
the  depletion  is  often  so  great  and  there  is  so  little  absorption  of  food  that 
the  patients  must  in  certain  cases  be  sustained  by  alcohol  for  several 
days. 

Alcoholic  stimulants  are  contra-indicated  in  all  acute  febrile  processes 
where  there  is  high  temperature,  dry  skin,  flushed  face,  and  a  full,  strong 
pulse.     In  such  conditions  they  are  often  injurious. 

The  method  of  administering  stimulants  is  of  no  little  importance. 
Brandy  and  whisky  are  in  most  cases  to  be  preferred  to  the  wines,  but 
not  always.  Champagne  may  be  substituted  when  spirits  are  not  well 
borne  by  the  stomach.  For  infants  under  one  year  old,  brandy  should 
be  diluted  with  at  least  eight  parts  of  water.  It  is  commonly  given  in 
too  concentrated  a  form.  Altogether  the  best  method  of  administra- 
tion is  to  determine  the  amount  to  be  given  in  every  twelve  hours,  have 
it  diluted  sufficiently,  and  then  administer  it  in  small  doses  at  short 
intervals.  In  this  way  vomiting  is  rarely  produced.  The  addition  of 
brandy  to  the  water  required  by  the  thirst  makes  it  less  likely  to  disturb 
the  stomach. 

The  quantity  of  alcohol  will  depend  very  much  upon  circumstances. 
An  infant  one  year  old,  for  whom  alcoholic  stimulants  are  needed  at  all, 
should  be  given,  to  begin  with,  half  an  ounce  of  whisky  or  brandy  during 
twenty-four  hours,  the  quantity  being  increased  for  a  short  period  to  an 
ounce  and  a  half,  or  in  bad  cases  even  to  two  ounces  ;  but  it  is  very  rarely, 
if  ever,  advisable  to  go  beyond  this  limit. 


50  PECULIARITIES   OF  DISEASE   IN   CHILDREN. 

In  children  four  years  old  double  the  amount  may  be  employed  in  the 
corresponding  conditions.  Larger  quantities  than  those  mentioned  are  of 
doubtful  advantage.  Alcohol  when  used  injudiciously  is  capable  of  doing 
much  liarm. 

Tonics. — Cod-liver  oil  stands  at  the  head  of  the  list  of  tonics  for  young 
children.  It  is  particularly  in  the  convalescence  after  acute  diseases  of 
the  respiratory  tract  that  we  see  its  most  striking  benefit.  It  is  also  of 
very  great  use  in  antemia,  and  in  a  large  number  of  children  who  are 
extremely  delicate.  In  these  patients  it  may  be  advantageously  adminis- 
tered throughout  the  greater  part  of  nearly  every  winter  season.  In  con- 
valescence after  attacks  of  gastro-enteric  disease  it  is  not  nearly  so  useful, 
and  often  must  be  withheld  for  a  long  time.  It  is  a  mistake  to  give  cod- 
liver  oil  at  any  time  when  the  tongue  is  coated,  the  digestion  poor,  and  the 
stomach  easily  disturbed.  In  the  case  of  infants,  as  a  rule,  the  pure  oil 
is  to  be  preferred  to  the  emulsions,  but  this  is  not  always  the  case.  The 
administration  of  small  doses — i.  e.,  ten  or  twenty  drops  of  the  oil  three 
times  a  day  continued  for  a  long  period — is  much  better  than  the  use  of 
larger  doses  for  a  shorter  time. 

A  perfect  preparation  of  iron  for  use  in  infancy  has  not  yet  been  dis- 
covered. During  the  first  few  years  all  astringent  preparations  should  be 
avoided.  For  use  at  this  age  the  best  forms  are  probably  the  bitter  wine, 
Robin's  peptonate,  Gude's  peptomanganate,  Drees's  albuminate,  and  the 
malate  of  iron.  The  peptonate  and  peptomanganate  have  the  advantage 
of  mixing  easily  with  milk.  For  older  children  nothing  is  more  satisfac- 
tory than  Blaud's  pills. 

Arsenic  is  second  only  to  iron  in  the  treatment  of  the  auj^mia  of  chil- 
dren, and  in  very  many  cases  it  is  to  be  preferred  to  iron.  The  tablet 
triturates  of  arsenious  acid,  one  one-hundredth  of  a  grain,  may  be  given 
immediately  after  meals  three  times  a  day,  or  one  or  two  drops  of  Fowler's 
solution  largely  diluted  with  water. 

Alcohol  is  of  very  great  value  as  a  tonic  in  combination  with  some  of 
the  bitters,  either  small  doses  of  quinine,  nux  vomica,  or  the  bitter  wine 
of  iron.  Usually  wines,  especially  sherry,  are  to  be  preferred  to  spirits, 
although  some  children  take  spirits  better.  When  combined  with  a  bitter 
there  is  little  danger  of  the  formation  of  the  alcoholic  habit,  even  though 
its  use  may  be  long  continued. 

Of  the  bitter  tonics,  quinine  and  nux  vomica  are  easily  superior  to  all 
others. 

Opiates. — Strong  objections  have  been  urged  by  many  against  the 
employment  of  opium  in  the  diseases  of  infancy.  While  oi:)iates  have 
no  doubt  been  abused,  the  fact  remains  that  opium  is  almost  as  valu- 
able a  remedy  in  the  treatment  of  disease  during  the  first  five  years 
as  at  any  other  period  of  life.  Infants  are,  however,  peciiliarly  suscep- 
tible to  the  drug,  and  relatively  much  smaller  doses  are  required   than 


OPIATES— ANODYNES. 


51 


of  most  medicines.  If  the  physician  will  accustom  himself  to  the  use 
of  very  small  doses,  he  will  be  surprised  to  see  how  satisfactory  are  the 
effects  produced. 

The  most  useful  preparations  for  young  children  are  paregoric,  Dover's 
powder,  the  deodorized  tincture,  morphine,  and  codeine.  The  follow- 
ing table  gives  what  may  be  considered  safe  initial  doses  at  the  different 
ages  : 


1  month. 


Paregoric tH,  i 

Deodorized  tincture ^'l  A" 

Dover's  powder i  Gr.  ^,y 

Morphine Gr.  tuW 

Codeine i  Gr.  ta^t 


3  months. 

1  year. 

5  years. 

Tfi  ii 

Gr.^ 

Gr.dur 
Gr.  -2^ 

TTl  V  to  X 

mitoi 
Gr.  i  to  i 
Gr.  Yhis 
Gr.^ 

^,  XXX  to  xl 

TTJ,  ii  to  iii 
Gr.  ii  to  iii 
Gr.  ^(f  to  ^ 
Gr. -ji-o  toi 

Ordinarily  doses  like  the  above  should  not  be  repeated  oftener  than 
every  two  hours.  In  exceptional  circumstances,  as  when  very  great  pain 
is  present,  the  dose  may  be  given  more  frequently.  In  the  hypodermic 
use  of  morphine  it  should  be  remembered  that  its  effects  are  always  more 
uniform  and  striking  than  when  the  drug  is  administered  by  the  mouth, 
and  the  dose  should  therefore  be  smaller.  In  every  instance  where  a  full 
dose  of  opium  has  been  given  the  physician  should  wait  until  the  effects 
have  subsided  before  the  dose  is  repeated. 

Anodynes. — Chloral  is  usually  well  borne  even  by  quite  young  infants. 
In  them  it  should  never  be  administered  by  the  mouth,  but,  on  account 
of  its  irritant  properties,  always  by  the  rectum.  After  rectal  administra- 
tion its  effects  are  usually  manifest  in  half  an  hour,  and  sometimes  sooner. 
The  dose  for  an  infant  of  one  month  is  one  grain ;  three  months,  two 
grains ;  one  year,  three  to  five  graitis.  It  may  be  repeated  every  two  to 
four  hours,  according  to  indications.  Other  drugs  may  replace  this  in 
most  diseases,  but  in  the  case  of  infantile  convulsions  nothing  is  so  reliable 
as  chloral. 

Belladonna  is  well  borne  by  children,  and  in  larger  doses  than  most 
drugs.  A  tolerance  is  quite  readily  established.  The  eruption  is  more 
readily  produced  than  the  other  physiological  effects,  and  even  quite  small 
doses  may  be  sufficient  to  bring  out  a  very  abundant  blush.  The  parents 
should  be  advised  of  this  fact,  lest  undue  alarm  be  felt. 

The  drugs  classed  as  antipyretics — phenacetine,  antipyrine,  and  anti- 
febrine — are  exceedingly  valuable  in  the  treatment  of  many  diseases  of 
infancy  where  irritative  nervous  symptoms  are  prominent.  In  many  cases 
they  may  advantageously  take  the  place  of  opium,  except  where  pain  is 
the  principal  symptom,  as  in  otitis  or  pleurisy.  In  all  conditions  wliere 
spasm  is  a  prominent  symptom,  whether  of  the  larynx  or  bronchi,  or  local 
or  general  convulsions,  antipyrine  is  especially  valuable. 


52  PECULIARITIES  OP   DISEASE   IN  CHILDREN. 

Drugs  well  borne  by  Children. — In  this  list  might  be  mentioned 
belladonna,  the  bromides,  the  iodides,  chloral,  quinine,  calomel — in  fact, 
all  mercurials — and  alcohol. 

The  drugs  not  well  borne  include  particularly  cocaine  and  all  prepa- 
rations of  oijium.  In  the  case  of  many  others,  while  the  constitutional 
effects  are  well  tolerated,  they  must  be  given  carefully  to  young  infants, 
since  they  are  irritants  to  the  stomach.  In  this  class  may  be  mentioned 
the  salicylates,  salol,  the  astringent  preparations  of  iron,  and  the  acids. 

Counter-irritants. — These  are  of  great  value  in  a  large  variety  of  dis- 
eases. Blisters  should  never  be  employed  in  the  case  of  infants,  and  very 
rarely,  and  never  needlessly,  in  the  case  of  older  children.  In  the  latter 
they  may  be  required  in  inflammations  of  the  ear,  of  the  joints,  or  of  the 
spine ;  they  should  never  be  applied  to  the  chest. 

The  mustard  paste  is  probably  the  most  satisfactory  means  of  pro- 
ducing quick  counter-irritation  over  a  large  surface.  To  make  a  mustard 
paste :  Take  one  part  powdered  mustard  and  six  parts  of  wheat  flour,  mix 
with  lukewarm  water,  and  spread  between  two  layers  of  muslin.  This 
should  be  removed  as  soon  as  a  thorough  redness  of  the  skin  has  been 
produced — in  most  cases  from  five  to  eight  minutes,  according  to  the 
strength  of  the  mustard  employed.  This  may  be  repeated  as  often  as 
every  three  hours,  and  continued  for  a  week  if  necessary,  without  pro- 
ducing excoriations  of  the  skin.  For  older  children  the  paste  may 
be  made  one  part  mustard  to  four  parts  flour.  In  pulmonary  diseases 
it  should  be  large  enough  to  surround  the  chest.  When  it  is  used 
to  produce  general  reaction  in  heart  failure  it  should  cover  the  entire 
trunk. 

The  mustard  ])ack. — The  child  is  stripped  and  laid  upon  a  blanket, 
and  the  trunk  is  surrounded  by  a  large  towel  or  sheet  saturated  with 
mustard  water.  This  is  made  as  follows  :  One  tablespoonful  of  mustard 
to  one  quart  of  tepid  water.  In  this  a  towel  is  dipped,  and  while  drij^- 
ping  wound  around  the  entire  body.  The  patient  should  then  be  rolled 
in  the  blanket.  This  pack  may  be  continued  for  ten  or  fifteen  minutes, 
at  the  end  of  which  time  there  will  usually  be  a  very  decided  redness  of 
the  whole  body.  It  may  be  repeated  according  to  indications.  Where  it 
is  desired  to  produce  a  general  counter-irritation,  the  mustard  pack  is  not 
quite  as  efficient  as  the  mustard  bath,  but  it  has  the  advantage  in  causing 
much  less  disturbance  to  the  patient.  The  mustard  pack  is  useful  in  the 
condition  of  collapse  or  of  great  prostration  from  an}^  cause  whatever,  in 
convulsions,  and  in  cerebral  or  pulmonary  congestion. 

The  turpentine  stupe  is  made  by  wringing  a  piece  of  flannel  out  of 
water  as  hot  as  can  be  borne  by  the  hand.  Upon  this  is  sprinkled  ten  or 
fifteen  drops  of  the  spirits  of  turpentine.  The  stupe  is  then  applied  to 
the  body  and  covered  with  oiled  silk  or  dry  flannel.  It  is  useful  chiefly 
in  abdominal  pains  or  inflammations,  but  in  infancy  must  be  carefully 


POULTICES.  53 

watched  or  vesication  will  be  produced.  For  continuous  use  it  is  not  so 
valuable  as  the  mustard  paste. 

Stiimdating  Uniinetits  containing  turpentine  and  other  irritants  are 
useful  in  intiammation  of  the  chest,  although  less  reliable  than  the  mus- 
tard paste.  One  of  the  mildest  and  most  useful  pre})arations  is  camphor- 
ated oil.  Another  is  olive  oil  four  parts  and  turpentine  one  part.  These 
may  either  be  rubbed  upon  the  surface,  or  a  piece  of  flannel  may  be  satu- 
rated with  them  and  then  applied  to  the  skin.  The  old-fashioned  spice 
bag  is  useful  in  many  cases  where  a  very  mild  counter-irritant  is  desired 
over  the  abdomen. 

Dry  cups  may  be  used  even  in  young  infants,  to  relieve  acute  pul- 
monary congestion.  They  are  sometimes  of  very  great  value,  and  may 
succeed  in  cases  in  which  there  is  no  reaction  from  the  mustard.  From 
four  to  six  cups  may  be  applied,  and  the  effect  may  be  continued  by  the 
a})plication  of  the  mustard  paste.  Wet  cups  should  never  be  used  in 
young  children. 

Poultices  are  useful  in  local  inflammations  about  the  glands  of  the 
neck,  the  joints,  and  in  cellulitis  in  various  parts  of  the  body.  The  pro- 
longed use  of  poultices  can  not  be  too  strongly  condemned  in  cases  of 
otitis.  In  diseases  of  the  chest,  poultices  may  do  harm  because  their 
weight  embarrasses  respiration,  and  sometimes  because  of  the  exposure 
when  they  are  changed.  They  are  most  useful  in  pulmonary  diseases  in 
which  there  is  great  pain,  as  in  pleurisy  or  in  pleuro-pneumonia.  In 
bronchitis  and  in  broncho-pneumonia  they  are  objectionable,  certainly  for 
prolonged  use,  on  account  of  their  weight.  Better  effects  can  generally  be 
produced  by  hot  fomentations  and  counter-irritation.  Ground  flaxseed  is 
the  best  material  for  poultices.  This  should  be  mixed  with  boiling  water 
until  the  proper  consistency  is  reached,  when  the  poultice  should  be  put 
into  a  bag  of  muslin.  The  poultice  should  be  covered  with  oiled  silk  or 
cotton  batting,  so  that  it  will  retain  its  heat  as  long  as  possible.  To  be  of 
value,  poultieos  must  be  applied  hot  and  changed  frequently. 

Hot  fomentations  are  more  cleanly  than  poultices  and  much  more 
•easily  changed.  One  of  the  best  means  of  applying  them  is  by  a  piece  of 
spongio-piline  wrung  from  water  as  hot  as  the  hand  can  bear.  Where 
this  can  not  be  obtained,  a  large  piece  of  flannel  may  be  used  in  the  same 
way,  covered  with  cotton  batting,  and  then  with  oiled  silk.  This  method 
of  using  hot  fomentations  is  exceedingly  satisfactory  for  applications  to  the 
extremities. 

Cold. — Cold  is  useful  in  all  forms  of  inflammation  of  the  eyes  and 
brain.  In  inflammation  of  the  cervical  lymi)h  glands  and  of  the  joints  it 
is  of  undoubted  value,  but  its  advantage  over  heat  is  (piestionable.  The 
efticiency  of  both  cold  and  heat  in  these  cases  depends  largely  upon  the 
method  of  application.  Sometimes  in  pleurisy  much  greater  relief  is  ob- 
tained from  the  use  of  an  ice  bag  to  the  chest  than  from  hot  applications, 


54  PECULIARITIES   OF   DISEASE   IN   CHILDREN. 

but  this  is  not  the  general  exjaerience.  The  treatment  of  pneumonia  by 
the  application  of  the  ice  bag  to  the  chest  has  some  excellent  advocates, 
although  my  own  experience  has  not  led  me  to  look  upon  it  with  much 
favor.  It  is  admissible  only  in  lobar  pneumonia.  The  use  of  cold  in  in- 
flammations of  the  larynx,  trachea,  or  bronchi  is,  in  my  opinion,  positively 
contra-indicated,  certainly  so  in  infants  and  young  children. 

Cold  is  best  applied  to  the  head  by  an  ice  cap  made  like  a  helmet ;  an 
ordinary  rubber  or  flannel  bag  filled  with  ice  may  answer  the  purpose. 
The  rubber  coil  filled  with  ice  water  is  also  an  excellent  method.  For 
inflamed  glands  or  joints  the  ice  bag  should  be  used ;  for  the  eyes  cold 
compresses  changed  every  minute. 

The  Hot  Pack. — All  clothing  is  to  be  removed  and  the  child's  body 
covered  with  towels  wrung  from  Avater  at  a  temperature  of  from  100°  to 
110°  F.,  after  which  the  body  should  be  rolled  in  a  thick  blanket.  These 
hot  applications  may  be  changed  every  twenty  or  thirty  minutes  until  free 
perspiration  is  produced,  which  may  be  continued  as  long  as  necessary. 
This  is  mainjy  useful  in  uremia. 

The  Hot  Bath,  like  the  mustard  pack  or  the  mustard  bath,  may  be 
used  to  promote  reaction  in  cases  of  sliock  or  collapse.  The  patient  should 
be  put  into  the  bath  at  a  temperature  of  100°  F.,  the  water  being  gradu- 
ally raised  to  105°,  or  even  to  110°,  but  rarely  above  this  point.  The  body 
should  be  well  rubbed  while  the  jDatient  is  in  the  bath.  A  thermometer 
should  be  kept  in  the  water  to  see  that  the  temperature  does  not  go  too 
high.    During  the  bath,  in  most  cases,  cold  should  be  applied  to  the  head. 

The  Hot-Air  or  Vapour  Bath. — All  the  clothing  should  be  removed 
and  the  patient  laid  upon  the  bed  with  the  bedclothing  raised  above  the 
body  ten  or  twelve  inches,  and  sustained  by  means  of  a  wicker  support. 
The  bedclothing  should  be  pinned  tightly  about  the  neck,  so  that  only 
the  head  is  outside.  Beneath  the  bed  clothing  hot  vapour  is  introduced 
from  a  croup  kettle  or  a  vapourizer.  This  will  usually  induce  free  per- 
spiration in  fifteen  or  twenty  minutes.  It  may  be  continued  from  twenty 
to  thirty  minutes  at  a  time.  Instead  of  vapour,  hot  air  may  be  intro- 
duced in  the  same  way.  The  air  space  about  the  body  is  indispensable. 
The  vapour  bath  is  applicable  chiefly  to  cases  of  uremia. 

The  Mustard  Bath. — Four  or  five  tablespoonfuls  of  powdered  mustard 
should  be  mixed  for  a  few  minutes  with  one  gallon  of  tej)id  water.  To 
this  should  be  added  four  or  five  gallons  of  plain  water  at  a  temperature 
of  100°  F.  The  temperature  of  the  bath  may  be  raised  by  the  addition  of 
hot  water  to  105°  or  110°  F.  if  desired.  Nothing  is  more  efficient  than 
the  hot  mustard  bath  for  a  general  derivative  effect  in  bringing  the  blood 
to  the  surface  in  cases  of  shock,  collapse,  heart  failure  from  any  cause,  or 
in  sudden  congestion  of  the  lungs  or  brain.  The  bath  should  not  usually 
be  continued  for  more  than  ten  minutes.  If  necessary,  it  may  be  repeated 
in  an  hour. 


NASAL   SPRAY. 


55 


The  Bran  Bath. — Put  one  quart  of  ordinary  wheat  bran  in  a  bag  made 
of  coarse  muslin  or  cheese  cloth  and  place  this  in  four  or  tlve  gallons  of 
water.  The  bran  bag  should  be  frequently  squeezed  and  moved  about 
until  the  bath  water  resembles  a  thin  jiorridge.  It  may  be  of  any  tem- 
perature desired,  but  usually  about  90°  to  05°  F.  is  best.  A  bran  bath  is 
of  great  value  in  cases  of  eczema,  excoriations  about  the  buttocks,  or  in 
other  cases  where  the  skin  is  very  delicate,  and  plain  water  seems  to  irri- 
tate it. 

The  Tepid  Bath  may  be  given  at  a  temi)erature  of  95°  to  100°  F.  It  is 
very  useful  in  many  conditions  of  excitement  or  extreme  nervous  irrita- 
bility.    To  induce  sleep  it  is  often  more  efficient  than  drugs. 

The  Cold  Sponge  or  Shower  Bath  should  be  given  in  the  morning 
before  breakfast,  and  in  a  warm  room.  The  child  should  stand  in  a 
foot  tub  containing  warm  water  enough  to  cover  the  feet,  then  a  large 
sponge  holding  about  a  pint  of  water  at  a  temperature  of  from  40°  to  60° 
F.  should  be  squeezed  three  or  four  times  over  the  chest,  shoulders,  and 
spine  of  the  child,  the  skin  being  rubbed  meanwhile.  The  bath  should 
not  last  more  than  half  a  minute.  It  should  be  followed  by  a  brisk  rub- 
bing until  a  thorough  reaction  is  established.  This  is  very  useful  at  all 
ages,  but  a  particularly  valuable  tonic  in  delicate  children.  It  may  be 
used  in  those  only  eighteen  months  old.  Not  the  least  of  the  beneficial 
results  is  the  full  expansion  of  the  lungs  from  the  strong  cry  which  the 
bath  usually  excites.  In  younger  infants  a  cold  plunge  may  be  sub- 
stituted. This  should  be  merely  a  single  dip  of  the  entire  body  in 
water  at  a  temperature  of  50°  to  60°  F.  In  order  that  beneficial  effects 
shall  -follow  the  cold  plunge  or  cold  sponging,  a  good  reaction  must  be 
established.  If  children  lack  suffi- 
cient vitality  to  secure  this,  and  if 
they  remain  pale,  pinched,  and  blue 
for  some  time  after  the  bath,  it 
must  be  discontinued  altogether, 
or  water  of  a  higher  temperature 
used. 

Nasal  Spray. — This  may  be  either 
of  an  aqueous  or  oily  solution.     For 
the  oil  spray  an  atomizer  similar  to 
that   shown    in    the    accompanying 
cut  should  be  employed.     It  is  valu- 
able in  cases  of  dry  catarrh,  where  there  is  a  formation  of  crusts  in  the 
nose.     A  variety  of  oils  nuiy  be  used  in  the  spray,  albolene  being  per- 
haps  as   satisfactory   as   any.     Fig.    8   shows   an   efficient   atomizer   for 
albolene. 

There  are  a  good  many  forms  of  hand  atomizers  to  be  found  in  the 
market  for  the  production  of  an  aqueous  spray.     For  a  cleansing  nasal 


Fi(i. 


-Albolene  atomizer. 


56  PECULIARITIES   OF   DISEASE   IN   CHILDREN. 

spray,  DobelFs*  solution,  Seller's  f  solution,  Listerine  ten-per-cent  solu- 
tion, or  a  two-per-cent  solution  of  boric  acid  may  be  used. 

Nasal  Syringing. — lu  cases  of  considerable  nasal  obstruction  and  in 
the  more  serious  affections  of  the  rhino-pharynx  only  the  syringe  can  be 
considered  an  efficient  means  of  cleansing  the  cavity.  The  nasal  syringe 
should  be  small  enough  to  be  easily  worked  with  one  hand.  It  should 
have  a  soft-rubber  tip  to  prevent  injuring  the  nose,  and  the  tip  should  be 
large  enough  to  fill  the  nostril.  The  best  syringe  for  nasal  use  is  shown 
in  Fig.  9.     This  is  made  either  of  glass  or  hard  rubber  and  fulfils  all  the 


Fig.  9. — Nasal  syringe. 

conditions  mentioned. |  It  is  easy  of  action,  can  be  readily  cleansed,  and 
holds  about  half  an  ounce.  The  same  syringe  should  not  be  used  for  more 
than  one  patient,  unless  it  has  been  very  thoroughly  disinfected.  In  hos- 
pitals, and  even  in  private  practice,  nasal  syringes  are  frequent  carriers  of 
Infection.  Two  positions  may  be  used  in  nasal  syringing.  In  diphtheria, 
scarlet  fever,  or  any  constitutional  disease  attended  by  great  depression,  the 
child  should  not  be  removed  from  the  bed.  The  syringing  may  be  done 
by  a  single  nurse  who  stands  at  the  head  of  the  bed,  alternately  syringing 
the  right  and  left  nostril,  turning  the  head  from  side  to  side  (Fig.  10). 
The  other  method  is  to  hold  the  child  erect  on  the  lap  with  the  head  in- 

*  Dobell's  solution : 

Sodium  biborate 3  j 

Sodium  bicarbonate. 3  j 

Glycerin  of  carbolic  acid 3  ij 

Water  to  make  half  a  pint. 

f  Seller's  solution : 

Sodium  bicarbonate §  j 

Sodium  biborate §  j 

Sodium  benzoate gr.  xx 

Sodium  salicylate gr.  xx 

Eucalyptol  gi".  x 

Thymol gr.  x 

Menthol gr.  v 

Oil  gaultheria gtt.  vj 

Glycerine ^  vii j  ss. 

Alcohol I  ij 

Water  to  make  sixteen  pints. 

This  is  also  sold  in  tablets,  one  of  which  is  dissolved  in  four  ounces  of  water  to 
make  the  solution  of  the  above  strength. 

X  Tins  is  made  by  the  Goodyear  Company. 


NASAL  SYRINGING. 


57 


clined  ii  little  forward,  the  syringing  being  done  by  a  person  who  stands 
behind.  In  syringing,  the  water  should  come  out  of  tlie  opposite  nostril 
or  out  of  the  mouth,  to  make  it  certain  that  the  rhino-pharynx  has  been 


Method  ot'.syriiijjuig  the  nose. 


reached.     "When  properly  done,  no  prostration  and  very  little  irritation 
are  caused. 

Syringing  the  mouth  and  pharynx  is  useful  in  many  pathological  con- 
ditions of  these  parts,  particularly  in  children  too  young  to  gargle. 
Either  an  ordinary  hard-rubber  piston  syringe  or  a  bulb  (Davison)  syr- 
inge may  be  used.  If  the  pharynx  is  to  be  reached,  the  nozzle  is  used  as  a 
tongue  depressor.  This  should  be  placed  at  the  angle  of  the  mouth  be- 
tween the  back  teeth.  The  child  should  be  held  in  the  sitting  posture, 
with  the  head  inclined  forward.     Only  mild  solutions  should  be  employed. 


58 


PECULIARITIES   OP   DISEASE   IX    CHILDREN. 


Inhalations. — These  are  of  very  great  utility  in  all  affections  of  the 
respiratory  tract.  To  be  efficient,  the  patient  should  be  put  under  a  tent. 
A  satisfactory  tent  may  be  made  by  erecting  a  T-shaped  piece  of  wood  at 
the  head  and  foot  of  the  crib  and  throwing  over  this  a  large  sheet  folded 
and  pinned  at  the  corners.  Another  method  is,  to  stretch  a  cord  around 
the  top  of  each  of  the  four  posts  of  the  crib,  or  simply  from  the  centre  of 
the  head  piece  to  the  centre  of  the  foot  piece ;  the  sheet  should  be  used  as 
in  the  first  instance.  A  very  good  tent  may  be  improvised  by  throwing  a 
large  sheet  over  an  open  umbrella.  Instead  of  an  ordinary  cotton  sheet 
one  of  rubber  cloth  may  be  used.  For  hospital  use  I  have  found  it  con- 
venient to  have  a  rubber  cover  made  to  fit  closely  over  the  top  of  the  crib 
to  be  used  for  inhalations.  The  better  the  tent  the  more  satisfactory  are 
the  results  from  inhalations. 

Inhalations  may  be  in  the  form  of  vapour  or  spray.  The  apparatus 
employed  may  be  the  croup  kettle,  the  vapourizer,  or  the  steam  atomizer. 
As  all  of  these  are  used  with  alcohol  lamps,  innumerable  accidents  from 
fire  have  occurred  with  them.  Patients  and  nurses  should  always  be  cau- 
tioned regarding  this.  The  ordinary  croup  kettle  is  a  clumsy  affair  and 
especially  likely  to  be  the  cause  of  accidents.  In  Fig.  11  is  shown  one 
of  an  improved  pattern,*  which  possesses  the  advantages  both  of  the  ordi- 
nary croup  kettle  and  of  the 
vapourizer.  The  base  has  been 
weighted,  to  prevent  the  appa- 
ratus being  easily  upset.  The 
pail  is  low,  which  fact  also  contributes 
to  its  stability.  It  is  jirovided  with  a 
safety  alcohol  lamp,  the  flame  of  which 
can  be  regulated  by  a  screw.  The 
lamp  holds  enough  alcohol  to  burn 
from  five  to  six  hours.  This  kettle 
may  be  used  to  produce  simple  vapour, 
or  vapour  from  lime  water,  or  a  medi- 
cated vapour  may  be  employed.  If  the 
latter  is  desired,  the  substance  to  be  va- 
pourized  is  placed  on  a  sponge  held  in 
the  expansion  of  the  spout.  The  kettle 
should  be  filled  with  hot  water  before 
using.  It  should  be  placed  upon  the 
floor  or  a  low  box  beside  the  crib,  so  that  the  end  of  the  spout  is  just  in- 
side the  tent  at  a  level  with  the  surface  of  the  bed. 

The  vapourizer  f  (Fig.  13)  is  one  of  the  most  satisfactory  means  of 


rV  croup  kettle. 


*  Made  by  Lewis  &  Conger,  New  York. 
f  Made  by  Whitall  &  Tatum,  Philadelphia. 


OILED-SILK  JACKET. 


59 


obtaining  medicated  inhalations.     The  boiler  is  half  filled  with  water,  and 
the  substance  to  be  vapourized  is  placed  upon  a  sponge  which  lies  on  a  per- 


FiG.  12. — Vapourizer. 


Fig.  13. — Steam  atomizer. 


forated  diaphragm  placed  at  the  top  of  the  boiler,  so  that  all  the  steam 
generated  in  the  boiler  passes  through  it. 

The  steam  atomizer  is  shown  in  Fig.  13.  For  this  no  tent  is  required. 
It  should  be  placed  about  one  and  a  half  or  two  feet  from  the  patient's 
face,  and  the  clothing  protected  by  a  rubber  sheet.  This  is  very  efficient 
where  steam  or  vapour  of  lime  water  are  used,  but -is  not  to  be  advised  for 
carbolic  acid,  creosote,  etc. 

Oiled-silk  Jacket. — In  all  forms  of  acute  pulmonary  inflammation  this 
form  of  local  application  has  largely  supplanted  the  time-honoured  poul- 
tice, both  in  hospital  and  in  private  practice.  It  keeps  the  skin  at  a  uni- 
form temperature,  maintains  a  moderate  degree  of  counter-irritation,  and 
gives  the  patient  a  great  deal  of  comfort.  The  jacket  consists  of  three 
layers— an  outer  one  of  oiled 

silk,  an  inner  one  of  cheese  |~^~- — ^ -^-'^ 

cloth  or  gauze,  and  a  middle  — 

one  of  cotton  batting  or  wool. 
The  middle  layer  should  be 
half  an  inch  in  thickness. 
The  purpose  of  the  lining  is 
to  keep  the  cotton  in  posi- 
tion. Fig.  14  shows  the  pat- 
tern of  the  jacket.  It  is  gen- 
erally made  in  two  pieces, 
each  of  which  should  be  about 

twelve  inches  wide  and  twelve  inches  long  for  a  child  of  one  year.  These 
are  sewed  together  along  one  border  and  lapped  at  the  other,  where  it 
is  secured  by  safety  pins      A  i)roperly  made  jacket  will  last  two  weeks. 


Fni.  14. — Pattern  for  oiled-silk  jacket. 


60 


PECULIARITIES  OP  DISEASE   IN   CHILDREN. 


Stomach- Washing  consists  in  the  introduction  of  water  into  the  stom- 
ach through  a  flexible  catheter  or  stomach  tube  and  then  siphoning  it 
out.  It  was  introduced  into  general  practice  among  infants  by  Epstein, 
of  Prague.     To  Seibert  (New  York)   is  due  the  credit  of  bringing  the 

subject  prominently  before  the  minds  of 
the  medical  profession  in  America.  It  is 
one  of  the  most  valuable  therapeutic 
measures  we  possess.  Stomach-washing 
has  been  employed  almost  daily  for  the 
past  seven  years  in  the  hospitals  with 
which  I  am  connected,  during  which 
period  the  stomach  has  been  washed 
many  thousand  times.  Xo  accident 
whatever  has  occurred,  and  the  operation 
may  be  considered  entirely  free  from 
danger ;  in  fact,  it  is  difficult  to  pass 
the  tube  anywhere  else  than  into  the 
oesophagus.  The  amount  of  prostration 
may  be  compared  to  that  of  an  ordinary 
attack  of  vomiting. 

The  apparatus  for  stomach-washing 
is  very  simple  (Fig.  15).  There  is  re- 
quired a  soft-rubber  catheter,  size  16, 
American  scale  (24  French) — one  with  a 
large  eye  is  preferred ;  a  glass  funnel, 
holding  four  to  six  ounces ;  two  feet  of 
rubber  tubing,  and  a  few  inches  of  glass  tubing  to  join  this  to  the  cathe- 
ter. The  child  should  be  held  in  a  sitting  posture  (Fig.  16),  the  body 
well  protected  by  a  rubber  sheet,  with  a  large  basin  conveniently  near. 
The  catheter  should  be  moistened.  While  the  tongue  is  depressed  with 
the  forefinger  of  the  left  hand,  the  catheter  is  passed  rapidly  back  into  the 
pharynx  and  down  the  oesophagus.  It  is  important  that  the  first  part 
of  the  introduction  should  be  as  rapid  as  possible,  for  if  the  child  begins 
to  gag  from  the  pharyngeal  irritation  the  introduction  of  the  tube  may 
be  quite  difficult.  No  resistance  is  ordinarily  encountered  after  the  tube 
reaches  the  oesophagus.  About  ten  inchesof  the  catheter  should  be  passed 
beyond  the  lips.  When  it  has  reached  the  stomach  the  funnel  should  be 
raised  as  high  as  possible,  to  allow  the  escape  of  gases  almost  invariably 
present.  It  should  then  be  lowered,  in  order  to  siphon  out  the  fluid  con- 
tents. If  nothing  escapes,  the  funnel  is  then  to  be  raised  and  from  two 
to  six  ounces  of  water  poured  into  it  from  a  pitcher ;  the  funnel  is  then 
lowered  and  the  water  siphoned  out.  This  procedure  is  repeated  from 
four  to  ten  times,  or  until  the  fluid  comes  back  perfectly  clear.  About  a 
quart  of  water  is  ordinarily  used.     Various  solutions  have  been  advised 


Fig.  15. — Apparatus  for  stoinach- 
wa.-sliintf. 


STOMACH-WASHING. 


61 


for  stomach-washing,  but  nothing  is  better  than  boiled  water,  used  at  the 
temperature  of  from  100°  to  110°  F. — the  higher  temperature  being  em- 
ployed when  the  gastric  irritation  is  very  great.  Through  the  tube  are 
easily  discharged  mucus  and  small  curds;  larger  ones  are  gradually  broken 
down  by  repeated  washing.  Vomiting  may  be  induced  by  overdistending 
the  stomach  with  water.  If  there  is  great  thirst  there  is  often  an  advan- 
tage in  leaving  one  or  two  ounces  of  water  in  the  stomach.  To  this  water 
it  is  at  times  beneficial  to  add  lime  water. 

Stomach-washing  in  its  application  is  practically  limited  to  children 
under  two  and  a  half  years.     It  is  easiest  in  those  under  eighteen  months. 


Fig.  16. — Position  tor  stoinacli-washing. 


Children  of  three  years  and  over  arc  usually  so  much  alarmed  and  struggle 
so  violently  as  to  make  it  difficult  and  undesirable. 

The  indications  for  stomach- washing  are  :    1.  In  acute  indigestion, 
either  with  or  without  persistent  vomiting.     Here  the  purpose  is  simply 


^2  PECULIARITIES  OF   DISEASE   IN   CHILDREX. 

to  clear  the  stomach  of  its  irritating  contents,  and  a  single  washing  may 
be  sufficient.  2.  In  chronic  indigestion  attended  with  a  great  production 
of  gastric  mucus,  and  sometimes,  though  rarely,  by  dilatation  of  the  stom- 
ach. In  these  cases  daily  washing  is  required  for  a  considerable  period. 
3.  In  poisoning. 

Gavage. — Gavage  consists  in  the  forcible  introduction  of  food  into  the 
stomach  through  a  tube.  It  has  long  been  employed  in  France,  and  was 
popularized  there  by  Tarnier  in  the  treatment  of  premature  infants. 
Until  1892  it  was  but  very  little  used  in  this  country — chiefly  after  op- 
erations upon  the  mouth  and  larynx.  Recent  experience,  however,  has 
shown  it  to  have  a  much  wider  application. 

The  same  apparatus  is  employed  as  in  stomach-washing,  and  the 
method  is  similar,  with  the  exception  that  for  gavage  the  child  should  be 
placed  flat  upon  the  back,  the  head  being  steadied  by  an  assistant.  In 
older  children  a  mouth-gag  is  often  necessary.  Sometimes,  where  there  is 
great  resistance  to  the  introduction  of  the  tube  through  the  mouth,  it  may 
be  passed  through  the  nose.  After  the  tube  has  entered  the  stomach  the 
funnel  should  be  raised  to  allow  the  gas  to  escape.  The  food  is  then 
poured  into  the  funnel;  as  soon  as  it  has  disappeared  the  tube  is  tightly 
pinched  and  quickly  withdrawn,  to  prevent  food  from  trickling  into  the 
pharynx,  since  this  is  often  a  cause  of  vomiting.  In  young  infants,  after 
removing  the  tube,  it  is  well  to  keep  the  jaws  separated  by  the  fingers  for 
a  few  moments  to  prevent  gagging.  If  the  food  is  regurgitated  this  usu- 
ally happens  at  once.  It  may  then  be  introduced  a  second  time.  After 
feeding,  the  child  should  be  kept  absolutely  quiet  upon  the  back. 

In  cases  where  all  the  food  is  given  by  gavage  the  interval  between 
feedings  must  be  considerably  longer  than  under  other  circumstances. 
The  food  given  should  be  either  wholly  or  partly  predigested,  since  diges- 
tion in  these  cases  is  usually  feeble.  The  stomach  should  be  washed 
before  the  first  feeding,  and  afterward  at  least  once  a  day,  in  order  to 
remove  mucus  and  to  be  sure  that  it  is  empty  before  the  meal  is  given. 

Gavage  is  valuable,  as  already  indicated  in  connection  with  the  incu- 
bator, in  the  management  of  premature  infants  and  after  certain  opera- 
tions upon  the  mouth  and  neck.  It  is  also  useful,  first,  in  the  case  of  very 
young  infants,  who,  suffering  from  severe  malnutrition,  can  not  be  induced 
to  take  food  enough  to  sustain  life  ;  secondly,  in  many  acute  diseases,  par- 
ticularly in  septic  cases  where  the  child  will  not  readily  take  the  necessary 
food,  as  in  diphtheria,  scarlet  fever,  typhoid,  pneumonia,  etc. ',  thirdly,  in 
many  cases  of  cerebral  disease  where  food  is  refused  on  account  of  delirium 
or  coma ;  and,  fourthly,  in  uncontrollable  vomiting.  This  last  use  of 
gavage  has  been  very  fully  worked  out  by  Kerley,  who  found,  after  a  large 
number  of  experiments,  that  food  given  by  gavage  was  often  retained, 
when  very  much  smaller  quantities  administered  by  the  spoon,  bottle,  or 
even  from  the  breast,  were  immediately  vomited.     Kerley's  experiments 


IRRIGATION   OP   THE  COLON.  53 

were  conducted  in  the  Xew  York  Infant  Asylum  during  my  service  there, 
and  his  results  have  been  verified  by  subsequent  experience  in  that  and  in 
other  institutions.  The  explanation  seems  to  be  that  the  passage  of  the 
tube  causes  less  irritation  of  the  pharynx  than  does  the  food  after  it 
has  been  swallowed,  vomiting  being  due  apparently  to  such  pharyngeal 
irritation.* 

Gavage  is  a  very  simple  procedure  and  one  which  a  nurse  can  easily  be 
taught.  It  is  free  from  danger,  and  in  a  great  majority  of  cases  food  is  not 
regurgitated.  Much  of  the  success  in  using  it  depends  upon  the  rapidity 
with  which  it  can  be  done.  With  a  little  experience  only  fifteen  or  twenty 
seconds  are  required.  In  acute  septic  cases  not  only  may  food  be  given, 
but  also  such  medicines  and  stimulants  as  may  be  required,  with  little  or 
no  trouble.  The  advantage  of  gavage  over  the  continued  coaxing  or  hold- 
ing the  nose  and  forcing  the  patient  to  swallow  will  be  at  once  apparent 
to  one  using  it. 

Irrigation  of  the  Colon. — By  irrigation  of  the  colon  is  meant  the  flush- 
ing of  the  entire  large  intestine  by  fluids  injected  high  up  through  a 
catheter  or  rectal  tube.  Under  no  circumstances  is  it  possible  to  inject 
fluids  beyond  the  ileo-caecal  valve,  but  we  can  be  quite  sure  that  if  proper 
precautious  be  taken  they  will  reach  as  high  as  this  point. 

The  apparatus  required  for  irrigating  the  colon  is  a  fountain  syringe, 
five  or  six  feet  of  rubber  tubing,  and  a  flexible  rectal  tube  or  soft-rubber 
catheter — No.  18  or  20,  American  scale,  being  preferred.  The  child  is 
placed  upon  the  back,  with  the  thighs  flexed  and  the  buttocks  brought  to 
the  edge  of  the  bed  or  table.  It  should  lie  upon  a  rubber  sheet  so  arranged 
as  to  form  a  trough  emptying  into  a  large  basin  or  tub.  The  clothing  is 
rolled  up  to  the  hips.  The  bag  containing  the  water  is  hung  four  or  five 
feet  above  the  bed.  The  catheter  is  oiled  and  inserted  just  within  the 
anus  before  the  water  is  turned  on.  As  it  flows  the  catheter  is  gradually 
pushed  upward  to  a  distance  of  twelve  or  fourteen  inches.  The  water 
distending  the  intestine  in  advance  of  the  catheter  usually  makes  its  intro- 
duction quite  easy.  If,  however,  the  attempt  be  made  to  introduce  the 
catheter  before  turning  on  the  water,  it  almost  invariably  doubles  upon 
itself.  In  Fig.  17  is  shown  the  colon  of  an  infant  of  six  months  in  posi- 
tion. It  is  the  peculiar  curve  and  the  great  length  of  the  sigmoid  flexure 
that  make  the  introduction  of  water  difficult,  unless  the  tube  is  passed 
quite  to  the  descending  colon.  When  this  is  done  the  remainder  of  the 
colon  fills  with  ease ;  but  if  the  tube  is  introduced  only  three  or  four 
inches  the  irrigation  is  not  likely  to  extend  beyond  the  sigmoid  flexure. 

Usually  a  pint,  and  often  a  quart,  will  be  introduced  before  any  water 
returns.     This  is  an  advantage,  since  one  can  then  be  reasonably  sure  that 

*  For  fuller  report  of  Dr.  Kerley's  cases  see  Archives  of  Paediatrics,  February,  1892 ; 
also  article  by  the  writer.  New  York  Medical  Record,  April  28,  1894. 
6 


64 


PECULIARITIES  OF   DISEASE   IX   CHILDREN. 


the  upper  part  of  the  colon  has  been  reached.  The  water  is  passed  from 
time  to  time  alongside  the  catheter,  often  with  considerable  force.  At 
least  a  gallon  of  water  should  be  used  for  a  single  irrigation.  The  wash- 
ing should  be  continued  until  the  water  returns  quite  clean.  Gentle 
kneading  of  the  abdomen  should  be  continued  during  the  irrigation,  par- 
ticularly the  early  part  of  it,  to  facilitate  the  passage  of  the  water  into  the 


Fig.  17. — Colon  of  a  child  six  months  old,  in  position.     (From  a  photograph.) 


upper  part  of  the  colon.  At  the  end  of  the  irrigation  the  rubber  tube  is  de- 
tached and  the  water  allowed  to  escape  through  the  catheter,  which  remains 
in  situ.  Sometimes  as  much  as  a  pint  of  water  remains  in  the  intestine. 
This  is  usually  passed  within  half  an  hour.  As  the  irrigation  of  the  colon 
almost  invariably  excites  active  peristalsis  of  the  lower  ileum,  this  part  of 
the  intestine  is  emptied  as  well.  It  is  to  be  remembered  that  the  colon 
of  an  infant  six  months  old  will  hold  one  pint  without  distention,  and  at 
the  age  of  two  years  from  two  to  three  pints. 

Irrigation  of  the  colon  is  useful  to  clear  this  part  of  the  intestine  of 
mucus,  faecal  matter,  undigested  food,  and  the  products  of  decomposition. 


ENEMATA. 


G5 


It  may  also  be  employed  as  a  means  of  local  medication  in  ileo-colitis. 
Where  the  object  is  simply  to  cleanse  the  intestine,  a  saline  solution — a 
teaspoonful  of  common  salt  to  a  pint  of  water — is  preferred.  In  cases  of 
inflammation  of  the  colon  various  astringent  injections  may  be  used  ;  but 
the  employment  of  antiseptic  injections  is  of  doubtful  advantage. 

The  temperature  of  the  water  used  for  irrigation  may  be  varied  accord- 
ing to  the  special  indications.  For  ordinary  purposes,  where  cleansing 
only  is  aimed  at,  the  temperature  of  from  80°  to  95°  F.  seems  to  be  best. 
When  the  body  temperature  is  high,  or  when  there  is  much  pain,  tenes- 
mus and  straining,  ice  water  has  important  advantages.  The  patient's 
temperature  may  often  be  reduced  as  effectively  by  an  ice-water  injection 
as  by  a  bath.  In  cases  of  collapse  or  great  prostration  hot  injections  may 
be  employed;  these  should  not  be  higher  than  110°  F.,  but  at  this  tem- 
perature they  may  be  used  with  safety. 

Irrigation  under  most  circumstances  is  required  only  once  in  twenty- 
four  hours.  When  it  is  employed  it  is  important  to  use  a  large  quantity 
of  water.  In  cases  of  ileo-colitis  with  severe  symptoms  two  irrigations  a 
day  may  be  advantageous.  This  means  of  treatment  certainly  forms  a 
most  valuable  addition  to  our  therapeutics  in  the  management  of  intesti- 
nal diseases.  AVith  ordinary  care  irrigations  are  free  from  danger.  They 
must  be  done  thoroughly  to  be  of  value,  and  either  by  the  physician  him- 
self or  an  experienced  nurse.  The  chief  points  of  importance  are,  that 
the  catheter  should  be  introduced  high  into  the  bowel,  and  that  a  large 
quantity  of  fluid  should  be  employed. 

Enemata. — Simple  enemata  are  useful  in  infants  and  older  children, 
to  empty  the  bowels  in  cases  of  constipation.  Where  an  immediate  effect 
is  desired  the  most  efficient  is  one  containing  glycerine — e.  g.,  for  an 
infant,  one  teaspoonful  to  one  ounce  of  water.  Oil  enemata  are  useful 
where  the  faical  mass  is  hard  and  dry  and  expelled  with  difficulty.  For 
this  purpose  from  two  drachms  to  half  an  ounce  of  sweet  oil  maybe  given. 
Enemata  should  always  be  given  with  care,  and  preferably  a  rubber  tube 
should  be  attached  to  the  nozzle  of  the  syringe,  since  injury  may  be  done 
by  a  hard-rubber  or  metal  tip. 

Nutrient  enemata  are  of  very  little  value  in  infancy.  In  older  chil- 
dren they  may  be  used  as  in  adults.  For  this  purpose  either  completely 
peptonized  milk  or  some  of  the  forms  of  beef  peptones,  like  Mosquera's 
beef  jelly,  may  be  employed.  In  giving  stimulants  in  enemata  care  should 
always  be  taken  that  they  be  well  diluted — one  part  of  brandy  to  at  least 
eight  parts  of  water. 

The  administration  of  drugs  per  rectum  is  useful  in  certain  cases 
where,  on  account  of  the  unpleasant  taste  or  vomiting,  the  administration 
by  mouth  is  difficult.  In  this  connection  we  may  mention  particularly 
quinine  and  chloral.  As  a  diluent  milk  is  preferable  to  water.  If  quinine 
is  used,  the  bisulphate  is  the  best  preparation,  but  this  must  be  well  diluted. 


QQ  PECULIARITIES   OP   DISEASE   IN  CHILDREN. 

The  use  of  stronger  solutions  than  four  grains  to  the  ounce  often  results 
in  the  production  of  rectal  catarrh.  The  temperature  of  all  enemata  which 
are  to  be  retained  should  be  about  100°  F.  It  is  necessary  in  infancy  to 
press  the  buttocks  together  for  at  least  an  hour  afterwards  to  prevent  the 
expulsion  of  the  injection. 

Hypodermic  Medication. — This  is  not  often  used  in  childhood,  but  it 
must  not  be  forgotten  that  it  is  at  times  of  the  greatest  service  even  in 
infancy.  The  use  of  morphine  hypodermically  in  convulsions,  of  mor- 
phine and  atropine  in  cholera  infantum,  of  atropine  in  opium  poisoning, 
of  strychnine  in  heart  failure,  as  in  pneumonia  and  syncope,  may  be  cited 
as  examples.  These  are  all  conditions  in  which  the  hypodermic  needle 
may  save  life. 

Massage. — In  older  children  massage  is  useful  for  the  same  conditions 
as  those  for  which  it  is  employed  in  adults ;  the  most  important  are 
ansemia  and  general  malnutrition — in  conjunction  with  the  "  rest  treat- 
ment " — in  chorea,  and  in  chronic  constipation.  For  the  last  mentioned 
only  abdominal  massage  is  employed.  The  special  method  of  doing  this 
will  be  referred  to  in  the  chapter  on  Constipation.  In  children,  even  more 
than  in  adults,  it  is  necessary  that  in  the  beginning  only  the  mildest  move- 
ments of  massage  should  be  employed,  and  these  but  for  a  short  time. 

In  infancy  massage  has  a  limited  application,  and  it  is  doubtful 
whether  it  really  does  more  than  can  be  accomplished  by  the  general 
friction  of  the  body.  This  rubbing,  either  with  the  bare  hand,  or  with 
cocoa  butter,  or  some  other  fat,  is  very  useful  in  all  forms  of  malnutrition, 
in  rickets,  and  in  wasting  diseases  where  the  circulation  is  feeble  and  the 
muscular  tone  low.  Any  form  of  fat  may  be  employed  for  inunction. 
Cocoa  butter  is  cleanly  and  has  a  pleasant  odor,  and  is,  I  think,  quite  as 
valuable  as  the  more  commonly  employed  cod-liver  oil,  which  is  exceed- 
ingly disagreeable.  The  inunctions  should  be  given  daily  after  the  morn- 
ing bath,  the  child  lying  upon  the  nurse's  lap  before  an  open  fire,  covered 
only  by  a  blanket.  The  rubbing  should  be  continued  for  fifteen  to  twenty 
minutes  each  time. 


PART  IT. 

SECTION   I. 
DISEASES  OF  THE  NEWLY  BOEN. 

CHAPTER   I. 

ASPHYXIA. 

The  lungs  in  the  full-term  foetus  are  of  a  uniform  dark  red  colour,  and 
show  very  distinctly  upon  their  surface  the  lobular  divisions.  They  are 
firm  and  solid  and  readily  sink  in  water.  The  connective  tissue  is  very 
abundant,  and  forms  distinct  fibrous  septa,  which  stretch  through  tlie 
lungs  in  every  direction. 

Inflation  of  the  lungs  begins  with  the  first  cry  uttered  by  the  infant 
as  it  is  born  into  the  world.  The  parts  first  expanded  are  the  anterior 
borders  of  the  lungs,  then  the  upper  lobes,  and  finally  the  lower  lobes 
posteriorly.  The  superficial  lobules  are  nearly  always  expanded  before 
those  in  the  interior  of  the  lung.  The  inflation  is  sometimes  irregular, 
because  of  the  accumulation  of  mucus  in  some  of  the  bronchial  tubes. 
The  right  lung  is  frequently  stated  to  be  expanded  earlier  than  the  left. 
Although  this  is  often  the  case,  there  is  no  uniformity  in  this  respect. 
The  important  point  to  be  remembered  is,  tliat  the  parts  last  iuflated  are 
the  posterior  portions  of  the  lower  lobes.  The  expansion  of  the  lungs  is  a 
gradual  process,  and  in  healthy  infants  it  is  probably  not  complete  much 
before  the  end  of  the  second  day.  In  delicate  children  it  may  be  post- 
poned for  several  days,  or  even  weeks.  The  above  statements  are  based 
upon  post-mortem  observations  upon  infants  dying  from  various  causes 
during  the  first  weeks.  It  has  often  been  a  matter  of  great  surprise  to 
find  at  autopsy  on  an  infant  two  or  three  days  old,  that  less  than  one  half 
of  the  lung  tissue  was  expanded,  although  the  child  had  breathed  well 
and  shown  no  signs  of  atelectasis.  Under  normal  conditions  at  full  term 
inflation  of  the  lung  takes  place  very  readily,  but  not  so  readily  in  pre- 
mature or  delicate  infants,  on  account  of  the  feebleness  of  the  respiratory 
muscles.  The  longer  it  is  postponed  after  birth  the  more  difficult  does  it 
become,  on  account  of  the  changes  which  occur  in  the  collapsed  air  vesi- 

67 


08  DISEASES   OF   THE   NEWLY  BORN. 

cles.  The  condition  of  the  child  in  utero  may  be  described  as  one  of 
foetal  apnoea,  its  oxygen  being  received  and  its  carbon  dioxide  discharged 
through  the  placenta,  which  is  essentially  the  organ  of  respiration  at  this 
period.  This  condition  is  interrupted  by  cutting  off  the  supply  of  oxygen 
and  the  accumulation  of  carbon  dioxide  in  the  blood.  AVhich  of  these  is 
the  important  factor  in  inducing  iiulinonary  respiration  has  been  much 
debated ;  but  the  best  experimental  evidence  seems  to  show  that  it  is  the 
want  of  oxygen  which  stimulates  the  respiratory  centres. 

Under  the  term  "  asphyxia  "  may  be  included  all  cases  in  which  pri- 
mary respiration  is  not  spontaneously  established  with  sufficient  force  to 
maintain  life.  Usually  there  is  no  attempt  at  pulmonary  respiration  until 
after  the  birth  of  the  child,  but  it  may  occur  in  utero  or  at  any  stage  of 
parturition.     Asphyxia  may  be  of  intra-uterine  or  extra-uterine  origin. 

Etiology. — 1.  Intra-uterine  aaphyxia.  The  maternal  causes  include 
any  disturbance  of  the  placental  circulation  during  labour — anything 
which  prolongs  the  second  stage  of  labour,  convulsions,  haemorrhage,  the 
use  of  ergot  in  the  second  stage,  or,  finally,  the  death  of  the  mother.  The 
causes  relating  to  the  child  are  pressure  upon  the  cord,  multiple  winding 
of  the  cord  about  the  neck,  early  separation  of  the  placenta,  and  pressure 
upon  the  brain.  If  the  respiratory  stimulus  comes  before  the  birth  of 
the  child,  the  effort  at  respiration  may  cause  the  entrance  into  the  mouth 
aud  air  passages  of  amniotic  fluid,  mucus,  blood,  meconium,  etc. 

2.  Extra-lit erine  asphyxia.  This  condition  is  a  much  less  common 
one.  It  arises  from  causes  quite  apart  from  those  above  mentioned,  and 
depends  upon  malformations  or  intra-uterine  disease  of  the  organs  of 
respiration,  circulation,  or  of  the  brain.  It  may  be  secondary  to  an  injury 
of  any  of  these  organs  received  during  parturition.  It  is  also  seen  in  pre- 
mature infants,  where  it  depends  upon  the  feeble  development  of  the  nerve 
centres  and  respiratory  muscles  and  upon  the  soft,  yielding  chest  walls. 

Lesions. — In  infants  dying  of  intra-uterine  asphyxia  there  are  seen 
the  usual  changes  found  in  death  from  suffocation,  together  with  the  effects 
of  attempts  at  breathing  in  utero.  There  is  general  congestion  of  all  the 
viscera,  particularly  of  the  brain  and  its  meninges,  the  liver,  and  the  lungs. 
They  may  show  small,  punctate  haemorrhages,  and  occasionally  large  ex- 
travasations. Blood  or  bloody  serum  may  be  found  in  any  of  the  serous 
cavities.  The  right  heart  is  overdistended  with  dark,  soft  clots,  and  the 
blood  generally  is  more  fluid  than  normal.  The  lungs  may  contain  no 
air,  but  more  frequently  there  are  small,  scattered  areas  in  which  lobular 
inflation  has  taken  place.  If  the  child  has  lived  several  hours  there  are 
larger  areas  of  expanded  lung,  especially  in  the  upper  lobes,  and  these 
may  even  be  emphysematous,  if  artificial  inflation  has  been  employed. 
In  the  mouth,  nose,  larnyx,  and  even  as  far  as  the  finest  bronchi,  there 
may  be  found  aspirated  materials — amniotic  fluid,  blood,  mucus,  or  me- 
conium.    In  extra-uterine  asphyxia  there  are  organic  changes  in  the  vis- 


ASPHYXIA.  69 

cera — malformations  of  the  lungs  or  the  heart,  intra-uterine  pneumonia 
or  pleuritic  effusion,  malformation  of  the  diaphragm  and  sometimes  of 
the  brain. 

Symptoms. — Under  normal  conditions  the  newly-born  infant  begins  at 
once  to  scream  and  to  use  its  limbs,  the  purplish  colour  of  the  skin  giving 
place  in  a  few  moments  to  a  rosy  pink.  In  the  first  degree  of  asphyxia — 
asphyxia  livida — the  child  is  deeply  cyanosed.  Either  no  attempt  what- 
ever is  made  at  respiration,  or  it  is  superficial  and  repeated  only  at  long 
intervals.  The  pulse  is  slow,  full,  and  strong.  The  vessels  of  the  cord 
are  distended.  Muscular  tone  is  preserved,  and  also  cutaneous  irritability, 
so  that  with  the  application  of  almost  any  kind  of  external  stimulus,  respi- 
ration is  excited  and  the  symptoms  disapjiear. 

In  the  second  degree — asphyxia  pallida — the  picture  is  quite  a  different 
one.  The  face  is  pale  and  death-like,  though  the  lips  may  still  be  blue. 
The  heart's  action  is  weak,  and  by  palpation  can  rarely  be  felt  at  all.  By 
auscultation  the  sounds  are  feeble,  irregular,  and  usually  slow.  The  cord 
is  soft,  pale,  and  flaccid,  and  its  vessels  nearly  empty.  The  sjihincters  are 
relaxed,  and  meconium  oozes  from  the  anus.  There  is  entire  loss  of  tone 
in  the  voluntary  muscles,  so  that  the  extremities  and  entire  body  seem 
perfectly  limp.  Cutaneous  sensibility  is  abolished.  The  extremities  are 
often  cold.  There  may  occur  a  few  short,  convulsive  contractions  of  the 
respiratory  muscles,  but  these  are  without  effect  and  soon  cease.  Unless 
such  cases  receive  the  most  prompt  and  efficient  treatment,  the  heart's 
action  becomes  more  and  more  feeble  until  it  ceases  and  death  occurs. 
Other  cases  are  partly  resuscitated  and  may  survive  for  a  few  hours  or 
days,  when  they  gradually  sink,  respiration  becoming  more  and  more 
feeble  in  spite  of  all  efforts  to  maintain  it.  Between  these  two  extremes 
all  degrees  of  severity  are  seen. 

In  extra-uterine  asphyxia  there  may  be  some  attempts  at  voluntary 
respiration  continuing  for  several  hours,  sometimes  for  a  day  or  two,  but 
this  may  be  inadequate  to  sustain  life. 

Diagnosis. — Almost  the  only  condition  with  which  asphyxia  is  likely 
to  be  confounded  is  cerebral  compression  from  a  meningeal  haemorrhage. 
The  difficulties  in  the  case  are  much  increased  by  the  fact  that  the  two 
conditions  are  not  infrequently  associated.  It  may  then  be  impossible  to 
tell  that  in  addition  to  asphyxia,  intracranial  haemorrhage  is  present.  If  the 
haemorrhage  is  extensive  and  the  asphyxia  only  moderate,  a  diagnosis  is 
jiossible  in  most  of  the  cases.  In  haemorrhage  there  is  often  a  history  of 
undue  compression  during  delivery — sometimes  the  use  of  forceps.  The 
fontanel  is  bulging ;  there  is  coma,  and  there  may  be  paralysis.  The  re- 
spiratory murmur  may  be  quite  strong  for  several  hours,  but  it  gradually 
fails  as  the  child  becomes  completely  comatose.  Ansemia  resulting  from 
a  large  haemorrhage,  like  that  due  to  rupture  of  the  cord,  may  simulate  the 
severe  form  of  asphyxia. 


70  DISEASES  OP  THE  NEWLY  BORN. 

Prognosis. — This  depends  upon  the  grade  of  asphyxia  and  the  treat- 
ment employed.  There  is  but  little  tendency  to  spontaneous  recovery  in 
any  form.  In  the  milder  cases  recovery  is  almost  invariable  with  any 
intelligent  treatment.  In  the  severest  cases  the  outcome  is  always  doubt- 
ful, although  by  persistent  effort  many  that  are  apparently  hopeless  may  be 
saved.  In  a  prognosis  as  to  the  ultimate  result,  the  frequent  complica- 
tion of  asphyxia  with  meningeal  haemorrhage  should  always  be  kept  in 
mind.  Apart  from  this  complication  it  is  doubtful  whether  asphyxia  has 
anything  to  do  with  the  production  of  idiocy. 

Treatment. — In  every  case  the  first  step  is  to  clear  the  mouth  and 
pharynx  of  mucus  by  means  of  the  finger  covered  with  absorbent  cotton. 
In  the  milder  forms  respiration  is  usually  excited  either  by  spanking  the 
child  or  the  alternate  use  of  hot  and  cold  baths.  If  the  hot  bath  is  em- 
ployed, the  water  should  be  from  110°  to  120°  F.,  or  about  as  hot  as  the 
hand  will  bear.  After  a  few  moments  the  child  may  be  dipped  into  cold 
water,  or  the  body  may  be  douched  with  it.  In  the  livid  cases  relief  is 
often  afforded  by  allowing  the  cord  to  bleed  for  a  few  moments  before  liga- 
tion. The  loss  of  half  an  ounce  of  blood  is  ordinarily  sufficient.  Simply 
swinging  the  child  in  the  air  is  a  powerful  stimulus  to  respiration.  The 
above  means  will  suffice  in  the  great  majority  of  cases.  In  the  more  severe 
forms,  however,  these  are  inadequate.  There  is  no  response  whatever  to 
external  stimulation,  either  by  heat  or  mechanical  irritation.  In  these 
cases  two  methods  of  resuscitation  may  be  employed  :  artificial  respiration 
and  direct  inflation  of  the  lungs. 

One  of  the  most  widely  employed  methods  of  inducing  artificial  respi- 
ration is  that  of  Schultze.  The  infant  is  grasped  by  both  axillae  in  such 
a  way  that  the  thumbs  of  the  physician  rest  upon  the  anterior  surface  of 
the  chest,  the  index  fingers  in  the  axillae,  and  the  remaining  fingers  extend- 
ing across  the  back.  The  child  is  thus  suspended  at  arm's  length  between 
the  knees  of  the  physician,  the  feet  downward  and  the  face  anterior.  The 
body  is  now  swung  forward  and  upward,  until  the  physician's  arms  are 
nearly  horizontal.  This  produces  the  inspiratory  effort.  When  this  point 
is  reached,  an  arrest  in  the  swinging  causes  flexion  of  the  trunk,  the  head 
now  being  directed  downward,  the  lower  extremities  fall  toward  the  phy- 
sician until  the  whole  weight  of  the  body  rests  upon  the  thumbs.  In  this 
way  expiration  is  produced.  Lusk  cautions  against  the  employment  of 
this  method  if  the  heart's  action  is  very  feeble,  as  it  may  cause  the  heart 
to  stop  altogether. 

A  method  introduced  by  Dew  has  been  extensively  employed  in  New 
York.  The  infant  is  grasped  in  such  a  way  that  the  neck  rests  between 
the  thumb  and  forefinger  of  the  left  hand,  the  head  being  allowed  to  fall 
far  backward,  the  upper  portion  of  the  back  resting  upon  the  palm  of  the 
hand ;  with  the  right  hand  the  knees  are  grasped  between  the  thumb 
and  fingers,  the  thighs  resting  against  the  palm  of  the  hand.     Inspiration 


ASPHYXIA.  71 

is  produced  by  depressing  the  pelvis  and  lower  extremities  thus  causing 
the  abdominal  organs  to  drag  upon  the  diaphragm,  and  at  the  same  time 
gently  bending  the  dorsal  region  of  the  spine  backward.  In  expiration 
the  movement  is  reversed,  the  head  being  brought  forward  and  flexed 
upon  the  thorax,  while  at  the  same  time  the  thighs  are  flexed  so  as  to 
bring  them  against  the  abdomen.  The  body  is  thus  alternately  folded 
upon  itself  and  unfolded  as  the  movements  are  carried  on.  If  there  is 
much  mucus  in  the  mouth,  the  movement  of  expiration  should  first  be 
made  with  the  body  completely  inverted.  This  method  is  simple,  efficient, 
and  much  less  fatiguing  than  that  of  Schultze  when  it  is  to  be  main- 
tained for  a  long  time.  It  is  also  of  great  advantage  in  that  it  can  be 
carried  on  while  the  child  is  in  the  hot  bath,  one  of  the  greatest  objec- 
tions to  the  method  of  Schultze  being  the  loss  of  animal  heat  incident  to 
its  use. 

In  all  cases  where  artificial  respiration  is  used  the  first  movement 
should  be  that  of  expiration,  to  expel,  so  far  as  possible,  foreign  substances 
from  the  air  passages.  The  movements  should  be  made  from  eight  to 
twelve  times  a  minute,  and  not  too  forcibly,  the  child  being  kept  in  the 
hot  bath  between  the  movements,  and  as  much  as  possible  during  them. 
As  long  as  the  heart  beats  resuscitation  is  possible,  and  the  case  should 
not  be  abandoned. 

Inflation  of  the  lungs  is  not  usually  of  so  much  general  value,  although 
it  is  sometimes  successful  when  all  other  means  have  failed.  It  may  be 
done  by  the  mouth-to-mouth  method,  or  by  the  introduction  of  a  catheter 


Fio.  18. — Ribemont's  laryngeal  tube  for  inflating  the  lungs. 

into  the  larnyx.  The  former  is  much  easier,  but  is  much  less  certain, 
since  the  air  is  liable  to  pass  into  the  stomach.  If,  however,  the  head  be 
carried  pretty  well  backward,  compression  made  over  the  epigastrium,  and 
the  nose  closed,  this  is  less  likely  to  occur.  The  introduction  of  a  flexible 
catheter  into  the  larynx  is  by  no  means  an  easy  matter  even  with  consid- 
erable practice.  The  use  of  a  stiff  catheter  is  not  so  difficult,  but  it  is  capa- 
ble of  doing  liarm.  A  much  better  instrument  is  the  laryngeal  tube  of 
Ribemont  (Fig.  18).  This  is  inserted  like  an  intubation  tube.  By  means 
of  the  rubber  bag  attached,  air  may  be  forced  into  the  lung,  or  mucus 
aspirated  from  the  trachea  and  bronchi  as  may  be  desired.  In  all  these 
methods,  but  especially  when  the  catheter  is  used,  care  is  necessary  not  to 
employ  too  much  force.     It  should  always  be  remembered  that  the  ca- 


Y2  DISEASES   OF   THE   NEWLY  BORN. 

pacity  of  tlie  Inngs  of  the  child  is  much  less  than  that  of  those  of  the 
physician.  Like  artificial  respiration,  inllation  is  to  be  used  in  connec- 
tion with  the  external  application  of  heat,  preferably  the  continuous  hot 
bath. 

A  method  lately  introduced  by  Laborde,  of  making  rhythmical  traction 
upon  the  tongue  eight  to  ten  times  a  minute  as  a  means  of  exciting  respira- 
tion, is  one  of  the  most  efficient  within  our  reach.  It  may  be  resorted  to 
in  conjunction  with  other  methods,  or  used  alternately  with  them. 

In  cases  of  asphyxia  it  is  not  enough  to  make  the  child  cry.  The 
deep  respirations  must  be  made  to  continue,  for  very  often  it  happens 
that  resuscitation  is  only  partial,  and  that  the  child  after  six  or  eight 
hours  lapses  into  its  previous  condition.  All  severe  cases  require  careful 
watching  for  the  first  twenty-four  or  thirty-six  hours,  as  a  repetition  of 
the  treatment  is  often  required. 


CHAPTER   II. 

CONGENITAL   ATELECTASIS. 

This  condition  is  one  in  which  there  is  a  persistence  of  the  foetal  state 
in  the  whole  or  in  any  part  of  the  lung. 

Atelectasis  is  the  pathological  condition  with  which  asphyxia  of  the 
newly  born  is  usually  associated.  In  most  of  the  cases  the  condition  of 
atelectasis  is  completely  overcome  by  the  means  employed  in  resuscitation ; 
in  some,  however,  these  means  are  only  partially  successful,  so  that  a  por- 
tion of  lung  of  variable  extent  remains  in  the  foetal  condition.  These  are 
the  circumstances  in  which  most  of  the  cases  of  atelectasis  arise.  But 
there  are  others  in  which  there  is  no  history  of  early  asphyxia,  where  the 
primary  respirations,  although  taking  place  spontaneously,  have  not  been 
of  sufficient  force  and  depth  to  produce  full  pulmonary  expansion.  This 
usually  occurs  in  feeble  infants,  or  in  those  who  are  premature.  The 
causes  of  congenital  atelectasis  are  therefore,  in  the  main,  those  mentioned 
as  producing  asphyxia. 

Lesions. — In  cases  where  the  child  dies  during  the  first  few  days  the 
amount  of  expanded  lung  is  often  very  small,  frequently  not  more  than 
one  fourth  of  the  pulmonary  area.  The  expanded  portion  is  usually  the 
anterior  borders  of  the  upper  lobes.  This  is  often  the  seat  of  acute  em- 
physema. The  rest  of  the  lung  is  still  in  the  foetal  state ;  it  is  of  a 
brownish-red  colour,  very  vascular,  does  not  crepitate,  and  shows  the  lobu- 
lar outlines  both  on  the  surface  and  on  section.  AVith  a  little  force  the 
atelectatic  lung  may  be  completely  inflated. 

If  children  have  lived  several  months,  nearly  the  whole  of  .the  upper 


CONGENITAL   ATELECTASIS.  Y3 

lobes  and  the  anterior  portion  of  the  lower  lobes  are  usually  well  inflated. 
These  portions  are  either  normal  or  slightly  enii)hyseniatous.  The  pos- 
terior portion  of  the  upper  lobes  and  tiic  lower  lobes  are  almost  invariably 
the  seat  of  the  atelectasis.  On  the  surface  even  these  portions  may  pre- 
sent quite  a  large  area  of  expanded  vesicles,  but  the  lobe  is  solid  to  the 
touch,  and  crepitates  but  slightly.  On  section  it  is  seen  that  only  the 
most  superficial  part  of  the  lung  is  inflated,  often  only  to  the  depth  of 
a  line,  while  the  interior  of  the  lobe  is  unexpanded.  Small  haemorrhages 
are  frequently  seen  beneath  the  pleura. 

It  is  usual  for  both  lungs  to  be  affected,  and  often,  but  by  no  means 
uniformly,  to  about  the  same  degree.  It  is  frequently  a  great  surprise  to 
discover  that  a  child  has  lived  two  or  three  months  without  presenting 
any  signs  of  cyanosis,  using  not  more  than  one  third  of  its  pulmonary  area. 
This  variety  of  atelectasis  closely  resembles  the  hypostatic  pneumonia  of 
delicate  infants,  and  very  often  the  two  conditions  are  associated.  It  may 
require  the  microscoj^e  to  decide  between  them.  If  congenital  atelectasis 
has  existed  for  some  months,  there  are  usually  found  evidences  of  pneu- 
monia. Inflation  is  not  so  easy  as  in  recent  cases,  but  with  force  the 
greater  part  of  the  lung  can  usually  be  expanded.  The  heart  commonly 
shows  the  right  auricle  and  ventricle  to  be  distended  with  dark  clots,  and 
there  is  occasionally  found  a  patent  foramen  ovale  or  some  other  form  of 
congenital  lesion.  The  liver  and  spleen  are  in  most  cases  coiigested,  and 
the  spleen  may  be  considerably  enlarged.  The  mucous  membrane  of  the 
stomach  and  intestines  is  sometimes  deeply  congested. 

Symptoms. — In  one  group  of  cases  the  children  are  asphyxiated  at 
birth,  but  the  attempts  at  resuscitation  have  been  only  partially  successful. 
Although  the  patients  may  live  for  a  few  days,  there  is  cyanosis,  which 
gradually  deepens,  and  death  takes  place  from  asphyxia,  exhaustion,  or 
convulsions. 

In  a  second  group  of  cases  the  infants  have  been  asphyxiated  at  birth, 
and  resuscitated  perhaps  with  difficulty,  but  to  all  appearance  completely. 
They  do  not  thrive,  however,  remaining  small  and  delicate,  gaining  very 
little  or  not  at  all  in  weight,  and  showing  poor  circulation,  cold  extremi- 
ties, and  occasionally  subnormal  temperature.  It  is  characteristic  of  these 
cases  that  the  cry  is  never  loud,  strong,  and  lusty.  Some  of  tliem  will  not 
cry  at  all.  Such  children  may  live  several  weeks,  or  even  months.  There 
may  develop  at  any  time,  often  quite  suddenly  and  without  assignable  cause, 
attacks  of  cyanosis  with  prostration.  Children  may  have  several  such  at- 
tacks, which  do  not  excite  suspicion  since  they  pass  away  s])ontaneonsly. 
In  other  cases  the  symptoms  are  so  severe  that  Miey  may  result  fatally  in  a 
few  hours,  death  being  frequently  preceded  by  convulsions.  If  energetically 
treated  the  symptoms  may  pass  away  but,  reajipearing  in  a  few  hours,  or 
again  after  a  week  or  more,  they  gradually  deepen  in  intensity  until  death 
occurs. 


'j'4  DISEASES  OF   THE   NEWLY  BORX. 

Two  cases  coming  under  my  observation  in  the  Xew  York  Infant 
Asylum  in  1890,  illustrate  this  point.  The  infants  were  twins,  ten  weeks 
old  and  delicate.  Suddenly  at  night  one  child  was  taken  with  convul- 
sions, became  deeply  cyanosed,  and  died  in  two  and  a  half  hours.  It  had 
been  suffering  from  a  slight  attack  of  indigestion  and  diarrhoea  for  a  week 
previous,  but  apparently  was  not  seriously  ill.  The  other  twin  had  been 
on  the  previous  day  as  well  as  for  several  weeks.  Two  hours  after  the 
death  of  the  first  child  the  second  was  taken  with  similar  symptoms,  dying 
in  a  few  hours.  At  autopsy  I  found  very  extensive  atelectasis  involving 
the  posterior  part  of  the  upper  and  the  greater  part  of  both  lower  lobes. 
The  lesions  were  almost  identical  in  the  two  cases.  In  both,  the  stomach 
was  greatly  distended  with  food  and  gas.  I  have  repeatedly  seen  the 
effect  of  overdistention  of  the  stomach  in  producing  cyanosis  in  young 
children,  and  in  this  instance  I  believe  it  to  have  been  the  exciting  cause 
of  the  final  symptoms.  It  was  subsequently  learned  that  during  the  six 
weeks  of  observation  the  nurse  had  witnessed  several  slight  attacks  of  cy- 
anosis in  one  of  the  infants. 

I  have  seen  a  number  of  such  cases,  in  which  there  was  nothing  what- 
ever to  attract  attention  to  the  lungs  until  the  final  attack  of  cyanosis 
occurred,  the  children  showing  only  the  signs  of  malnutrition.  In  not  all 
of  these  cases  is  there  a  history  of  asphyxia  at  birth.  Some  are  only  puny, 
delicate  or  premature,  exhibiting  during  the  early  weeks  of  life  all  the 
signs  of  feeble  vitality.  The  subsequent  course  is  the  same  as  in  those  in 
which  there  is  early  asphyxia.  The  duration  of  life  in  these  cases  depends 
chiefly  upon  the  extent  of  the  atelectasis. 

It  is  not  to  be  supjjosed  that  all  cases  of  congenital  atelectasis  ter- 
minate fatally.  Infants  in  whom  there  is  every  reason  to  believe  that 
atelectasis  exists,  from  the  occasional  attacks  during  the  first  few  weeks  of 
cyanosis,  feeble  cry,  poor  circulation,  etc.,  may  under  favourable  conditions 
recover  completely,  even  though  no  special  treatment  is  directed  to  the 
lungs. 

Diagnosis. — For  this  the  physical  signs  are  of  much  less  value  than  the 
symptoms.  It  should  be  remembered  that  the  principal  seat  of  the  disease 
is  the  lower  lobes  posteriorly.  Percussion  usually  gives  resonance  over  the 
entire  chest,  although  this  may  be  somewhat  diminished  posteriorly.  There 
is  not,  however,  so  much  change  as  one  would  expect  to  find,  for  the  col- 
lapsed areas  are  surrounded  by  others  which  are  overdistended,  and  there 
are  in  the  midst  of  the  collapsed  parts,  especially  upon  the  surface,  lobules 
which  are  inflated.  If  the  two  sides  are  involved  to  about  the  same  degree, 
as  is  often  the  case,  we  can  get  no  difference  in  the  percussion  note  over 
the  two  lungs,  and  the  change  from  the  normal  may  be  so  slight  as  not  to 
be  appreciable.  Where  only  one  lung  is  affected  a  difference  can  usually 
be  made  out.  The  respiratory  murmur  is  rarely  bronchial,  but  generally 
only  feeble  in  its  intensity,  and  rather  ruder  in  quality  than  normal.     As 


ICTERUS.  75 

in  the  case  of  percussion,  if  only  one  lung  is  affected  this  is  of  some  value 
in  diagnosis,  but  it  is  not  sufficiently  marked  to  be  readily  recognized 
when  both  sides  are  involved.     Occasionally  rales  are  present. 

Treatment. — In  the  newly-born  child,  whether  asphyxiated  or  not,  the 
physician  should  see  to  it  that  the  infant  not  only  cries,  but  does  so 
loudly  and  strongly,  and  that  this  cry  is  repeated  every  day.  If  children 
do  not  cry  naturally  they  must  be  made  to  do  so  by  the  alternate  use  of 
the  hot  and  cold  bath,  as  in  cases  of  asphyxia,  or  by  mechanical  means, 
like  spanking.  This  should  be  repeated  at  least  twice  a  day,  and  con- 
tinued for  from  lifteen  to  thirty  minutes.  It  may  seem  cruel,  but  it  is 
often  the  only  means  of  saving  life.  Expansion  of  the  lungs  is  much 
more  easily  induced  during  the  first  few  days  of  life,  becoming  more  and 
more  difficult  the  longer  it  is  delayed.  Provided  the  condition  is  recog- 
nized, treatment  is  fairly  successful.  In  institutions  where  delicate  infants 
spend  most  of  the  time  in  their  cribs,  atelectasis  is  likely  to  be  found. 
An  infant  needs  exercise,  and  this  is  often  only  to  be  obtained  by  taking 
the  child  from  its  crib  several  times  a  day,  by  general  friction,  massage, 
the  stimulus  of  fresh  air,  etc.  Nothing  is  more  certain  to  perpetuate 
atelectasis  than  to  allow  the  infant  a  life  of  feeble  vegetative  existence. 
Food  and  feeding  must  be  carefully  attended  to,  but  even  these  are  of  less 
importance  than  the  maintenance  of  the  animal  heat.  The  temperature 
is  often  subnormal,  and  should  be  closely  watched.  If  there  is  difficulty 
in  keeping  the  child  warm  it  should  be  rolled  in  cotton  and  surrounded 
by  hot  bottles,  or  kept  in  an  incubator  during  the  first  few  weeks.  (See 
page  10.)  During  attacks  of  cyanosis  the  same  means  are  to  be  employed 
as  in  cases  of  asphyxia  of  the  newly  born — cutaneous  stimulation  and  arti- 
ficial respiration — the  administration  of  drugs  being  of  little  or  no  value. 


CHAPTER   III. 

ICTERUS. 

Several  varieties  of  icterus  are  met  with  in  the  newly  born. 

1.  It  is  often  seen  in  the  various  forms  of  pyogenic  infection.  In 
such  cases  the  icterus  is  usually  mild. 

2.  It  may  depend  upon  syphilitic  hepatitis — a  rare  cause. 

3.  It  may  be  due  to  congenital  malformations  of  the  bile-ducts. 

4.  The  most  frequent  of  all  varieties  is  the  so-called  idiopathic  icterus, 
sometimes  spoken  of  as  "  physiological "  icterus. 

In  the  cases  included  under  the  first  and  second  heads  icterus  is  a 
minor  symptom.  The  other  varieties  are  sufficiently  important  to  require 
separate  consideration. 


76  DISEASES   OF  THE   NEWLY  BORN. 


MALFORMATIONS  OF   THE   BILE-DUCTS. 

The  common  bile-duct  is  the  most  frequently  affected.  There  may  be 
atresia  at  the  point  where  it  opens  into  the  intestine,  the  duct  may  be 
represented  by  a  fibrous  cord,  or  it  may  be  absent  altogether.  In  many 
cases  this  is  the  only  lesion  ;  in  others  it  is  associated  with  an  impervious 
hepatic  or  cystic  duct ;  in  still  others  the  common  duct  is  normal,  but 
the  cystic  or  hepatic  ducts  are  impervious. 

At  autopsy  all  the  organs  are  usually  found  intensely  jaundiced,  par- 
ticularly the  liver.  In  recent  cases  this  is  very  much  swollen,  but  pre- 
sents no  marked  organic  changes.  In  cases  which  have  lasted  several 
months  there  is  commonly  found  chronic  interstitial  hepatitis,  sometimes 
to  a  very  marked  degree.  This  was  present  in  nine  of  the  fifty  cases  col- 
lected by  Thompson.*  The  gall-bladder  is  usually  small,  and  often  rudi- 
mentary. In  cases  of  atresia  of  the  common  duct  it  may  be  greatly  dis- 
tended. 

The  condition  of  the  bile-ducts  is  ascribed  to  an  error  in  development 
and  subsequent  catarrhal  inflammation.  There  does  not  seem  to  be  suf- 
ficient evidence  to  prove  that  hereditary  syphilis  is  an  etiological  factor 
of  much  imj^ortance.  This  was  present  in  but  five  of  Thompson's 
cases. 

Symptoms. — The  most  striking  symptom  is  jaundice,  which  is  usually 
noticed  a  day  or  two  after  birth,  and  steadily  increases  until  it  becomes 
intense.  The  urine  is  colored  a  dark  brown  or  bronze  by  bile  pigment, 
and  even  the  meconium  stools  may  be  white,  except  in  cases  where  mal- 
formation is  limited  to  the  cystic  duct.  The  liver  as  a  rule  is  much  en- 
larged. The  spleen  is  often  swollen.  Ilsemorrhages  beneath  the  skin  or 
from  any  of  the  mucous  membranes  are  quite  common.  Vomiting  is 
usually  absent.  In  most  cases  there  is  progressive  wasting,  and  death 
within  the  first  few  weeks.  Of  Thompson's  fifty  cases,  nine  lived  less 
than  a  month,  and  only  eighteen  over  four  months.  Lotze  has  reported 
a  case  of  a  child  living  eight  months  with  an  impervious  hejiatic  duct. 
A  frequent  cause  of  death  in  the  rapid  cases  is  convulsions. 

These  malformations  cannot  be  influenced  by  any  treatment. 

PHYSIOLOGICAL   OR   IDIOPATHIC  ICTERUS. 

In  900  consecutive  births  at  the  Sloane  Maternity  Hospital  icterus 
was  noted  in  300  cases.  In  88  it  was  intense,  in  212  it  was  mild.  Ac- 
cording to  the  statistics  of  various  lying-in  hospitals  of  Germany,  it  was 
found  in  from  40  to  80  per  cent,  of  all  infants.  In  the  300  cases  just 
referred  to,  icterus  was  noticed  on  the  first  day  in  4,  on  the  second  day  in 
19,  on  the  third  day  in  72,  on  the  fourth  day  in  86,  on  the  fifth  day  in  67, 

*  Edinburgh  Medical  Journal,  1892. 


ICTERUS.  77 

and  on  or  after  the  sixth  day  in  44.     From  the  second  to  the  fifth  day  is 
therefore  the  usual  period  for  its  appearance. 

It  usually  increases  in  severity  for  one  or  two  days  and  then  slowly 
disappears.  The  average  duration  in  the  mild  cases  is  three  or  four  days ; 
in  those  of  moderate  severity  about  a  week ;  in  the  most  severe  cases  it 
may  last  for  two  weeks.  The  icterus  is  first  noticed  in  the  skin  of  the 
face  and  chest,  then  in  the  conjunctivae,  then  in  the  extremities.  The 
skin  varies  in  colour  from  a  pale  to  an  intense  yellow.  The  urine  in  most 
cases  is  normal.  It  sometimes  is  of  a  light  brown  colour,  and  only  in  the 
most  severe  cases  does  it  contain  bile  pigment.  According  to  Runge,  both 
urea  and  uric  acid  are  produced  in  larger  amounts  than  in  children  not 
icteric.  The  stools  are  unchanged,  the  normal  yellow  evacuations  occur- 
ring in  the  icteric  as  early  as  in  those  not  affected. 

According  to  some  observers,  in  infants  who  are  icteric  the  initial  loss 
in  weight  is  greater  and  the  subsequent  gain  slower  than  in  other  children. 
This  is  not  borne  out  by  the  Sloane  statistics.  Of  the  300  icteric  children, 
155  made  satisfactory  progress  in  every  respect  and  gained  rapidly.  The 
progress  in  106  cases  was  said  to  be  "  fair " — i.  e.,  at  the  time  of  dis- 
charge, usually  on  the  tenth  day,  a  slight  gain  in  weight  was  noted. 
The  remaining  39  did  badly,  not  gaining  in  weight  and  showing  other 
symptoms  of  malnutrition.  The  proportion  of  icteric  infants  who  did 
well,  moderately,  and  badly,  was  practically  the  same  as  of  the  other 
children  in  the  institution  not  suffering  from  icterus.  Icterus  occurs  with 
equal  frequency  in  both  sexes.  According  to  Kehrer,  it  is  more  frequent 
in  first  children  than  in  later  ones,  and  considerably  more  frequent  in 
premature  children  than  in  those  born  at  term.  The  presentation,  the 
duration  of  labour  and  its  character — whether  natural  or  artificial— have 
no  influence  upon  the  production  of  icterus.  As  a  rule  icteric  children 
appear  in  other  respects  healthy,  but  in  those  below  the  average  size  the 
icterus  is  apt  to  be  more  intense. 

Few  subjects  have  given  rise  to  wider  speculation  than  this  form  of 
icterus.  Its  exact  pathology  is  at  present  unknown.  Of  tlie  many  theo- 
ries advanced,  that  of  Silbermann  is  perhaps  the  most  satisfactory — viz., 
that  the  icterus  is  due  to  resorption,  and  is  hepatogenous  in  its  origin. 
With  this  view  Frerichs  and  Schultze  agree.  Silbermann  explains  the 
resorption  by  the  existence  of  stasis  in  the  capillary  bile-ducts  which  are 
compressed  by  the  dilated  branches  of  the  portal  vein  and  the  blood  capil- 
laries. The  change  in  the  circulation  of  the  liver  is  one  of  the  results  of 
the  cliange  in  the  blood  which  occurs  soon  after  birth.  This  results  from 
an  extensive  destruction  of  the  red  blood  cells — a  kind  of  blood  fermenta- 
tion. The  more  feeble  the  child  the  more  intense  the  icterus,  because 
the  blood  changes  are  more  intense.  In  consequence  of  tliis  destruction 
of  red  blood  cells  abundant  material  for  the  formation  of  bile  pigment 
exists  and  accumulates  in  the  hepatic  vessels. 


78  DISEASES   OP   THE   NEWLY  BORN. 

In  jaundiced  infants  who  have  died  from  accident  or  otlier  causes  tlie 
skin  and  almost  all  the  internal  organs  are  found  icteric.  There  is  also 
staining  of  the  internal  coat  of  the  arteries,  the  endocardium,  the  peri- 
cardium, and  the  pericardial  fluid.  Sometimes  the  subcutaneous  connect- 
ive tissue  is  yellow,  also  the  brain  and  cord  ;  the  spleen  and  kidneys  only 
in  the  most  severe  cases.  In  the  kidneys  uric-acid  infarctions  are  often 
found,  and  sometimes  bile  pigment.  The  liver  is  rarely  discoloured.  The 
bile-ducts  are  normal.  In  certain  cases  Birch-Hirschfeld  has  discovered 
bile  pigment  in  the  liver  cells. 

Tliis  jaundice  is  never  fatal,  and  is  not  serious.  Other  conditions, 
such  as  atelectasis,  may  coexist,  which  may  make  the  case  grave.  The  chief 
point  in  diagnosis  is  not  to  confound  physiological  icterus  with  that  de- 
pending upon  other  more  serious  conditions,  such  as  sepsis  or  congenital 
malformation  of  the  bile-ducts.  In  sepsis  other  symptoms  are  present, 
usually  an  abnormal  condition  of  the  umbilicus,  and  the  symptoms  ap- 
pear at  a  later  date.  In  malformation  of  the  bile-ducts  the  jaundice 
is  very  intense,  and  is  frequently  accompanied  by  marked  hepatic  en- 
largement. 

Physiological  icterus  requires  no  treatment. 


CHAPTER   IV. 
THE  ACUTE   INFECTIOUS  DISEASES   OF  THE  NEWLY  BORN. 

It  is  possible  for  the  newly-born  infant  to  suffer  from  almost  all  of  the 
common  infectious  diseases.  Smallpox  probably  has  been  most  frequently 
observed.  In  rare  instances  measles,  influenza,  typhoid  fever,  malaria, 
and  pneumonia  have  occurred  in  the  first  days  of  life.  As  the  mothers 
in  many  instances  were  suffering  from  the  diseases  during  or  just  prior  to 
delivery,  the  infants  appear  to  have  been  infected  before  birth  through  the 
circulation  of  the  mother.  In  other  cases,  especially  in  pneumonia  and 
influenza,  infection  may  take  place  soon  after  birth.  The  symptoms  of 
these  diseases  in  the  newly  born  differ  little  from  those  occurring  in  any 
young  infant.  The  prognosis,  however,  is  very  much  worse  on  account  of 
the  tender  age  and  feeble  resistance  of  the  patient. 

In  addition  to  the  diseases  mentioned,  there  are  other  forms  of  infec- 
tion which  belong  especially — some  of  them  exclusively — to  the  newly 
born.  We  shall  consider  :  (1)  The  Pyogenic  Diseases,  which  are  due  to 
the  entrance  of  pyogenic  germs ;  in  this  class  are  to  be  included  Ophthal- 
mia and  Erysipelas;  (2)  Tetanus  ;  and  (3)  diseases  probably  infectious,  but 
as  yet  not  proved  to  be  so— Acute  Eatty  Degeneration,  Epidemic  Hemi- 
globiuuria,  and  Pemphigus. 


THE  ACUTE   PYOGENIC   DISEASES.  79 


THE  ACUTE   PYOGENIC   DISEASES. 


This  group  of  diseases — known  also  as  puerperal  fever  of  infants,  or 
sepsis  in  the  newly  born — presents  a  great  variety  of  symptoms  and  lesions. 
They  have,  however,  the  one  feature  in  common,  viz.,  that  they  result  from 
the  entrance  of  pyogenic  bacteria  *  into  the  body  of  the  child.  The  two 
micro-organisms  most  frequently  causing  the  suppurative  processes  are 
the  staphylococcus  pyogenes  aureus  and  the  streptococcus.  These  are 
probably  the  exciting  cause  of  four-fifths  of  the  cases.  Tiie  remainder 
are  due  to  one  or  more  of  the  other  bacteria  which  cause  suppuration. 
The  germs  may  be  found  alone,  or  they  may  be  associated  with  others. 
In  the  investigations  nuide  thus  far  the  streptococcus  has  been  most  fre- 
quently found.  This  was  discovered  by  Prudden  in  the  dust  of  a  ward  in 
the  New  York  Infant  Asylum,  where  several  cases  had  occurred,  also  in 
an  umbilical  abscess,  and  in  the  pseudo-membranous  sore  throat  of  one 
of  the  cases.  Of  a  group  of  three  cases,  all  occupying  the  same  bed  at  the 
Sloane  Maternity  Hospital,  one  was  studied  bacteriologically  by  Prudden, 
and  showed  only  streptococci.  A  case  of  meningitis  occurring  in  the 
same  hospital  was  studied  by  Van  Gieson,  who  found  in  cultures  from  the 
exudate  only  streptococci,  which  were  also  present  in  the  umbilical  vessels. 
The  streptococcus  was  discovered  by  Allard  in  cases  of  osteomyelitis.  In 
three  recent  cases  of  my  own,  all  with  multiple  joint  suppuration,  the 
staphylococcus  was  foiMid  in  two  and  the  streptococcus  in  one — in  every 
case  in  pure  culture.  The  severity  of  the  symptoms  depends  somewhat 
upon  the  nature  of  the  bacteria  which  excite  the  disease,  the  form  being 
usually  milder  when  due  to  the  staphylococcus  than  when  due  to  the 
streptococcus.  Still  more  important,  however,  is  the  degree  of  virulence 
of  the  bacteria  at  the  time  of  infection.  Thus  the  streptococcus  sometimes 
excites  only  a  very  mild,  and  at  others  a  most  violent  inflammation. 

Most  frequently  the  avenue  of  entrance  is  the  umbilical  wound.  This 
obtains  probably  in  four  fifths  of  the  cases.  It  may  be  through  an  abra- 
sion of  the  skin,  such  as  often  exists  about  the  anus  or  genitals,  through  a 
wound  about  the  scalp  or  body  inflicted  during  instrumental  delivery, 
through  erosions  of  the  mucous  membrane  of  the  mouth,  or  through  the 
eyes.  Infection  through  the  milk  is  denied  by  some  writers.  Although  it 
has  been  shown  that  in  a  great  proportion  of  the  cases  the  milk  of  a 
woman  suffering  from  mastitis  or  from  septicaemia  contains  pyogenic 
germs,  still  the  taking  of  these  into  the  stomach  is  very  unlikely  to  in- 

*  There  were  formerly  described  cases  of  "  septicaemia  "  in  the  newly  born ;  but  re- 
stricting this  term  to  its  present  significance — an  infection  due  to  bacterial  products 
only — septicjemia  is  of  doubtful  occurrence  at  this  period,  unless  we  include  as  such 
some  of  the  forms  of  diarrhceal  disease.  The  cases  of  "  sepsis "  in  the  newly  born 
studied  by  modern  methods  have  shown  with  great  uniformity  the  presence  of  pyo- 
genic bacteria. 


8Q  DISEASES   OF  THE  NEWLY  BORK 

feet  the  infant.  Karlinski  has  reported  a  fatal  case,  in  which  the 
milk  appeared  to  be  the  means  of  infection,  and  by  experiments  on  ani- 
mals he  proved  the  possibility  of  infection  in  this  manner.  Bacteria  may 
be  aspirated  dnring  or  after  labonr,  giving  rise  to  septic  pneumonia.  The 
source  of  the  poison  may  be  other  septic  cases  in  an  institution,  either 
among  infants  or  mothers.  It  may  be  carried  by  the  physician,  the  nurse, 
the  instruments,  or  the  dressings. 

Infection  through  the  umbilicus  may  occur  either  before  or  after  the 
separation  of  the  cord.  The  poison  may  enter  through  the  umbilicus, 
although  this  may  give  no  external  evidence  of  disease.  This  was  true 
in  a  case  recently  studied  by  Van  Gieson,  in  which  the  infant  died  of 
meningitis  when  eight  days  old.  The  cord  had  healed  properly,  and  at 
the  autopsy  the  navel  appeared  normal.  It  was  accidentally  discovered 
that  the  umbilical  vessels  inside  the  body  contained  pus.  From  this  the 
meningitis  evidently  arose,  as  the  same  bacteria  were  found  by  culture 
both  there  and  in  the  brain.  Entering  through  the  mouth,  bacteria  may 
lead  to  infectious  processes  in  the  throat,  or  spreading  downward  may 
involve  the  stomach  and  intestines,  rapidly  producing  death  ;  or  the  ali- 
mentary tract  may  be  the  focus  from  which  infection  of  distant  parts  may 
arise. 

Clinical  Varieties. —  Omphalitis. — In  this  variety  there  is  inflammation 
of  the  umbilicus,  and  cellulitis  of  the  abdominal  wall  in  the  immediate 
neighbourliood.  This  results  in  the  formation  of  an  umbilical  phlegmon. 
It  may  terminate  in  resolution,  in  abscess,  or  in  gangrene.  The  usual 
termination  is  in  abscess.  These  abscesses  may  be  small  and  superficial, 
or  they  may  be  more  deeply  seated  between  the  abdominal  muscles  and 
the  peritoneum.  OmiDhalitis  usually  begins  in  the  second  or  third  week 
of  life,  before  the  umbilicus  has  cicatrized.  Locally  there  are  redness, 
swelling,  and  induration.  The  process  may  result  in  abscess,  there  may 
be  diffuse  inflammation  of  the  abdominal  walls  of  an  erysipelatous  char- 
acter with  extensive  sloughing,  or  the  infection  may  spread  to  the  peri- 
tonaeum. 

Infammation  of  the  nmbilical  vessels. — This  is  one  of  the  most  fre- 
quent primary  j^rocesses  in  pyemic  infection.  The  umbilical  arteries  are 
more  frequently  involved  than  the  vein.  According  to  Eunge,  inflamma- 
tion of  the  vessels  is  always  preceded  by  inflammation  of  the  connective 
tissue  which  surrounds  them,  as  the  poison  is  taken  up  by  the  lymphat- 
ics and  not  by  the  blood-vessels.  Omphalitis  is  frequently  present,  but  in 
gome  cases  the  umbilicus  shows  nothing  abnormal. 

In  arteritis  the  vessels  may  be  involved  to  any  degree :  sometimes 
only  a  short  distance  from  the  abdominal  Avail,  sometimes  quite  to  the 
bladder.  They  contain  pus,  and  often  septic  thrombi.  Saccular  dilata- 
tion is  frequently  present  at  several  points.  Pus  sometimes  exudes  from 
the  umbilical  stump  on  pressure.    The  other  lesions  accompanying  arteritis 


THE   ACUTE   PYOGENIC   DISEASES.  81 

are  those  of  py?emic  infection,  more  or  less  widely  distributed.  There  are 
frequently  peritonitis,  suppuration  of  the  joints,  erysipelas,  multii^le  ab- 
scesses of  the  cellular  tissue,  sometimes  suppurative  parotitis.  Atelectasis 
is  common.  Pneumonia  was  found  in  twenty-two  of  Runge's  fifty-five 
cases. 

In  cases  of  phlebitis,  the  umbilical  vein  is  usually  involved  for  its  entire 
length  from  the  abdominal  wall  to  the  liver.  This  may  lead  to  an  acute 
interstitial  hepatitis  going  on  to  suppuration,  or  to  phlebitis  of  the  portal 
vein  and  some  of  its  branches.  In  either  case  there  is  more  or  less  paren- 
chymatous hepatitis,  and  often  multiple  abscesses  of  the  liver,  most  of  the 
patients  being  jaundiced.     Peritonitis  also  is  a  frequent  complication. 

Peritonitis. — This  is  one  of  the  most  frequent  pathological  processes 
in  pyemic  infection,  and  is  very  often  the  cause  of  death.  It  is  generally 
associated  with  umbilical  arteritis,  and  often  with  erysipelas.  In  a  con- 
siderable number  of  cases  it  is  the  most  important  lesion  found.  It  may 
be  localized  or  general.  Localized  peritonitis  is  generally  in  the  neigh- 
bourhood of  the  umbilicus  or  of  the  liver.  It  may  result  in  adhesions,  or 
in  the  formation  of  peritoneal  abscesses.  More  frequently  the  peritonitis 
is  general,  and  resembles  the  septic  peritonitis  of  adults.  There  is  a  great 
outpouring  of  lymph  coating  the  intestines  and  other  viscera  and  the 
inner  surface  of  the  abdominal  wall,  causing  adhesions  between  the  ab- 
dominal contents.  Collections  of  sero-pus  are  found  in  the  pelvis  and  in 
various  pockets  formed  by  the  adhesions.  Sometimes  blood  is  present  in 
the  exudation. 

The  special  symptoms  which  indicate  peritonitis  are  vomiting,  abdomi- 
nal tenderness  and  distention,  and  protrusion  of  the  umbilicus.  The  ab- 
dominal enlargement  is  chiefly  from  gas,  but  may  be  partly  from  fluid. 
There  are  present  thoracic  respiration,  dorsal  decubitus,  and  flexion  of 
the  thighs  as  in  all  varieties  of  acute  peritonitis.  The  temperature  is 
usually  high. 

Pneumonia. — The  most  common  form  seen  is  pleuro-pneumonia. 
There  is  an  abundant  exudate  of  grayish-yellow  lymph  covering  the 
lung.  Occasionally  collections  of  pus  are  found  in  the  sacs  formed  by 
the  adhesions.  Serous  effusions  are  rare.  The  pulmonary  lesion  con- 
sists usually  in  a  broncho-pneumonia,  with  consolidation  of  larger  or 
smaller  areas  in  the  lungs — more  often  in  the  upper  than  in  the  lower 
lobes.  It  is  not  uncommon  for  minute  abscesses  to  be  found  in  the  lung 
at  various  points.  There  is  a  purulent  bronchitis  of  the  larger  and 
smaller  tubes. 

The  symptoms  are  obscure  and  often  indefinite.  The  only  character- 
istic ones  are  cyanosis  and  rapid  respiration,  with  recession  of  the  chest 
walls  on  inspiration.  The  physical  signs  are  inconstant  and  uncertain. 
Pneumonia-^annot  usually  be  diagnosticated  during  life.  In  most  of  the 
fatal  cases  of  pyogenic  infection,  whatever  its  type,  there  is  found  some 


82  DISEASES  OP  THE  NEWLY  BORN. 

involvement  of  the  lungs.  The  changes  are  most  extensive  in  cases  in 
which  the  serous  membranes  are  involved. 

Pericarditis  is  rare  and  usually  associated  with  pleurisy.  Endocar- 
ditis is  very  rare.     Hirst  has,  however,  reported  a  case. 

Meningitis. — The  pia  mater  is  the  least  liable  to  be  affected  of  all  the 
serous  membranes,  with  the  possible  exception  of  the  pericardium.  When 
meningitis  is  present  it  is  usually  associated  with  peritonitis  or  with 
pleurisy.  The  lesions  are  those  of  acute  purulent  meningitis  with  a 
copious  exudation,  sometimes  associated  with  meningeal  hgemorrhages, 
or  with  acute  encephalitis  and  the  production  of  multiple  minute  ab- 
scesses in  the  cortex.  The  local  symptoms  are  usually  not  marked,  and 
are  sometimes  very  obscure.  The  most  characteristic  are  stupor,  strabis- 
mus, dilated  pupils,  opisthotonus,  bulging  fontanel,  convulsions,  and  occa- 
sionally localized  paralyses.     The  temperature  is  generally  high. 

Gastro-enteritis. — Diarrhoea  is  a  frequent  symptom  in  all  septic  cases, 
constipation  being  rarely  present.  In  many  instances  vomiting  is  a  promi- 
nent symptom.  In  a  small  proportion  of  cases  the  most  important  local 
lesions  are  in  the  intestines,  generally  in  the  nature  of  a  superficial 
catarrhal  inflammation. 

Pseiido-inemhranous  infiammations  of  the  throat. — These  are  rarely 
seen  in  the  newly  born.  In  1888  J.  Lewis  Smith  made  a  report  on  a 
group  of  five  cases  occurring  as  a  small  epidemic  in  the  ^ew  York 
Infant  Asylum.  They  were  associated  Avith  other  lesions,  and  all  were 
fatal.  In  several  cases  there  was  omphalitis.  One  of  these  was  studied 
biologically  by  Prudden,  who  found  no  Loeffler's  bacilli,  but  streptococci 
both  in  the  exudation  in  the  throat  and  in  the  umbilical  abscess.  The 
streptococcus  was  cultivated  from  the  dust  of  the  ward,  and  it  is  probable 
that  this  was  the  nature  of  the  infection  in  all  the  cases.  These  throat 
inflammations  are  to  be  regarded  as  one  manifestation  of  a  general  strep- 
tococcus infection. 

Osteomyelitis. — Allard  *  has  reported  a  series  of  cases  in  which,  after 
the  general  and  local  symptoms  of  pyogenic  infection  had  existed  for  some 
time,  suppuration  occurred  over  various  bones,  especially  the  humerus, 
tibia,  metatarsal  bones,  sacrum,  etc.  Trephining  revealed  the  lesions  of 
osteomyelitis.  The  abscesses  usually  made  their  appearance  between  the 
fourth  and  the  sixth  week.  The  most  rapid  case  died  on  the  fourteenth 
day,  and  none  lasted  more  than  two-and-a-half  months. 

Joint  suppuration. — In  certain  pysemic  cases,  and  in  some  in  which 
there  are  no  other  symptoms,  acute  suppuration  in  the  joints  occurs  with- 
out any  change  in  the  bones  themselves.  This  may  come  on  very  acutely 
in  the  first  or  second  week,  or  more  slowly  as  late  as  the  third  or  fourth 
week.     A  single  joint  may  be  involved,  or  at  times  almost  every  articula- 

*  These,  Paris,  1890. 


THE  ACUTE   PYOGENIC  DISEASES.  83 

tion  in  the  body.  I  have  recently  seen  four  cases  of  this  kind.  In  one, 
a  shoulder  and  one  temporo-maxillary  articulation  were  involved. ;  in  an- 
other, a  shoulder  and  hip;  in  the  remainder  there  were  multiple  lesions 
affecting  nine  or  ten  joints,  including  the  elbows,  ankles,  and  sterno-clavic- 
ular  joints,  together  with  the  wrists,  fingers,  and  toes. 

Abscesses  in  the  cellular  tissue. — These  are  quite  frequent,  and  may 
occur  with  suppuration  in  the  joints  or  internal  organs,  or  they  may  exist 
as  the  only  lesion.  They  may  be  found  where  the  adipose  tissue  is  scanty, 
as  over  the  heels,  the  elbows,  and  the  malleoli  ;  also  in  the  thighs,  the 
isciiio-rectal  region,  and  sometimes  in  the  abdominal  walls.  They  are 
nearly  always  multiple.  They  vai-y  in  size  from  that  of  a  small  pea  to  one 
containing  half  an  ounce  of  pus.  They  are  due  to  the  introduction  of 
pyogenic  germs,  usually  staphylococci.  Their  course  is  benign,  and  they 
require  no  treatment  except  incision  and  cleanliness.  Where  there  is  a 
disposition  to  their  continued  formation,  the  skin  should  be  washed  with 
an  antiseptic  solution. 

Erysipelas. — This  is  seen  especially  during  the  first  two  weeks  of  life, 
and  most  frequently  starts  from  the  umbilicus,  although  it  may  follow  any 
wound  or  abrasion  of  the  skin.  When  originating  at  the  umbilicus  it  is 
generally  complicated  by  other  lesions,  such  as  peritonitis  and  umbilical 
phlebitis.  If  it  start  from  any  other  part  of  the  body  it  may  be  uncom- 
plicated. It  is  now  pretty  well  agreed  among  bacteriologists  that  the 
difference  between  the  streptococcus  pyogenes  and  the  streptococcus  of 
erysipelas  is  in  the  degree  of  their  virulence.  While  we  have  the  two 
extremes  well  marked — typical  erysipelas  on  the  one  hand,  and  sim- 
ple cellulitis  terminating  in  a  circumscribed  suppuration,  on  the  other — 
we  have  all  the  intermediate  grades  of  severity  between  them. 

Erysipelas  starting  at  the  umbilicus  gives  rise  to  an  area  of  indura- 
tion, with  a  redness  which  is  quite  sharply  circumscribed.  It  may  be 
superficial,  or  it  may  involve  the  deeper  tissues.  It  may  terminate  in 
diffuse  suppuration  or  in  gangrene.  The  erysipelas  of  the  newly  born 
tends  to  spread  with  rapidity,  often  extending  over  nearly  the  whole 
trunk.  The  general  symptoms  are  great  prostration,  high  temperature — 
from  102°  to  105°  F. — localized  pain  and  tenderness,  great  restlessness, 
wasting,  vomiting,  and  diarrhea.  The  disease  is  always  serious,  and  when 
starting  from  the  umbilicus  usually  fatal.  The  prognosis  is  better  in  cases 
originating  elsewhere,  but  under  all  conditions  the  disease  is  a  very  seri- 
ous one. 

Distribution  of  the  Lesions. — The  frequency  of  the  different  visceral 
lesions  in  eighty-seven  autopsies  published  by  Bednar  was  as  follows : 
Peritonitis  in  twenty-nine,  pneumonia  in  fifteen,  pleurisy  in  ten,  menin- 
gitis in  nine,  meningeal  h;vmorrIiage  in  eight,  encephalitis  in  eight,  cere- 
bral hemorrhage  in  four,  entero-colitis  in  five,  pericarditis  in  four.  In 
thirty-one  cases  there  was  umbilical  arteritis,  and  in  nine  cases  umbilical 


84  DISEASES  OF   THE   NEWLY  BORN. 

phlebitis.  There  was  one  case  each  of  pulmonary  haemorrhage,  pleural 
hasmorrhage,  acute  hydrocephalus,  acute  bronchitis,  and  suppuration  in 
the  cellular  tissue.  Runge's  later  observations  of  thirty-six  cases  showed 
umbilical  arteritis  in  thirty,  umbilical  phlebitis  in  three,  and  normal  um- 
bilicus in  three.  He  found  pneumonia  in  twenty-two  of  fifty-five  cases. 
Other  lesions  frequently  associated  are  atelectasis,  swelling  and  softening 
of  the  spleen,  cloudy  swelling  of  the  liver  and  kidneys,  occasionally  with 
foci  of  suppuration  in  these  organs.  The  blood  is  dark,  and  coagulates 
imperfectly. 

General  Symptoms. — These  may  begin  at  any  time  during  the  first  ten 
days — very  rarely  after  the  twelfth  day.  Fever  is  an  exceedingly  variable 
symptom — it  may  be  very  high  ;  it  may  be  almost  absent ;  occasionally 
there  is  subnormal  temperature.  The  course  of  the  temperature  is  very 
irregular.  Wasting  is  constant  and  quite  rapid.  It  depends  upon  the 
inability  to  take  and  digest  food,  upon  the  intestinal  complications,  and 
upon  infection.  In  quite  a  number  of  cases  wasting  is  almost  the  only 
symptom.  Icterus  is  exceedingly  common ;  in  many  of  the  worst  cases 
it  is  intense.  It  is  met  with  where  the  liver  is  the  seat  of  an  acute  paren- 
chymatous or  acute  suppurative  inflammation,  and  in  many  other  cases 
where  it  depends  apparently  upon  the  blood  changes.  Haemorrhages  are 
common,  and  may  be  the  direct  cause  of  death.  They  are  most  frequent 
from  the  umbilicus,  from  the  intestine,  and  into  the  subcutaneous  cellu- 
lar tissue.  They  may  occur  in  almost  any  organ  or  from  any  mucous 
membrane.  Nervous  symptoms  are  generally  present,  and  are  sometimes 
marked.  They  are  restlessness,  rolling  of  the  head,  a  constant  whining 
cry,  twitchings  of  the  muscles  of  the  extremities  or  face,  stiffening  of  the 
body,  more  rarely  general  convulsions.  Late  in  the  disease,  dulness  and 
stupor  are  present.  The  pulse  is  rapid  and  weak  and  the  respirations  are 
often  irregular  even  when  there  is  no  cerebral  complication.  Diarrhoea  is 
frequent ;  the  stools  are  green,  brown,  sometimes  black  from  the  presence 
of  blood,  and  are  often  very  foul.     Vomiting  is  less  common. 

In  addition  to  these  there  are  symptoms  due  to  the  various  forms  of 
local  inflammation — peritonitis,  me7iingitis,  pneumonia,  subcutaneous  su])- 
puration  and  gangrene,  these  all  being  found  in  varying  degrees  and  in 
various  combinations. 

Prophylaxis, — Pyogenic  infection  of  the  child,  like  puerperal  fever  in 
the  mother,  may  be  considered  a  preventable  disease.  Its  occurrence  is 
usually  due  to  a  failure  to  carry  out  proper  rules  regarding  cleanliness  and 
asepsis  in  connection  with  delivery.  The  statistics  of  the  Moscow  Lying- 
in  Asylum,  published  by  Miller  in  1888,  show  that  previous  to  the  general 
introduction  of  antiseptic  methods,  from  six  to  eight  per  cent  of  all  in- 
fants born  in  the  institution  died  from  some  variety  of  infection.  In 
twenty-three  hundred  successive  labours  at  the  Sloane  Maternity  Hospital, 
in  New  York,  up  to  January,  1893,  not  a  single  marked  case  occurred. 


OPHTHALMIA.  85 

From  these  figures  it  will  be  evident  that  in  the  vast  majority  of  cases 
the  occurrence  of  a  case  of  infection  of  a  serious  nature,  is  the  fault  of  the 
physician  or  nurse  in  attendance. 

The  umbilicus  should  be  cleansed  and  treated  like  any  other  fresh 
wound.  Dry  dressing  should  invariably  be  employed,  and  antiseptic 
gauze  or  salicylated  cotton  in  preference  to  household  linen.  If  suppu- 
ration occurs  at  the  time  the  cord  separates,  the  parts  should  be  cleansed 
daily  with  1-3,000  bichloride  solution,  and  powdered  with  iodoform.  All 
wounds  of  the  face,  scalp,  and  other  parts  should  be  treated  in  the  same 
way.  The  ligatures  and  everything  which  comes  in  contact  with  the  um- 
bilical wound  should  be  sterilized.  Careful  attention  should  be  given  to 
the  mouth,  genitals,  and  all  the  muco-cutaneous  surfaces,  to  prevent  ex- 
coriations and  intertrigo.  Finally,  every  septic  case  occurring  in  an  insti- 
tution should  be  immediately  isolated.  A  nurse  in  charge  of  a  septic 
woman  should  not  have  the  care  of  the  infant. 

Prognosis. — Pyogenic  infection  in  the  newly  born,  even  in  its  mildest 
forms,  is  a  serious  disease,  and  in  its  severer  forms  is  almost  invariably 
fatal.  Few  cases  recover  in  which  there  is  present  any  form  of  visceral 
inflammation. 

Treatment. — The  treatment  of  cases  of  pyogenic  infection  practically 
resolves  itself  into  the  treatment  of  individual  symptoms  as  they  arise. 
Wherever  suppuration  occurs,  external  abscesses  should  be  evacuated  and 
treated  antiseptically.  For  the  local  inflammations  of  the  lungs,  peri- 
tonaeum, and  brain,  little  or  nothing  can  be  done  in  the  way  of  direct 
treatment.  The  condition  is  one  to  be  prevented,  but  not  cured.  The 
general  indications  are  to  sustain  the  patient  by  proper  feeding  and  the 
use  of  stimulants  whenever  required  by  the  pulse.  For  local  use  in  ery- 
sipelas, nothing,  in  my  experience,  is  better  than  a  teu-per-cent  ointment 
of  ichthyol  made  up  with  lanoline,  kept  constantly  applied.  When 
affecting  only  one  of  the  extremities,  the  treatment  by  the  Kraske  method, 
of  making  scarifications  beyond  the  line  of  redness  and  covering  with  wet 
bichloride  dressings,  is  sometimes  successful,  but  this  is  not  applicable  to 
cases  involving  the  trunk. 

OPHTHALMIA. 

Ophthalmia  of  the  newly  born  is  to  be  classed  among  the  pyogenic  dis- 
eases. It  usually  consists  in  a  purulent  conjunctivitis.  In  the  more  severe 
cases  there  may  be  ulceration  of  the  cornea,  and  even  perforation  into  the 
anterior  chamber  of  the  eye. 

The  infectious  nature  of  this  ophthalmia  is  now  fully  established.  In 
the  most  severe  cases  the  micro-organism  generally  found  has  been  the 
gonococcus;  but  in  the  milder  forms  the  gonococcus  is  absent,  and  any 
of  the  common  pyogenic  germs  may  be  found.  In  the  gonorrhoeal  cases 
the  infection  occurs  during  labour  from  the  secretions  of  the  mother. 


36  DISEASES   OP  THE   NEWLY  BORN. 

from  the  examining  fingers  of  the  physician,  or  from  instruments  ;  or 
after  birth  from  infected  cloths  and  other  materials  which  come  in  con- 
tact with  the  eye.  Healthy  lochia  produce  only  a  catarrhal  inflammation. 
The  infection  occurring  after  birth  may  take  place  at  any  time.  That 
due  to  gonorrhoeal  infection  from  the  mother  is  generally  manifested  on 
the  third  day,  and  is  often  violent  from  the  outset. 

The  symptoms  are  swelling  of  the  lids,  chemosis,  copious  purulent  dis- 
charge, sometimes  hemorrhages  from  the  lids,  ulceration  and  there  may 
even  be  sloughing  of  the  cornea.  The  course  of  the  disease  depends  upon 
the  cause  and  upon  the  treatment  employed.  In  the  cases  not  due  to 
the  gouococcus  the  course  is  generally  benign,  and  with  ordinary  cleanli- 
ness usually  results  in  recovery  without  any  permanent  damage  to  the 
sight.  The  gonorrhoeal  cases,  unless  energetically  treated  from  the  outset, 
are  very  frequently  followed  by  permanent  loss  of  vision.  The  best  sta- 
tistics upon  the  causes  of  blindness  in  adults  show  that  from  twenty-six 
to  thirty  per  cent  of  such  cases  are  due  to  ophthalmia  in  the  newly  born. 
This  disease  is  occasionally  complicated  by  other  symptoms  of  gonorrhoeal 
infection  of  a  pyaemic  nature.  Widmark,  Lucas,  and  Davies-Colley  have 
reported  cases  followed  by  acute  articular  symptoms. 

Prophylaxis  is  of  the  utmost  importance.  Crede's  statistics  show  that 
in  1874  the  frequency  of  ophthalmia  in  his  lying-in  hospital  was  13-6  per 
cent.  In  the  three  years  ending  1883,  among  1,160  newly-born  children 
only  one  or  two  cases  occurred.  The  method  of  prophylaxis  which  he 
adopted  consists  in  dropping  into  the  eyes  of  every  child,  immediately  after 
birth,  one  or  two  drops  of  a  two-per-cent  solution  of  nitrate  of  silver. 
The  general  adoption  of  Crede's  method,  or  of  some  similar  means  of  dis- 
infection, has  resulted  in  a  very  great  diminution  in  the  frequency  of  oph- 
thalmia throughout  the  world.  These  prophylactic  means  should  be 
obligatory  in  all  institutions,  and  should  be  used  in  all  cases  in  private 
practice  wherever  there  is  any  possible  suspicion  of  the  existence  of  gon- 
orrhoea. In  all  other  cases  the  eyes  should  be  carefully  cleansed  with  a 
saturated  solution  of  boric  acid.  The  use  before  delivery  of  an  antiseptic 
vaginal  douche  is  theoretically  indicated,  but  practically  it  has  been  found 
to  be  inadequate  to  the  prevention  of  the  disease. 

Treatment. — Everything  which  comes  in  contact  with  the  eyes  should 
be  carefully  disinfected.  All  cloths,  cotton,  etc.,  used  for  cleansing  should 
be  immediately  burned.  The  strictest  antiseptic  precautions  should  be  in- 
sisted on  to  prevent  the  spread  of  the  infection  by  nurses.  In  institutions 
containing  infants,  severe  cases  of  ophthalmia  should  always  be  isolated. 
The  most  important  thing  is  to  keep  the  eyes  clean.  In  severe  cases  they 
must  be  cleansed  every  twenty  minutes,  night  and  day.  It  is  best  accom- 
plished by  means  of  an  eye-dropper  with  a  slightly  bulbous  tip,  inserted 
alternately  at  the  inner  and  the  outer  angle  of  the  eye,  and  the  fluid  in- 
jected with  force  sufficient  to  empty  thoroughly  the  conjunctival  sac.    For 


TETANUS.  87 

this  purpose  a  saturated  solution  of  l)oric  acid,  or  a  1-5,000  solution  of  bi- 
chloride, may  be  employed,  the  important  feature  being  that  the  eye  be 
cleansed  thoroughly,  and  so  frequently  that  the  pus  is  never  allowed  to 
accumulate.  Once  or  twice  in  twenty-four  hours  two  or  three  droj^s  of  a 
one-per-cent  solution  of  nitrate  of  silver  should  be  put  into  the  eye  ;  or  a 
stronger  solution  may  be  employed  and  immediately  neutralized  with  a 
salt  solution.  1'he  next  most  valuable  moans  of  treatment  is  cold.  Ice- 
cold  compresses  should  be  employed  for  thirty  minutes  every  two  hours 
in  the  milder  cases,  while  in  the  most  severe  ones  they  must  be  used  con- 
tinuously. These  should  be  cooled  by  placing  them  on  a  block  of  ice,  and 
changed  at  least  every  minute,  so  that  they  are  kept  cold.  If  the  cornea 
is  involved  the  pupil  should  be  kept  dilated  by  means  of  atropine,  and  this 
is  wise  in  all  severe  cases. 

TETANUS. 

Tetanus  is  an  acute  infectious  disease  characterized  by  tonic  muscular 
spasm,  which  increases  in  severity  by  paroxysms  occurring  at  longer  or 
shorter  intervals.  It  may  be  limited  to  the  muscles  of  the  jaw  (trismus), 
or  may  affect  all  the  muscles  of  the  trunk,  extremities,  and  neck. 

Though  many  writers  have  sought  to  maintain  a  difference  between 
tetanus  of  the  newly  born  and  tetanus  of  later  life,  whether  traumatic  or 
not,  their  identity  has  been  admitted  for  at  least  a  dozen  years.  The  dis- 
covery of  the  exact  cause  of  tetanus  is  due  to  the  work  of  Nicolaier,  who 
in  1884  found  a  bacillus  in  the  soil,  with  which  he  produced  the  disease  in 
animals.  He  demonstrated  the  presence  of  this  bacillus  in  the  wounds  of 
tetanus  patients.  Xicolaier  did  not,  however,  obtain  the  germ  in  pure 
culture ;  but  this  was  done  by  Kitasato  in  1889.  The  bacillus  is  generally 
known  as  Xicolaier's  bacillus.  Since  that  time  the  germ  has  been  found 
in  the  wounds  of  numerous  patients  with  tetanus,  including  newly-born 
infants. 

The  rapidity  with  which  the  infection  spreads  from  the  point  of  inoc- 
ulation is  very  remarkable,  as  shown  by  Kitasato's  experiments.  Thus,  if 
one  hour  elapsed  after  infection  before  cauterizing  the  inoculated  wound, 
the  animal  succumbed  to  the  disease.  The  bacilli  are  not  found  in  the 
blood  or  internal  organs.  The  symptoms  of  the  disease  have  been  shown 
to  depend  upon  the  absorption  of  a  toxic  product  of  the  tetanus  bacillus 
called  tetano-toxine. 

The  germ  of  tetanus  usually  gains  access  to  the  body  of  the  infant 
through  the  umbilical  wound.  It  exists  in  the  soil,  and  the  disease  pre- 
vails endemically  in  certain  localities.  It  is  common  in  certain  parts 
of  Long  Island  and  New  Jersey.  Among  the  negroes  in  some  parts  of 
the  South  it  has  for  many  years  occurred  with  great  frequency.  It  is 
stated  that  on  one  of  the  islands  of  the  Hebrides  every  fourth  or  fifth 
child  dies  of  tetanus.     In  a  single  house  in  Copenhagen-  eighteen  cases 


88  DISEASES  OF  THE  NEWLY  BORN. 

were  observed.  Tetanus  is  rare  except  where  dirt  and  filth  prevail ;  but 
these  alone  are  not  sufficient  to  produce  the  disease.  It  is  a  very  rare  dis- 
ease in  the  tenements  of  New  York. 

Lesions. — There  are  no  essential  lesions  of  tetanus.  Those  which  have 
been  found  have  been  partly  accidental  and  partly  a  result  of  the  disease 
rather  than  its  cause.  In  most  of  the  cases  intense  hyperaemia  of  the 
spinal  cord  and  its  membranes  is  found,  and  not  infrequently  small  ex- 
travasations of  blood.  Such  small  haemorrhages  are  occasionally  found  in 
the  meninges  of  the  brain — more  frequently  at  the  base  than  at  the  con- 
vexity. In  rare  instances  haemorrhages  of  considerable  size  have  occurred 
into  the  brain  itself.  The  lungs  are  generally  congested,  and  the  right 
side  of  the  heart  overdistended.  In  most  of  the  cases  the  umbilicus  has 
not  healed,  and  it  may  present  evidences  of  septic  infection  in  varying 
degrees. 

Symptoms. — These,  as  a  rule,  begin  on  the  fifth  or  sixth  day,  or  at 
the  time  of  the  separation  of  the  cord.  The  first  symptoms  may  not 
appear  until  the  tenth  or  twelfth  day,  but  rarely  later  than  this.  Gen- 
erally the  first  thing  noticed  is  difficulty  in  nursing,  which,  on  examina- 
tion, is  found  to  be  due  to  rigidity  of  the  jaws  (trismus).  Nursing  may 
be  impossible  on  this  account.  The  muscles  of  the  jaw  feel  hard,  the  lips 
pout  and  all  the  muscles  of  the  face  seem  firm.  Soon  a  slight  stiffening 
of  the  body  occurs,  the  child  straightening  the  back  as  it  lies  upon  the 
lap  and  continuing  rigid  for  a  moment  or  two.  In  the  interval  it  is  at 
first  completely  relaxed.  These  paroxysms  soon  increase  in  frequency 
until  they  may  come  on  every  few  minutes,  being  excited  by  any  move- 
ment of  the  body.  The  relaxation  is  then  only  partial,  and  the  neck  and 
extremities,  sometimes  nearly  the  whole  body,  become  rigid  and  stiff  as  a 
piece  of  wood.  The  arms  are  extended,  the  thumbs  adducted,  and  the 
hands  clenched.  The  thighs  and  legs  are  extended,  and  no  motion  is  pos- 
sible at  the  hip  or  knee.  The  jaws  can  be  separated  slightly  or  not  at  all. 
The  firm  contractions  of  the  facial  muscles  give  a  peculiar  expression  to 
the  features.  There  is  a  low,  whining  cry.  Swallowing  is  difficult,  some- 
times impossible.  The  pulse  is  rapid  and  soon  becomes  weak.  The  tem- 
perature at  first  is  normal,  but  in  the  most  acute  cases  rises  rapidly  to  104° 
or  even  106° ;  in  the  milder  cases  it  does  not  go  above  101°  F. 

Death  is  due  to  exhaustion,  to  fixation  of  the  respiratory  muscles,  or 
to  spasm  of  the  larynx.  In  the  less  severe  cases  all  the  symptoms  are 
milder,  and  there  may  be  intervals  in  which  the  rigidity  is  scarcely  notice- 
able, so  that  respiration  and  deglutition  may  be  carried  on  for  some  time. 
In  cases  which  terminate  in  recovery  the  temperature  is  but  slightly  ele- 
vated. The  tonic  contractions  gradually  become  less  severe,  and  the 
paroxysms  less  frequent.  The  children  usually  suffer  for  several  weeks 
from  the  general  symptoms  of  malnutrition,  which  are  proportionate  to 
the  severity  of  the  attack.     Of  eighty-eight  fatal  cases  which  are  reported 


TETAXUS.  89 

by  Stadtfeldt  all  but  five  died  between  the  ages  of  six  and  ten  days.  The 
duration  of  the  disease  in  the  fatal  cases  is  seldom  more  than  forty-eight 
hours,  often  less  than  twenty-four  hours  ;  in  those  terminating  in  recov- 
ery, between  one  and  three  weeks. 

Prognosis. — No  disease  of  infancy  is  more  fatal  than  tetanus.  Where 
it  prevails  eudemically  it  is  regarded  by  the  laity  as  so  uniformly  fatal  that 
usually  no  physician  is  called.  Scattered  through  medical  literature  are 
quite  a  large  number  of  isolated  cases  in  which  recovery  has  occurred.  At 
the  present  time  the  j^roportion  of  fatal  cases  is  probably  between  ninety 
and  ninety-five  per  cent.  Sporadic  cases  more  frequently  recover  than 
those  occurring  in  districts  where  the  disease  is  endemic.  The  later  the 
development  of  the  symptoms,  the  slower  their  course,  and  the  lower  the 
temperature  the  more  likely  is  the  case  to  recover. 

Prophylaxis. — A  proper  understanding  of  the  nature  of  the  disease  has 
brought  with  it  the  means  of  rational  prevention.  The  first  essential  is 
obstetrical  cleanliness,  Avhich  must  include  scissors,  hands,  dressings,  liga- 
tures— in  short,  everything  which  comes  in  contact  with  the  umbilical 
wound.  In  districts  where  tetanus  is  endemic,  thorough  antiseptic  treat- 
ment of  the  umbilicus  should  be  insisted  upon,  both  at  the  first  dressing 
and  later,  particularly  at  the  time  of  the  separation  of  the  cord. 

Treatment. — All  drugs  whose  physiological  action  is  that  of  motor 
depressants  of  the  spinal  cord  have  a  certain  amount  of  value  in  tetanus. 
The  most  important  ones  are  chloral,  the  bromides,  and  calabar  bean. 
Nearly  all  the  reported  cures  have  been  by  one  of  these  drugs  or  a  com- 
bination of  them.  The  mistake  usually  made  is  in  using  too  small  doses 
to  be  of  any  efiicacy.  Enough  to  produce  the  physiological  effects  of  the 
drug  must  be  given.  The  initial  dose  should  not  be  large,  but  it  should 
be  repeated  until  the  full  effects  are  obtained.  Of  those  mentioned,  chloral 
has  been  the  one  most  generally  relied  upon.  An  hourly  dose  of  one  or 
two  grains  is  usually  required.  If  no  effect  is  visible  in  ten  or  twelve 
hours  the  dose  may  be  further  increased,  as  the  patient  is  in  much  greater 
danger  from  the  disease  than  he  can  possibly  be  from  the  drug.  Cliloral 
may  be  given  by  the  mouth  or  by  the  rectum,  but  must  always  be  well 
diluted.  The  single  case  of  recovery  Avhich  I  have  witnessed  was  one 
treated  by  the  bromide  of  potassium.  This  infant  took  eight  grains  every 
two  hours  for  three  days,  afterwards  smaller  doses.  Calabar  bean  has  the 
advantage  in  that  its  extract  may  be  given  hypodermically ;  one  tenth  of 
a  grain  may  be  administered  from  three  to  ten  times  daily,  according  to 
the  severity  of  the  symptoms.  Monti  has  reported  two  cases  cured  by 
its  use.  The  child  must  at  all  times  be  kept  as  quiet  as  possible,  without 
unnecessary  handling  or  bathing.  If  nursing  or  feeding  by  the  mouth  is 
impossible,  because  the  jaws  cannot  be  separated,  the  child  may  be  fed 
by  a  tube  passed  through  the  nose.  This  is  greatly  to  be  preferred  to 
rectal  alimentation.     Drugs  may  be  administered  in  the  same  way. 


90  DISEASES  OF  THE  NEWLY  BORN. 

TJte  antitoxine  treatment. — Behring  and  Kitasato,  after  a  series  of 
experiments  upon  animals,  have  produced  a  substance  called  tetanus 
antitoxine  which  has  the  power  of  neutralizing  the  tetanus  poison.  In 
animals  immunity  is  produced  by  its  injection.  It  is  also  curative 
in  those  cases  where  tetanus  has  been  induced  artificially.  As  yet 
the  number  of  cases  in  which  this  treatment  has  been  applied  to  man 
is  too  small  to  admit  of  positive  deductions  regarding  its  value.  The 
practical  difficulties  in  applying  it  are  great,  because  of  the  very  rapid 
absorption  of  the  tetanus  poison  from  the  wound.  The  treatment  is  not 
efficient  unless  it  is  adopted  very  early  in  the  disease.  This  is  not  always 
easy,  as  cases  are  not  common.  In  Italy,  ten  cases,  chiefly  of  traumatic 
tetanus,  have  been  reported  cured  by  the  antitoxine ;  but  experience  else- 
where has  not  been  quite  so  satisfactory.  In  England,  two  cases  of  trau- 
matic tetanus  have  been  cured  by  the  injection  of  the  serum.  Escherich 
has  recently  reported  (1894)  four  cases  of  tetanus  in  the  newly  born  treated 
by  antitoxine,  with  one  recovery,  the  symptoms  of  this  case  diminishing 
rapidly  after  the  second  injection.  Papiewski  treated  three  cases  by  this 
method,  two  of  which  recovered,  but  the  course  was  such  that  the  result 
could  hardly  be  attributed  to  the  antitoxine.  The  tetanus  antitoxine  is 
now  prepared  by  Behring  and  by  the  Xew  York  Health  Department ;  it 
is  used  subcutaneously  like  the  diphtheria  antitoxine. 


EPIDEMIC  HEMOGLOBINURIA  (WINCKEL'S   DISEASE). 

The  essential  features  of  this  disease  are  hsemoglobinuria  with  icterus 
and  cyanosis,  this  combination  giving  the  skin  a  deeply  bronzed  hue  {niala- 
die  hronzee).  It  is  a  rare  disease,  but  has  generally  occurred  epidemically 
in  institutions.  It  is  usually  fatal.  All  the  symptoms  point  to  an  acute, 
rapid  disintegration  of  the  red  blood-cells — a  sort  of  blood  fermentation. 
The  changes  have  been  compared  with  those  produced  in  the  blood  in 
poisoning  by  chlorate  of  potash  or  phosphorus.  The  cause  is,  without 
doubt,  some  sort  of  infection,  but  its  exact  nature  has  not  been  discovered. 
Although  generally  called  by  the  name  of  Winckel,*  who  in  1879  made  a 
full  report  upon  an  epidemic  of  twenty-three  cases  in  a  hospital  in  Dres- 
den, the  disease  was  quite  well  described  by  Charrinf  in  1873,  with  a 
report  of  fourteen  cases,  and  observed  by  Bigelow,J  in  Boston,  in  1875. 
All  the  cases  included  in  Winckel's  report  occurred  in  one  institution, 
affecting  one  fourth  of  the  children  born  during  the  period. 

There  are  cyanosis,  and  a  more  or  less  intense  icterus  of  the  skin  and 


*  Winckel,  Veroffentlich.  der  padiatrischen  Section  der  Gesellsch.  i.  Heilk.,  Berlin, 
April.  1879. 

t  Charrin,  These  de  Paris,  1873. 

X  Bigelow,  Boston  Medical  and  Surgical  Journal,  March,  1875. 


FATTY   DEGENERATION,  91 

internal  organs.  The  umbilical  vessels  are  usually  normal.  The  kidneys 
are  swollen,  show  small  haemorrhages  into  their  substance,  and  under  the 
microscope  the  straight  tubes  are  seen  to  be  filled  with  crystals  of  haemo- 
globin, but  contain  no  blood-cells.  The  bladder  frequently  contains 
brownish,  smoky  urine.  The  spleen  is  swollen  and  filled  with  blood  pig- 
ment, which  is  diffused  throughout  the  cells  of  the  pulp,  and  free  in  the 
blood-vessels.  Punctate  haemorrhages  are  seen  in  most  of  the  other  vis- 
cera. Fatty  degeneration  is  at  times  observed  in  the  heart  and  liver. 
Peyer's  patches  and  the  mesenteric  glands  are  frequently  swollen. 

This  disease  most  frequently  attacks  those  who  have  been  previously 
healthy.  The  symptoms  usually  begin  from  the  fourth  to  the  eighth  day 
after  birth.  They  are  intense  and  fulminating  in  character,  seldom  lasting 
more  than  two  days,  and  often  only  one.  The  early  symptoms  are  general 
restlessness,  rapid  pulse  and  respiration,  prostration,  cyanosis  of  the  face, 
and  general  icterus,  which  is  at  first  slight,  but  steadily  increases  until  it 
becomes  intense,  the  skin  resembling  that  of  a  mulatto.  The  temperature 
is  normal  or  slightly  elevated.  Gastro-enteric  symptoms  are  occasionally 
present,  but  they  are  not  a  feature  of  this  disease.  There  is  rapid  asthenia, 
often  terminating  in  coma  or  convulsions.  The  most  characteristic  symp- 
toms are  those  connected  with  the  urine.  It  is  passed  frequently,  in  small 
quantities,  with  j^ain  and  straining.  It  is  of  a  brown,  smoky  colour,  and 
under  the  microscope  shows  ha?moglobin  in  considerable  quantity,  renal 
epithelium,  and  sometimes  granular  casts  and  blood-cells,  but  does  not 
contain  bile  pigment.  Albumin  is  sometimes  present,  but  not  in  large 
quantity.  Examination  of  the  blood  shows  an  increase  of  the  white  cells 
and  many  free  granules. 

Treatment  is  of  little  avail,  since  all  severe  cases  die.  It  is  to  be 
directed  against  individual  symptoms. 

FATTY  DEGENERATION   OF  THE  NEWLY  BORN  (BUHL'S  DISEASE). 

A  disease  has  been  described  by  the  author  whose  name  it  bears,  the 
essential  nature  and  causation  of  which  are  unknown.  It  is  character- 
ized by  inflammatory  changes  leading  to  fatty  degeneration  in  the  viscera, 
especially  the  heart,  liver,  and  kidneys ;  it  seldom  lasts  more  than  two 
weeks,  and  is  almost  invariably  fatal.  There  may  be  luemorrhages  in  any 
of  the  viscera,  into  the  serous  cavities,  or  from  any  mucous  membrane. 
In  the  lungs  are  found  large  or  small  haemorrhagic  infarctions,  and  the 
bronchi  contain  blood  and  bloody  mucus.  There  is  granular  or  fatty  de- 
generation of  the  epithelial  cells  of  the  alveoli.  In  cases  that  have  lasted 
some  time,  the  heart-muscle  is  pale,  soft,  and  fatty.  The  liver  in  re- 
cent cases  is  large  and  soft ;  in  those  of  longer  standing  it  is  pale  and 
jaundiced,  and  shows  marked  fatty  degeneration.  The  spleen  is  large 
and  soft.  The  stomach  and  intestines  contain  blood,  and  the  mucous 
membrane  shows  ecchymoses.      The   epithelium   of  the  tubules  of  the 


92 


DISEASES  OF  THE  NEWLY  BORN. 


kidney  is  fatt}',  and  the  tubes  are  choked  with  granuhir  and  fatty  detri- 
tus. The  umbilicus  is  normal,  but  often  there  are  haemorrhages  into  the 
neic^hbouring  tissues.  Many  of  the  lesions  are  similar  to  the  ordinary 
post-mortem  changes,  and  when  found  they  should  not  be  interpreted  as 
pathological  unless  the  autopsy  has  been  made  within  at  least  twelve  hours 
after  death. 

The  disease  occurs  most  frequently  in  patients  who  have  previously 
presented  the  symptoms  of  asphyxia,  which  to  a  greater  or  less  degree 
have  persisted.  In  other  respects  the  infants  may  be  strong  and  well- 
nourished.  The  symptoms  develop  gradually.  Those  most  constantly 
present  are  vomiting  of  blood,  bloody  stools,  icterus,  and  oedema  which 
may  aifect  only  the  dependent  parts,  or  may  be  general.  When  the  cord 
separates  there  is  often  bleeding  at  the  umbilicus.  The  constitutional 
symptoms  are  prostration,  rapid  loss  in  weight,  and  all  the  evidences  of 
malnutrition.  There  is  no  appreciable  rise  in  temperature.  External 
heemorrhages  may  be  wanting  altogether.  Death  occurs  from  progressive 
asthenia  or  haemorrhage.  The  clinical  features  resemble  those  of  pyogenic 
infection,  but  in  Buhl's  disease  the  umbilicus  is  healthy,  aside  from  occa- 
sional hemorrhages,  and  there  is  no  rise  of  temperature.  The  disease 
occurs  in  isolated  cases,  not  in  groups.  The  treatment  is  entirely  symp- 
tomatic. 

PEMPHIGUS. 

Pemphigus  is  a  term  used  to  designate  a  lesion  rather  than  a  disease. 
By  it  is  meant  an  eruption  of  bullre  occurring  usually  upon  a  red  base, 
the  contents  being  in  most  cases  clear  serum.  The  term  has  been  made 
in  the  past  to  include  several  different  diseases  even  in  the  newly  born. 

1.  Traumatic  pemphigus  is  a  condition  which  has  been  induced  by 
putting  infants  into  very  hot  baths. 

2.  Pemphigus  is  seen  as  one  of  the  lesions  of  congenital  syphilis.  In 
these  cases  the  eruption  is  often  present  at  birth.  It  rarely  appears  after 
the  fourteenth  day.  The  bullse  are  often  seen  upon  the  palms  and  the 
soles,  but  may  be  present  on  any  part  of  the  body.  These  infants  are 
usually  in  a  wretched  condition,  and  die  in  a  few  weeks,  often  in  a  few 
days. 

3.  There  is  a  variety  of  pemphigus  which  seems  clearly  due  to  infec- 
tion. This  has  been  observed  in  small  epidemics  in  institutions.  Quite  a 
number  of  such  epidemics  have  been  seen  in  Europe,  but  none  that  I  am 
aware  of  have  been  reported  in  America.  Koch  reports  twenty-three  cases 
occurring  in  two  3'ears  in  the  practice  of  one  midwife,  she  herself  being 
probably  the  source  of  infection.  The  same  writer  states  that  in  two  cases 
the  disease  developed  upon  the  breasts  of  mothers  who  were  nursing  af- 
fected children.  While  the  infectious  character  of  the  disease  is  pretty 
generally  admitted,  the  exact  nature  of  the  exciting  cause  has  not  yet  been 


HAEMORRHAGES.  93 

determined.  Strclitz  discovered  iu  tlie  exudate  two  varieties  of  patho- 
genic cocci.     Demme  fcnmd  diplococci. 

The  clinical  picture  presented  by  this  form  of  pemphigus  is  so  striking 
that  the  disease  can  scarcely  be  mistaken.  The  symptoms  begin  in  most 
cases  between  the  third  and  sixth  day  of  life.  There  is  a  bullous  erup- 
tion, which  appears  upon  the  abdomen,  neck,  face,  or  thighs.  It  is  com- 
monly seen  first  upon  the  trunk.  Usually  there  are  but  ten  or  twenty 
bullaj  present ;  but  nearly  the  whole  body  may  be  covered  except  the 
palms  and  soles,  where  they  are  rarely  seen.  They  may  even  appear  upon 
the  conjunctiva  or  the  mucous  membrane  of  the  mouth.  The  single  vesi- 
cles vary  in  size  from  one  fourth  to  one  or  two  inches  in  diameter.  They 
are  usually  rounded,  with  a  reddened  base.  The  contents  may  be  clear  or 
cloudy.  The  small  vesicles  may  coalesce  and  form  very  large  bulla?.  Rup- 
ture usually  occurs  in  one  or  two  days,  and  there  is  left  a  moist  red  sur- 
face, which  quickly  dries.  After  the  falling  off  of  the  crust  there  remains 
a  red  or  violet  patch  upon  the  skin.  The  eruption  may  come  out  quite 
rapidly,  almost  at  once,  or  the  disease  may  be  prolonged,  the  buUge  appear- 
ing in  crops  for  from  one  to  three  weeks.  If  ulceration  occurs  the  dura- 
tion of  the  disease  may  be  considerably  lengthened.  In  many  particulars 
the  pemphigus  resembles  impetigo  contagiosa,  with  which  it  has  no  doubt 
often  been  confounded. 

The  principal  point  in  diagnosis  is  to  distinguish  between  syphilitic 
and  non-syphilitic  pemphigus.  The  latter  usually  occurs  in  well-nourished 
infants,  and  has  a  much  better  prognosis.  In  infants  previously  healthy 
it  usually  ends  in  recovery  when  the  bulla?  are  few  in  number ;  but  ii  they 
develop  rapidly  over  a  large  surface  the  outlook  is  very  unfavourable. 

The  treatment  consists  in  absolute  cleanliness,  and  in  the  use  of  ab- 
sorbent antiseptic  powders,  such  as  equal  parts  of  boric  acid  and  starch, 
to  dry  up  the  eruption,  or  antiseptic  lotions,  such  as  1  to  10,000  bichloride, 
or  a  one-per-cent  solution  of  ichthyol. 


CHAPTER  V. 
HEMORRHAGES. 

HEMORRHAGES  are  quite  frequent  during  the  first  days  of  life,  and  are 
important  not  only  from  the  fact  that  they  are  often  the  cause  of  death, 
but,  when  the  brain  is  the  seat,  from  their  remote  effects.  There  are  sev- 
eral conditions  in  the  newly  born  which  predispose  to  bleeding — the 
extreme  delicacy  of  the  blood-vessels,  and  the  great  changes  taking  place 
in  the  blood  itself  and  in  the  circulation  in  the  transition  from  intra- 
uterine to  extra-uterine  life.     Haemorrhages  may  complicate  many  of  the 


94  DISEASES  OF   THE   NEWLY  BORN. 

diseases  of  the  early  days  of  life,  such  as  syphilis  or  sepsis,  or  they  may 
exist  alone. 

The  cases  may  be  divided  into  two  groups :  (1)  Traumatic  or  Acci- 
dental Haemorrhages,  which  depend  upon  causes  connected  with  delivery ; 
(2)  Spontaneous  Ha?morrhages,  or  The  Ha^morrhagic  Disease  of  the 
Newly  Born. 

TRAUMATIC  OR  ACCIDENTAL  HAEMORRHAGES. 

These  are  mainly  due  to  pressure  in  natural  labour,  or  to  means  em- 
ployed in  artificial  delivery,  but  some  of  them  may  possibly  result  from 
injuries  received  before  birth.  Their  position  is  influenced  by  the  presen- 
tation and  the  nature  of  the  means  employed  in  delivery.  They  are  more 
frequent  in  large  children,  in  difficult  labours,  and  where  from  any  cause 
the  body  of  the  child  has  been  subjected  to  undue  pressure.  The  most 
important  of  these  are  hgematoma  of  the  sterno-mastoid,  cephalhsematoma, 
and  certain  of  the  siugle  visceral  hemorrhages,  which  may  be  intracranial, 
thoracic,  or  abdominal. 

Hsematoma  of  the  Sterno-Mastoid. — Haematoma,  or,  as  it  is  sometimes 
called,  induratioii  of  the  sterno-mastoid  muscle,  leads  to  the  formation  of 
a  tumour  in  the  belly  of  the  mnscle.  It  is  a  rare  condition,  nsually  no- 
ticed in  the  second  or  third  week  of  life,  and  it  disappears  spontaneously, 
without  causing  any  permanent  deformity.  The  tumour  varies  from  three 
quarters  of  an  inch  to  one  inch  and  a  half  in  length,  being  about  tlie  size 
and  shape  of  a  pigeon's  egg.  It  is  movable,  almost  cartilaginous  to  the 
touch,  and  sometimes  slightly  tender.  The  situation  of  the  tumour  is  usu- 
ally about  the  centre  of  the  muscle.    There  is  no  discoloration  of  the  skin. 

In  about  two  thirds  of  the  cases  it  occurs  after  breech  presentations. 
It  is  much  more  frequent  upon  the  right  than  upon  the  left  side.  In 
twenty-seven  cases  collected  by  Henoch  the  right  side  was  involved  in 
twenty-one  and  the  left  in  only  six  cases.  Tlie  explanation  of  this  differ^ 
ence  is  to  be  found  in  the  obstetrical  position.  Earely,  both  sides  may 
be  involved.  The  head  is  usually  inclined  towards  the  shoulder  of  the 
affected  side  and  rotated  towards  the  opposite  side.  The  tumour  is  fre- 
quently discovered  by  accident.  Often  it  is  the  slight  rotation  of  the  head 
which  is  first  noticed.  Hgematoma  of  the  sterno-mastoid  is  frequently 
mistaken  for  an  enlarged  lymphatic  gland ;  its  position,  however,  is  diag- 
nostic. The  swelling  slowly  diminishes  in  size,  and  in  most  cases  by  the 
end  of  the  third  month  has  entirely  disappeared.  Occasionally  a  slight 
torticollis  remains  for  a  longer  time,  but  in  the  majority  of  cases  the  re- 
covery is  perfect.  Haematoma  of  the  sterno-mastoid  is  due  to  the  twisting 
of  the  head  during  parturition.  It  is  not  an  evidence  of  the  employment 
of  any  improper  violence  in  delivery.  The  twisting  of  the  head  produces 
laceration  of  some  of  the  blood-vessels  of  the  muscle,  and  in  some  cases 
there  is  doubtless  rupture  of  some  of  the  fibres  ©f  the  muscle  itself.     Fol- 


CEPHALHEMATOMA.  95 

lowing  this  there  occurs  a  certain  amount  of  inflammation  of  the  muscle 
and  its  sheath.  The  tumour  is  due  partly  to  blood-extravasation  and 
partly  to  inflammatory  products.  In  one  or  two  recent  cases  in  which 
the  sheath  of  the  muscle  has  been  opened  it  has  been  found  filled  with 
blood.     Usually  the  inner  border  of  the  muscle  is  the  part  most  affected. 

The  prognosis  for  complete  recovery  is  good.  The  condition  requires 
no  treatment.     Operative  interference  is  positively  contra-indicated. 

Cephalhaematoma. — This  is  a  tumour  containing  blood,  situated  upon 
the  head,  usually  over  one  parietal  bone,  and  tending  to  spontaneous  dis- 
appearance by  absorption.  The  source  of  the  blood  is  the  rupture  of  the 
small  vessels  of  the  pericranium. 

Etiology. — Cephalhematoma  is  sometimes  due  to  a  distinct  traumatism 
like  the  application  of  forceps  or  to  some  other  injury  during  labour.  In 
the  majority  of  cases,  however,  there  is  no  evidence  of  such  injury,  and 
the  cases  are  regarded  as  of  spontaneous  origin.  Several  etiological  factors 
are  probably  present.  Besides  the  conditions  predisposing  to  all  htemor- 
rhages,  there  is  the  increased  pressure  in  the  blood-vessels  of  the  head 
during  delivery,  especially  when  labour  is  prolonged  or  difficult;  there 
may  be  changes  in  the  bone,  such  as  an  imperfect  development  of  the  ex- 
ternal table,  which  has  been  found  in  a  few  instances,  and  in  consequence 
of  which  the. periosteum  readily  separates  when  the  head  is  subjected  to 
the  pressure  of  the  pelvis ;  and,  finally,  there  may  be  changes  in  the  blood 
itself.  Cephalhaematoma  is  a  comparatively  rare  condition,  being  present, 
according  to  the  statistics  of  the  Sloane  Maternity  Hospital,  in  20  of  1,300 
consecutive  births,  or  1-6  per  cent.  This  is  rather  more  frequent  than  is 
stated  by  European  observers.  The  condition  is  more  common  after  first 
labours,  after  difiicult  labours,  and  in  vertex  presentations.  It  occurs 
twice  as  often  in  males  as  in  females,  probably  from  the  greater  size  of  the 
head  in  male  children. 

Lesio7is. — In  the  20  Sloane  cases,  the  situation  was  over  the  right  parie- 
tal bone  in  12 ;  over  the  left  in  2 ;  over  both  parietals  in  4 ;  over  the  occip- 
ital in  2.  The  location  of  the  tumour  seems  to  have  a  very  close  relation 
to  the  position  of  the  head  in  the  pelvis.  In  8  of  the  right-sided  cases  the 
head  was  in  the  left  occipito-anterior  position  ;  in  3  it  was  in  the  right 
occipito-anterior ;  in  1  case  the  position  was  unknown.  Of  the  cases  with 
occipital  tumours,  both  were  breech  presentations.  Of  the  16  cases  with  a 
single  tumour  the  labour  was  natural  in  10,  tedious  in  4,  and  in  2  forceps 
were  used.  Of  the  4  double  cases,  2  were  forceps  deliveries,  1  a  tedious 
labour,  and  but  1  was  natural. 

In  rare  cases  triple  tumours  are  met  with,  one  over  each  parietal  and 
one  over  the  occipital  bone.  The  attachment  of  the  periosteum  along  the 
sutures,  usually  limits  the  tumour  to  the  surface  of  one  bone.  It  never  ex- 
tends across  the  sutures  or  over  the  fontanel.  In  cases  where  there  is  a 
more  definite  injury,  such  as  the  forceps,  the  tumour  may  be  present  over 


96  DISEASES  OF   THE   NEWLY  BORN. 

any  one  of  the  cranial  bones,  but  more  frequently  over  the  parietal.  The 
seat  of  the  haemorrhage  is  between  the  periosteum  and  the  cranium.  The 
scalp  shows  punctate  hajmorrhages  and  sometimes  infiltration  with  blood. 
In  recent  cases  the  blood  is  fluid  ;  later  it  is  coagulated.  There  is  often 
developed  aboi;t  the  blood-clot  a  sort  of  cyst  wall  which  limits  its  exten- 
sion. The  bone  is  roughened,  and  there  are  at  times  small  bony  plates  in 
the  under  surface  of  the  periosteum.  The  amount  of  extravasated  blood 
is  usually  from  half  an  ounce  to  an  ounce.  In  extreme  cases  it  may  be 
from  four  to  six  ounces.  The  cases  following  natural  delivery  are  gen- 
erally uncomplicated.  The  traumatic  cases  may  be  complicated  by  ex- 
travasations between  the  bone  and  the  dura  (internal  cephalhaematoma), 
or  by  meningeal  or  cerebral  haemorrhages.  If  there  is  a  wound,  infection 
may  be  followed  by  purulent  meningitis  and  even  by  cerebral  abscess. 

Symptoms. — The  tumour  is  usually  noticed  from  the  first  to  the  fourth 
dav  after  birth,  appearing  as  a  slight  prominence  in  one  of  the  positions 
indicated.  Gradually  increasing  in  size,  it  attains  its  maximum  at  the  end 
of  a  week  or  ten  days,  and  then  slowly  diminishes.  In  the  average  case 
the  tumour  is  about  the  size  of  a  hen's  egg,  and  is  oval  in  form.  In  marked 
cases  it  may  be  one  third  the  size  of  the  child's  head.  To  the  touch  it  is 
soft,  elastic,  fluctuating,  and  irreducible.  It  does  not  increase  with  the  cry 
or  cough.  There  is  no  extra  heat  and  no  sign  of  inflammation.  Usually 
the  tumour  does  not  pulsate,  although  in  rare  instances  pulsating  cephal- 
haematomata  have  been  seen.  Very  soon  the  tumour  is  surrounded  by  a 
marginal  ridge.  At  first  this  is  apparently  from  coagulation  of  blood,  but 
later  it  may  be  bony.  The  prominent  ridge  with  the  soft  centre  gives 
a  sensation  somewhat  like  that  of  a  depressed  fracture.  Sometimes  on 
pressure  there  is  obtained  a  sort  of  parchment-crackling.  This  is  gener- 
ally found  as  the  swelling  is  subsiding,  and  is  sometimes  clearly  due  to  the 
formation  of  minute  bony  plates  upon  the  inner  surface  of  the  perios- 
teum. It  may  be  found  when  there  is  nothing  but  thin  coagula  to  explain 
it.  In  certain  cases  following  severe  traumatism,  cephalhematoma  may 
be  complicated  with  wounds  of  the  scalp,  fracture  of  the  skull,  and  even 
lacerations  of  the  dura  mater  or  the  brain.  In  such  cases  the  tumour 
may  become  inflamed,  but  in  the  spontaneous  cases  this  is  extremely  rare. 
The  usual  signs  of  abscess  develop,  which  may  open  externally  or  burrow. 
Fortunately  this  termination  is  seldom  seen. 

As  a  rule,  without  any  interference,  the  uncomplicated  cases  go  on  to 
recovery.  The  complete  disappearance  of  the  tumour  may  be  expected  in 
from  six  weeks  to  three  months,  depending  on  its  size ;  but  a  hard,  uneven 
elevation  may  remain  at  its  site  for  a  longer  time.  The  cases  due  to  severe 
traumatism  are  more  serious,  the  gravity  depending  not  upon  the  cephal- 
haematoma but  upon  the  complicating  lesions. 

Diagnosis. — Cephalhaematoma  may  be  confounded  with  encephalocele. 
This,  however,  occurs  along  the  line  of  the  sutures  or  at  the  fontanels,  is 


VISCERAL   H^MOKRIiAGK.S.  97 

partly  reducible,  pressure  causes  cerebral  symptoms,  and  frequently  the 
tumour  increases  witli  respiratory  movements.  Hydrocephalus  is  distin- 
guished by  the  symmetrical  enlargement  of  the  head,  the  large  frontanels, 
and  the  widely  separated  sutures.  Caput  succedaneum  often  appears  in  the 
same  i)hice  as  a  cephalhematoma  and  at  the  same  time,  but  is  an  oedem- 
atous,  not  a  fluctuating  tumour,  is  not  circumscribed,  lacks  the  hard, 
marginal  border,  and  begins  to  disappear  by  the  second  or  third  day. 
From  a  depressed  fracture  of  the  skull,  it  is  differentiated  by  the  fact  that 
in  cephalhaimatoma  there  is  a  tumour  and  not  a  depression  ;  the  promi- 
nent margin  which  is  raised  above  the  contour  of  the  skull,  is  not  osseous 
and  the  skull  can  be  felt  at  the  bottom  of  the  centre  of  the  tumour. 

The  treatment  in  the  uncomplicated  cases  is  simply  protective,  all 
such  cases  tending  to  spontaneous  recovery.  No  local  or  general  treat- 
ment to  promote  absorption  is  required.  The  child  should  be  so  placed 
and  so  handled  that  no  injury  may  be  done  to  the  affected  part.  Com- 
presses are  unnecessary.  If  complications  exist,  such  as  injury  to  the 
bones,  dura,  or  brain,  they  are  to  be  treated  in  accordance  with  general 
surgical  principles.  Operative  interference  is  called  for  only  when  sup- 
puration has  occurred,  or  when  there  are  brain  symptoms  which  point  to 
the  existence  of  internal  as  well  as  external  cephalhaematoma. 

Visceral  Haemorrhages. — While  these  are  most  frequent  in  large  chil- 
dren and  following  difficult  labours,  they  may  occur  in  small  children  and 
where  the  labour  has  been  easy  and  normal — their  occurrence  here  being 
due  to  the  feeble  resistance  of  the  blood-vessels.  From  one  hundred  and 
thirty  autopsies  upon  still-born  children  or  those  dying  soon  after  birth, 
Spencer  concludes  that  intracranial  haemorrhages  are  more  frequent  in 
head-forceps  than  in  breech  cases,  and  more  frequent  in  breech  than  in 
natural  vertex  deliveries.  Other  visceral  haemorrhages  are  much  more 
frequent  in  breech  cases. 

Not  all  visceral  hsemorrhages  are  to  be  classed  as  traumatic.  They  are 
often  seen  with  the  spontaneous  haemorrhages  from  the  skin  or  mucous 
membranes.  When,  however,  they  are  single,  they  seem  to  me  of  trau- 
matic rather  than  of  pathological  origin. 

The  most  important  of  the  visceral  htemorrhages  are  intracranial. 
These  are  discussed  in  the  chapter  devoted  to  Birth  Paralyses.  Rarely 
there  may  be  large  haemorrhages  into  the  lung.  Here  the  blood  fills  the 
air  vesicles,  the  small  bronchi,  and  coagula  may  be  found  even  in  the 
larger  bronchi.  A  large  part  of  a  lobe  or  an  entire  lobe  may  be  involved. 
On  section  the  condition  resembles  atelectasis,  and  it  may  give  the  physical 
signs  of  consolidation. 

The  abdominal  viscera  suffer  more  than  those  of  the  thorax  because 
less  protected  against  pressure.  Small  haemorrhages  are  not  uncommon 
upon  the  surface  .of  any  of  the  viscera  covered  by  peritonaeum.  Intra- 
peritoneal haemorrhages  are  rare,  but  may  be  very  extensive,  amounting  to 


98  DISEASES   OF   THE   NEWLY  BORN. 

one  or  two  pints.  Sometimes  no  ruptured  vessel  can  be  found.  The 
hsemorrhage  may  be  primarily  in  the  peritoneal  cavity,  or  it  may  result 
from  rupture  of  one  of  the  viscera,  especially  the  suprarenal  capsule.  It 
may  be  large  enough  to  produce  death  from  loss  of  blood. 

Small  surface  hajmorrhages  of  the  liver  are  not  infrequent.  Occa- 
sionally one  of  considerable  size  occurs  separating  the  peritoneal  covering 
and  forming  a  tumour  generally  upon  the  superior  surface.  Such  lacer- 
ation may  be  produced  during  labour,  and  a  slow  accumulation  of  blood 
may  take  place  beneath  the  capsule,  death  resulting,  as  in  the  case  re- 
ported by  Mendelson  (New  York),  from  rupture  into  the  peritoneal  cavity 
on  the  third  day.  Stetfen  reports  a  case  of  laceration  of  the  capsule  of 
the  liver  in  a  still-born  infant.  Of  the  large  haemorrhages,  those  into  the 
suprarenal  capsules  are  perhaps  the  most  frequent.  Two  cases  have  re- 
cently occurred  in  the  Sloane  Maternity  Hospital.  In  one  of  these,  the 
specimen  of  which  I  examined,  the  capsule  was  distended  nearly  to  the 
size  of  an  orange,  and  the  kidney  surrounded  by  a  mass  of  blood-clots. 
Blood  was  extravasated  into  the  retroiDcritoneal  connective  tissue,  and 
rupture  had  taken  place  into  the  peritoneal  cavity,  which  contained  half 
a  pint  of  partly  coagulated  blood.  The  child  died  on  the  fifth  day.  This 
case  has  been  reported  in  full  by  Tuley.*  Ahlfeld  has  reported  a  case  of 
haemorrhage  into  both  suprarenals. 

Except  in  the  intracranial  variety,  visceral  haemorrhages  cause  few 
symptoms,  and  in  the  great  majority  of  cases  the  diagnosis  is  not  made. 
Intrapulmonary  ha?morrhages  have  given  rise  to  the  signs  of  consolida- 
tion of  the  lung  and  even  to  hemoptysis  (Miram's  case).  The  abdominal 
haemorrhages  are  the  most  obscure.  There  may  be  a  general  abdominal 
distention  with  the  usual  symptoms  of  loss  of  blood,  or  there  may  be  a 
circumscribed  swelling.  In  many  cases  nothing  is  noticed  until  a  rupture 
of  a  subperitoneal  haemorrhage  takes  place  into  the  general  peritoneal 
cavity,  when  there  may  be  sudden  collapse  and  death. 

The  visceral  haemorrhages  are  not  amenable  to  treatment.  The  prog- 
nosis depends  upon  the  size  and  position  of  the  hemorrhage.  In  the  cases 
of  abdominal  ha3morrhage  the  diagnosis  is  extremely  obscure  and  is  rarely 
made  during  life. 

SPONTANEOUS   HEMORRHAGES— THE    HEMORRHAGIC    DISEASE    OF 
THE   NEWLY  BORN. 

A  disposition  to  bleeding  is  seen  with  many  diseases  of  the  first  few  days 
of  life,  especially  those  of  an  infectious  character,  like  syphilis  and  pyaemia. 
With  most  of  these,  however,  the  haemorrhages  are  small,  and  the  condi- 
tion may  be  compared  to  the  hemorrhagic  tendency  seen  in  certain  forms 
of  infection  of  later  life,  such  as  measles,  smallpox,  and  malignant  endo- 

*  Archives  of  Pediatrics,  November,  1892. 


THE   HEMORRHAGIC   DISEASE.  99 

carditis.  There  is,  however,  a  class  of  cases  in  which  the  haemorrhages  are 
not  associated  with  any  other  known  process,  and  in  which  the  escape  of 
blood  from  the  small  blood-vessels  is  the  chief  or  essential  symptom.  In 
these  cases  the  bleeding  is  much  more  extensive  than  in  the  others  men- 
tioned. These  haemorrhages  are  characterized  by  the  fact  that  they  are 
spontaneous  in  origin,  having  no  connection  with  delivery,  they  are  mul- 
tiple in  location,  and,  while  little  influenced  by  treatment,  they  tend  to 
cease  spontaneously  after  quite  a  limited  time.  They  are  most  often  from 
the  umbilicus,  the  mucous  membranes  of  the  stomach  and  intestines,  or 
beneath  the  skin,  but  they  may  be  from  almost  any  mucous  surface  or 
into  any  organ  of  the  body. 

Etiology. — Exactly  what  causes  these  haemorrhages  is  as  yet  unknown, 
but  it  is  something  which  produces  changes  in  the  blood  or  in  the  blood- 
vessels, or  in  both,  whereby  the  vessels  are  no  longer  able  to  hold  their 
contents.  In  this  class,  as  well  as  in  the  traumatic  haemorrhages,  the 
predisposing  causes  of  bleeding  in  early  life  must  be  emphasized — viz.,  the 
fragile  condition  of  the  blood-vessels  and  the  great  changes  taking  place 
soon  after  birth  both  in  the  circulation  and  in  the  blood  itself.  These 
haemorrhages  are  not  common,  and  are  met  with  much  more  often  in  in- 
stitutions than  in  private  practice.  In  5,225  births  in  the  Boston  Lying-in 
Asylum,  Townsend  reports  32  cases  of  haemorrhage,  or  0-6  per  cent.  In 
the  Lying-in  Asylum  of  Prague,  Ritter  observed  190  cases  in  13,000  births, 
or  1-4  per  cent.  In  the  Foundling  Asylum  of  Prague,  Epstein  reports 
haemorrhages  in  8  per  cent  of  740  infants. 

These  cases,  except  in  very  rare  instances,  are  not  manifestations  of 
haemophilia.  Of  576  bleeders  collected  by  Grandidier,  only  12  had  a  his- 
tory of  hemorrhage  at  the  time  of  falling  off  of  the  cord,  and  symptoms 
very  rarely  appeared  before  the  end  of  the  first  year.  Haemorrhages  in 
the  newly  born  are  more  frequent  in  males,  while  in  haemophilia  females 
predominate,  13  to  1.  The  haemorrhagic  disease  of  the  nevrly  born  is  self- 
limited,  and  runs  a  definite  course  to  recovery  or  death.  The  tendency  to 
bleed  does  not  extend  beyond  a  few  weeks,  and  often  lasts  but  a  few  days ; 
those  who  survive,  recover  perfectly.  Circumcision  has  been  done  within 
a  few  days  after  the  cessation  of  the  ha?morrhages  without  any  unusual 
bleeding.  In  a  case  lately  under  observation  with  the  most  extensive 
subcutaneous  ha?morrhages  I  have  ever  seen,  all  tendency  to  bleed  had 
ceased  before  the  separation  of  the  cord,  although  there  had  previously 
been  bleeding  at  the  navel.  A  similar  case  is  reported  by  Townsend. 
These  cases  are  not  associated  with  difficult  delivery.  In  only  6  of  Town- 
send's*  50  cases  was  the  labour  abnormal.  This  is  borne  out  by  my  own 
experience.  Many  of  the  children  who  bleed  have  previously  been  anaemic 
and  in  poor  general  condition ;  but,  on  the  other  hand,  many  have  been 

♦Archives  of  P;vdiatrics,  1894,  p.  559. 


100       •  DISEASES  OF  THE   NEWLY  BORN. 

strong  and  given  every  indication  of  being  well  nourished.  Hereditary 
syphilis  is  associated  in  a  small  proportion  of  the  cases — from  2  to  6  per 
cent,  according  to  the  observations  of  Epstein,  Eitter,  and  Townsend. 
In  132  cases  of  congenital  syphilis  observed  by  Mracek,  14  per  cent  suf- 
fered from  hgeraorrhages. 

A  more  frequent  association  with  sepsis  has  been  observed.  Of  the  61 
cases  observed  by  Epstein  not  less  than  29,  and  of  the  190  cases  of  Eitter,*  24 
were  associated  with  sepsis.  In  the  Sloane  Maternity  Hospital,  New  York, 
in  1,500  consecutive  births  no  case  of  haemorrhage  worth  mentioning  oc- 
curred, and  during  this  period  there  was  not  a  single  case  of  marked 
sepsis  among  the  infants  born  in  the  hospital.  During  the  past  year 
(1895)  there  have  been  no  less  than  8  marked  cases  of  haemorrhage  in  the 
Xursery  and  Child's  Hospital  in  about  225  deliveries.  While  it  is  true 
that  more  cases  of  sepsis  (pyogenic  infection)  have  occurred  among  the 
children  during  this  period  than  is  usual,  it  is  striking  that  not  one  of 
these  haemorrhagic  cases  gave  any  evidence  of  sepsis,  and  that  none  of  the 
septic  cases  had  bleeding. 

From  the  foregoing  facts  it  is  quite  evident  that  not  all  the  cases  of 
bleeding  are  due  to  the  same  cause,  and  that  while  this  symptom  occurs 
in  cases  of  pyogenic  infection,  the  latter  does  not  explain  most  of  the  cases 
seen.  The  circumstances  in  which  the  lijemorrhagic  disease  occurs  point 
strongly  to  an  infectious  origin,  but  with  our  present  knowledge  we  cannot 
believe  this  cause  to  be  the  same  as  in  ordinary  sepsis — viz.,  the  entrance 
of  common  pyogenic  bacteria.  Bacteriological  findings  thus  far  have  not 
been  altogether  conclusive.  The  most  important  results  were  obtained 
in  two  cases  studied  recently  by  Gaertner.f  In  both  of  these  there  was 
found  in  the  blood  a  short  bacillus  resembling  in  some  respects  the  bacte- 
rium coli  commune,  but  differing  from  it  in  several  important  points. 
This  bacillus,  injected  into  the  peritoneal  cavity  in  young  animals,  chiefly 
dogs  a  few  days  old,  produced  a  disease  accompanied  by  hsemorrhages  re- 
sembling that  seen  in  the  newly  born.  The  bacillus  was  recovered  from 
the  blood  and  all  the  organs  of  these  animals.  In  a  recent  case  occurring 
at  the  Nursery  and  Child's  Hospital,  cultures  were  made  eight  hours  after 
death  by  Dr.  J.  J.  Mapes.  There  was  found  in  pure  culture  in  the  um- 
bilical arteries,  in  the  heart's  blood,  and  in  the  spleen,  a  bacillus  which 
in  morphological  and  culture  characteristics  was  apparently  identical  with 
that  described  by  Gaertner.  It  will,  however,  be  necessary  that  many 
other  cases  shall  be  recorded  before  the  etiological  connection  between 
this  germ  and  the  disease  is  established. 

While  these  hsemorrhages  are  not  traumatic,  bleeding  is  exceedingly 
prone  to  occur  in  the  skin  over  pressure  points  such  as  the  back,  the 

*  CEsterreiches  Jahrbiich  fiir  Padiatrik,  1871,  127. 
•)■  Archiv  fiir  Kinderheilkunde,  1895. 


THE    II^MOKKIIAGIC    DISEASE.  101 

elbows,  the  occiput,  and  the  sacrum.  It  is  also  common  from  the  mucous 
membranes  whicli  are  the  seat  of  pathological  processes,  especially  from 
the  eyes,  the  nose,  and  the  genitals. 

Lesions. — In  very  many  of  the  cases  the  autopsy  shows  nothing  except 
the  lui'morrhages  in  the  various  situations  and  the  blanching  of  the  organs 
due  to  the  loss  of  blood.  The  haemorrhages  of  the  brain  are  usually  me- 
ningeal and  diffuse.  They  are  considered  more  at  length  in  the  chapter 
upon  Birth  Paralyses.  The  pulmonary  haemorrhages  are  usually  small 
and  unimportant,  amounting  only  to  small  extravasations  into  the  sub- 
stance of  the  lung  or  ecchymoses  of  the  mucous  membrane  of  the  bronchi. 
Ecchymoses  may  be  seen  upon  the  surface  of  the  pleura,  the  pericardium, 
or  the  peritoneum,  but  large  haemorrhages  into  the  pleura  or  pericardium 
are  very  rare.  The  thymus  gland  is  often  the  seat  of  small  extravasa- 
tions. The  stomach  and  intestines  may  contain  considerable  blood  vari- 
ously disorganized  in  the  different  parts  of  the  canal,  and  there  may  be 
ecchymoses  of  the  mucous  membrane.  In  addition,  ulcers  may  be  found 
in  the  stomach  and  duodenum.  In  twenty-four  autopsies  upon  cases 
with  haemorrhage  from  the  stomach  and  intestines  collected  by  Dusser,* 
ulcers  were  found  in  the  stomach  in  nine  cases,  and  in  the  intestines  in 
four.  These  ulcers  are  multiple  and  are  small,  resembling  the  follicular 
ulcers  of  the  colon.  They  are  usually  superficial,  but  may  extend  to  the 
muscular  coat  and  may  even  perforate.  I  have  myself  found  ulcers  in  the 
stomach  in  a  single  case.  They  were  associated  with  a  moderate  amount 
of  follicular  gastritis.  The  intestinal  ulcers  are  found  only  in  the  duode- 
num and  resemble  those  of  the  stomach.  The  cause  of  these  ulcers  is 
somewhat  obscure ;  some  of  them  are  undoubtedly  dependent  upon  in- 
flammatory changes  probably  of  infectious  origin  ;  others  have  been  com- 
pared to  the  peptic  ulcers  of  later  life,  and  are  attributed  to  thrombi  in  the 
blood-vessels  of  the  mucous  membrane.  These  ulcers  are  found  in  but  a 
small  proportion  of  the  cases  in  which  bleeding  occurs  from  the  alimen- 
tary tract,  and  they  may  be  wanting  even  where  it  has  been  very  profuse. 

Small  extravasations  may  be  seen  upon  the  surface  of  the  liver,  the 
spleen,  or  the  kidneys.  They  may  also  be  found  in  the  substance  of  these 
organs.  The  large  htemorrhages  upon  the  surface  of  the  liver,  into  the 
suprarenal  capsules  and  other  subperitoneal  extravasations  have  been  in- 
cluded, improperly  perhaps,  in  the  group  of  traumatic  haemorrhages  dis- 
cussed in  the  preceding  chapter.  From  a  rupture  of  any  of  these  there 
may  be  large  extravasations  into  the  peritoneal  cavity.  Microscopical  ex- 
aminations of  the  blood-vessels  have  been  made  in  but  a  small  number  of 
cases.  Mracek  claims  to  have  found  evidences  of  endarteritis  in  some  of 
the  syphilitic  cases  in  which  there  was  bleeding.  The  changes  found 
in  the  blood  have    not   been   uniform  and    have   as   yet   been   only  im- 

*  These,  Paris.  1889. 


102  DISEASES   OP   THE   NEWLY  BORN. 

perfectly  studied.     The  associated  lesions  found  are  most  frequently  those 
due  to  sepsis. 

Symptoms. — The  time  of  beginning  is  most  frequently  in.  the  first 
week  of  life,  rarely  after  the  twelfth  day,  although  it  has  been  observed  as 
late  as  the  sixth  week.  As  a  rule,  the  hsemorrhages  from  the  stomach 
and  intestines  begin  earlier  than  those  from  the  navel  or  the  skin.  The 
location  of  the  hsemorrhage  in  Bitter's  190  cases  was  as  follows:  Um- 
bilicus, 138  (umbilicus  alone,  97) ;  intestines,  39 ;  mouth,  28 ;  stomach, 
20 ;  conjunctivre,  20 ;  ears,  9.  In  Townsend's  50  cases :  Intestines,  20  ; 
stomach,  14;  mouth,  14;  nose,  12;  umbilicus,  18  (umbilicus  alone,  3) ; 
subcutaneous  ecchymoses,  21  ;  abrasion  of  skin,  1 ;  meninges,  4 ;  cephal- 
haematoma,  3 ;  abdomen,  2  ;  pleura,  lungs,  and  thymus,  1  each. 

In  many  cases  nothing  is  noticed  until  the  haemorrhage  begins.  The 
child  may  be  previously  healthy  or  feeble.  The  first  bleeding  noticed  may 
be  from  the  stomach,  intestines,  or  any  of  the  mucous  surfaces,  beneath 
the  skin,  or  from  the  umbilicus.  The  amount  of  blood  lost  in  most  cases 
is  not  great,  but  there  is  a  continuous  oozing.  The  total  hsemorrhage 
may  be  only  one  or  two  drachms  or  it  may  reach  several  ounces.  The 
skin  is  usually  pale,  the  pulse  feeble,  and  the  general  condition  one  of  con- 
siderable prostration,  often  from  the  outset.  In  all  cases  there  is  rapid 
loss  of  weight.  The  temperature  may  be  high,  low,  or  subnormal.  A 
marked  elevation  of  temperature  may  depend  not  upon  the  haemorrhage 
but  upon  associated  conditions.  Fluctuations  in  temperature  during  the 
first  three  days  are  so  common  from  disturbances  of  nutrition,  that  I  attach 
much  less  importance  than  have  some  writers  to  this  symptom.  Icterus  is 
not  more  frequent  than  among  other  infants.  In  a  large  number  of  the 
cases  there  is  diarrhoea.    Convulsions  often  occur  at  the  close  of  the  disease. 

The  duration  of  the  disease  in  cases  which  recover  is  usually  but  one 
or  two  days.  In  fatal  cases  it  is  rarely  more  than  three  days,  and  often 
less  than  one.  Death  more  frequently  results  from  the  gradual  failure  of 
all  the  vital  forces  than  from  a  rapid  loss  of  blood. 

Umbilical  hcBmorrhage. — A  slight  oozing  from  the  umbilicus  not  in- 
frequently occurs  when  the  ligature  has  been  improperly  applied,  or  when 
there  is  so  much  shrinking  of  the  cord  that  the  ligature  has  loosened. 
Sometimes  rough  handling  at  the  time  of  the  separation  of  the  cord  may 
excite  a  little  bleeding.  All  the  above  conditions,  however,  are  usually  of 
trivial  importance  and  are  readily  controlled  by  simple  measures.  Spon- 
taneous haemorrhage  is  quite  a  different  matter.  It  is  rather  later  than 
bleeding  from  the  mucous  membranes,  usually  occurring  between  the 
fourth  and  the  seventh  day.  There  may  be  bleeding  into  the  cord  as  well 
as  from  its  free  extremity  before  it  separates ;  after  separation,  from  the 
stump.  A  slight  stain  upon  the  dressing  is  usually  the  first  note  of  warn- 
ing, but  in  exceptional  circumstances  a  gush  of  blood  is  the  first  symptom. 
The  haemorrhage  may  be  temporarily  arrested  by  various  means,  but  it 


THE   niEMORRHAGTC   DISEASE.  103 

shows  a  strong  tendency  to  recur  in  spite  of  everything  which  is  done. 
The  general  symptoms  depend  upon  the  amount  of  bleeding  and  the  rap- 
idity with  which  it  occurs.  It  is  the  same  as  in  other  haemorrhages  of  the 
newly  born.  The  usual  duration  is  two  or  three  days.  It  has  been  known, 
however,  to  persist  for  twelve  or  fourteen  days,  and  it  may  be  fatal  in  less 
than  twenty-four  hours  from  the  time  it  is  noticed. 

HcBtnorrhage  from  the  stomach  and  intestines. — This  occurs  much 
less  frequently  from  the  stomach  than  from  the  intestines.  The  latter 
is  called  mel«na.  Gastro-enteric  haemorrhages  begin,  in  tlie  great  ma- 
jority of  cases,  during  the  first  three  days  of  life.  Of  Dusser's  75  cases,  the 
haemorrhage  began  on  the  first  day  in  24  cases ;  on  the  second  day  in  22 
cases;  on  the  third  day  in  9  cases;  in  only  10  cases  later  than  the  ninth 
day,  and  in  no  instance  later  than  the  twelfth  day.  The  appearance  of 
the  blood  vomited  depends  upon  the  length  of  time  it  has  remained  in 
the  stomach.  Usually  it  is  in  dark  brown  masses,  and  not  very  abun- 
dant; more  rarely  bright  red  blood  may  be  ejected.  The  quantity  varies 
from  one  drachm  to  half  an  ounce.  Vomiting  is  liable  to  be  excited  by 
nursing.  The  blood  discharged  from  the  bowels  is  always  dark  coloured, 
usually  intimately  mixed  with  the  stool,  very  rarely  in  clots.  If  in  doubt 
between  blood  and  meconium,  one  should  look  for  the  corpuscles  with  the 
microscope.  When  this  is  not  conclusive  on  account  of  the  disorganiza- 
tion of  the  corpuscles,  a  chemical  test  for  haemoglobin  should  be  made. 
Concealed  haemorrhage  into  the  stomach  may  take  place,  which  may  even 
be  suflScient  to  produce  death,  no  blood  being  vomited  or  passed  by  the 
bowels.  In  such  cases  the  autopsy  may  reveal  quite  a  large  quantity  of 
blood,  both  in  the  stomach  and  intestines. 

Hemorrhage  from  the  month. — The  quantity  of  blood  is  rarely  large  ; 
but  it  is  here  that  it  is  often  first  seen.  Its  source  may  be  the  mucous 
membrane  of  the  mouth,  pharynx,  oesophagus,  stomach,  or  bronchi.  It 
may  be  associated  with  ulceration  of  the  hard  jDalate,  with  thrush,  or  with 
fissures  of  the  lips. 

Hemorrhages  from  the  nose  are  infrequent,  and  are  more  often  due  to 
syphilis  than  to  other  causes.  These  are  rarely  profuse,  but  are  frequently 
repeated. 

Subcutaneous  hcernorrhages. — These  may  appear  in  places  exposed  to 
pressure,  such  as  the  sacrum,  heels,  occiput,  or  back ;  or  in  t)thers  which 
are  not  so  exposed,  as  the  abdomen,  axilla%  or  thighs.  They  may  follow 
other  lesions  of  the  skin,  such  as  pemphigus,  eczema,  or  furunculosis.  In 
some  cases  these  haemorrhages  are  very  extensive,  as  in  one  recently 
under  observation,  where  nearly  one  third  of  the  thorax  was  covered. 
The  extravasations  are  surrounded  by  an  indurated  border.  Where  they 
occur  alone  or  form  the  principal  lesion,  the  prognosis  is  favourable. 

Hematuria. — The  urine  is  not  only  stained  with  blood,  but  sometimes 
contains  clots.     This  haemorrhage  mav  have  its  origin  in  the  bladder,  ure- 


104  DISEASES   OF   THE   NEWLY  BORN. 

thra,  or  kidney.  Blood  coming  from  the  kidney  is  sometimes  due  to  the 
irritation  of  uric-acid  infarctions,  and  may  have  nothing  to  do  with  the 
general  haemorrhagic  disease. 

Hiemorrhage  from  the  conjunctiva. — The  blood  usually  comes  in  drops 
from  between  the  eyelids,  chiefly  from  the  tarsal  surface.  It  is  generally 
preceded  by  conjunctivitis. 

Hcemorrhage  from  the  ears  may  originate  in  the  external  meatus  or 
the  middle  ear.     It  is  generally  preceded  by  otitis. 

Hcemorrhage  from  the  female  genitals. — This  not  infrequently  occurs 
without  hsemorrhages  elsewhere,  and  under  such  circumstances  is  rarely 
serious.  Cullingsworth  has  collected  thirty-two  cases  in  children  under 
six  weeks  of  age — no  case  having  resulted  fatally.  These  are  not  to  be  re- 
garded as  cases  of  precocious  menstruation.  They  are  frequently  preceded 
by  catarrhal  inflammations  of  the  vagina. 

Diagnosis. — This  is  generally  easy,  as  the  hemorrhages  are  usually 
multiple  and  some  of  them  external.  A  slight  hsemorrhage  from  the 
intestine  may  be  easily  overlooked.  Large  haemorrhages  into  the  internal 
organs  also  are  obscure  and  not  often  recognised.  Spurious  haemorrhages 
from  the  stomach  may  occur  as  in  the  vomiting  of  blood  which  has  been 
swallowed  during  parturition  or  sucked  from  the  breasts.  Bleeding  may 
take  place  from  the  mouth,  nose,  or  pharynx,  and,  after  being  swallowed, 
the  blood  may  be  vomited.  When  the  principal  bleeding  is  from  the  nasal 
mucous  membrane,  syphilis  should  be  suspected. 

Prognosis.  —  In  all  circumstances  the  haemorrhage  disease  in  the 
newly  born  has  a  bad  prognosis.  Of  seven  hundred  and  nine  cases  col- 
lected by  Townsend,  the  mortality  was  seventy-nine  per  cent.  No  ob- 
server has  seen  more  than  one  third  of  his  cases  recover.  In  any  single 
case  the  prognosis  depends  upon  the  extent  and  severity  of  the  haemor- 
rhage, upon  the  vigour  of  the  child,  and  upon  how  well  it  can  be  nour- 
ished. No  case  should  be  looked  upon  as  hopeless,  for  perfect  recovery  has 
repeatedly  taken  place  where  it  seemed  impossible. 

Treatment. — The  administration  of  drugs  internally  for  the  control  of 
hsemorrhage  is,  in  my  opinion,  entirely  without  influence  upon  the  dis- 
ease. The  general  treatment  should  have  reference  to  maintaining  the 
nutrition  by  careful  feeding,  judicious  stimulation,  and  attention  to  the 
circulation,  the  body  temperature,  and  the  general  condition  of  the  child. 
Externa]  haemorrhages  may  be  treated  locally.  Bleeding  points  on  the 
skin  or  mucous  membranes  within  reach,  are  best  treated  by  the  applica- 
tion of  chromic  acid  fused  on  a  probe,  or  of  nitrate  of  silver.  Umbilical 
hemorrhage  is  best  controlled  by  covering  the  umbilicus  with  a  small 
pad  of  sterile  cotton,  over  which  is  folded  from  either  side  the  skin  of  the 
abdominal  wall.  This  is  held  in  place  by  two  strips  of  adhesive  plaster 
crossing  the  umbilicus  obliquely.  After  ligature  en  masse  secondary  haem- 
orrhage often  occurs  at  the  separation  of  the  slough,  so  that  the  jDrocedure 


BIRTH    PARALYSES.  105 

is  frequently  unsuccessful.  The  actual  cautery  is  open  to  the  same  objec- 
tion. There  are  a  few  instances  on  record  where  bleeding  has  been  con- 
trolled by  covering  the  wound  with  plaster  of  Paris.  Astringents  are 
applicable  to  all  cases  of  external  haemorrhage — from  the  nose,  skin, 
vagina,  and  the  eyes.  Astringent  injections  for  gastro-enteric  haemor- 
rhages are  practically  useless,  as  the  blood  is  almost  invariably  either 
from  the  stomach  or  from  the  upper  part  of  the  small  intestine. 


CHAPTER   VI. 
BIRTH  PARALYSES. 

Birth  paralyses  are  chiefly  due  either  to  pressure  upon  the  child  by 
the  parts  of  the  mother  or  to  artificial  means  employed  in  delivery.  They 
may  be  cerebral,  spinal,  or  peripheral. 

Cerebral  paralyses  are  in  almost  every  instance  due  to  meningeal  haem- 
orrhage. Very  infrequently  they  depend  upon  cerebral  hemorrhage, 
laceration  of  the  brain,  or  pressure  from  a  depressed  fracture. 

Spinal  paralyses  are  extremely  rare,  and  only  a  few  examples  are  on 
record.  They  are  due  to  laceration  of,  or  hemorrhage  into  the  cord  or  its 
membranes.  These  lesions  produce  paraplegia,  the  exact  distribution  of 
which  depends  upon  the  point  at  which  the  cord  is  injured. 

Peripheral  paralyses  usually  affect  the  face  or  the  upjier  extremity. 
Paralysis  of  the  face  is  due  in  most  cases  to  the  application  of  the 
forceps.  Paralysis  of  the  upper  extremity  is  most  frequently  of  the 
*'  upper-arm  type,"  and  is  known  as  Erb's  paralysis.  It  usually  follows 
extraction  in  breech  presentations.  Peripheral  paralysis  of  the  lower 
extremity  is  almost  unknown. 

CEREBRAL   PARALYSIS. 

Cerebral  paralysis  is  often  used  synonymously  with  meningeal  haemor- 
rhage. This  lesion  is  not  infrequent,  and  is  of  great  importance  not  only 
from  its  immediate  effects,  but  because  upon  it  depend  many  of  the  cere- 
bral paralyses  seen  in  later  life.  According  to  Cruveilhier,  at  least  one 
third  of  the  deaths  of  infants  which  occur  during  parturition  are  due  to 
this  cause. 

Etiology. — The  same  predisposing  causes  exist  in  the  cases  of  menin- 
geal hemorrhages  as  in  others  occurring  at  this  time.  A  small  number  of 
cases  are  associated  with  syphilis ;  others  with  pyogenic  infection.  In  a 
few  cases  there  is  a  history  of  an  injury — usually  a  fall  or  blow  upon  the 
abdomen — during  the  last  months  of  pregnancy.    Meningeal  hemorrhage 


106  DISEASES   OF   THE   NEWLY  BORN. 

may  occur  as  one  of  the  lesions  in  the  haemorrhagic  disease  of  the  newly 
born.  The  most  important  causes,  however,  are  connected  with  parturi- 
tion. These  hgemorrhages  are  essentially  mechanical,  and  are  favoured 
by  everything  which  increases  or  prolongs  j)ressure  upon  the  head.  The 
conditions  with  which  they  are  associated  are  tedious  labour,  breech  pres- 
entations with  difficulty  in  extracting  the  head,  instrumental  deliveries, 
and  premature  births.  The  majority  occur  in  first-born  children.  Certain 
cases  are  associated  with  cardiac  malformations — according  to  Bednar,  a 
small  aorta  with  hypertrophied  heart,  or  the  transposition  of  the  large 
blood-vessels.  In  many  of  the  cases  there  is  also  a  haemorrhage  outside 
the  skull. 

Lesions. — These  haemorrhages  are  very  much  more  common  at  the 
base  than  at  the  convexity,  and  at  the  posterior,  than  at  the  anterior  part 
of  the  skull.  They  are  most  frequently  found  over  the  cerebellum  and 
the  occipital  lobes  of  the  cerebrum.  The  entire  extravasation  is  often 
beneath  the  tentorium.  The  extent  of  the  hasmorrhage  is  exceedingly 
variable.  There  may  be  a  single  large  clot  at  the  convexity  or  at  the  base 
(Plate  II),  the  haemorrhage  may  be  limited  to  the  convexity  of  one 
hemisphere,  or  it  may  cover  nearly  the  entire  surface  of  the  brain.  Dif- 
fuse haemorrhages  are  more  common  than  a  single  circumscribed  clot. 
Of  eleven  recent  cases  collected  by  McNutt  (New  York),  in  seven  cases 
with  vertex  presentations  the  lesion  was  principally  at  the  base,  and  usu- 
ally limited  to  that  region.  In  four  breech  cases,  however,  it  was  prin- 
cipally at  the  convexity.  The  source  of  the  blood  may  be  a  laceration  of 
one  of  the  sinuses  of  the  dura  mater  caused  by  the  overlapping  of  the 
parietal  bones.  This  was  found  in  one  of  the  cases  of  Hirst  (Phila- 
delphia). Much  more  frequently  the  blood  comes  from  one  of  the  cere- 
bral veins,  or  from  the  capillary  vessels  of  the  pia  mater.  In  thirty- 
seven  of  Bednar's  fifty-two  cases,  the  extravasation  was  beneath  the  pia 
mater.  In  the  remainder  it  was  between  the  pia  mater  and  the  dura — 
i.  e.,  in  the  arachnoid  cavity.  Hemorrhages  between  the  dura  and  the 
skull  may  be  said  never  to  occur  except  when  associated  with  fracture. 
If  the  child  is  still-born,  or  if  death  has  occurred  on  the  first  or  second 
day,  the  blood  is  partly  fluid  and  partly  coagulated  ;  later  it  is  entirely 
coagulated  and  may  have  undergone  partial  absorption.  The  amount  of 
extravasated  blood  varies  between  one  drachm  and  four  ounces,  the  aver- 
age amount  being  about  one  ounce.  The  blood  extends  into  the  fissures 
between  the  convolutions  and  sometimes  into  the  ventricles  along  the 
choroid  plexus,  although  this  is  rare.  In  large  hsemorrhages  the  brain 
substance  is  softened  and  in  places  may  be  quite  disintegrated ;  but  with 
small  extravasations  these  changes  are  very  slight.  In  cases  which  survive 
for  two  or  three  weeks  there  is  usually  a  certain  amount  of  meningitis. 
The  later  changes — those  of  arrested  development  of  the  cortex  and  cere- 
bral sclerosis — will  be  considered  in  the  chapter  devoted  to  Cerebral  Pa- 


PLATE  II. 


Meningeal  ILbmorrhage  in  the  Newly  Born. 

From  a  patient  in  the  Nursery  and  Child's  Hospital,  dying  on  the  sixth  day. 
Primary  respirations  poor;  child  very  dull  and  apathetic,  refused  to  nurse;  once  vom- 
ited blood  and  had  an  ecchymosis  of  the  right  conjunctiva.  On  the  last  day.  high 
temperature  (105'  F.)  and  general  convulsions.  Some  changed  blood  found  "in  the 
stomach  and  intestines  at  the  autopsy ;  brain  greatly  congested,  and  at  the  base  was 
the  clot  shown  in  the  picture. 


CEREBRAL   PARALYSIS.  107 

ralyses  in  the  section  on  Diseases  of  tlie  Nervous  System.  Haemorrhages 
into  the  membranes  of  tlie  upper  part  of  the  cord  are  found  in  a  large 
proportion  of  the  fatal  cases.  Associated  haemorrhages  of  the  lungs  and 
other  organs  are  not  uncommon. 

Symptoms. — If  the  hgemorrhage  is  large,  the  child  is  usually  still-born, 
although  its  movements  may  have  been  active  up  to  the  commencement  of 
labour.  When  the  hasmorrhage  is  not  so  large  as  to  be  immediately  fatal, 
the  child  may  show  no  symptoms  except  dulness  or  torpor,  with  feeble 
or  irregular  respiration,  death  following  within  the  first  twenty-four  hours. 
A  large  proportion  of  the  cases  are  born  asphyxiated,  and  frequently 
they  are  resuscitated  only  after  considerable  effort.  They  nurse  feebly, 
often  with  great  difficulty.  Convulsions  are  common  in  case^  which  last 
for  four  or  five  days,  and  more  with  cortical  haemorrhages  than  wuth  those 
at  the  base.  Opisthotonus  is  sometimes  present,  and  may  be  very  marked. 
The  limbs  may  be  rigidly  extended,  and  the  hands  clenched.  More  rarely 
there  is  complete  relaxation  of  all  the  muscles.  Sometimes  there  are  auto- 
matic movements.  The  respiration  is  usually  disturbed  ;  in  most  cases  it 
is  slow  and  irregular.  The  pulse  is  feeble  and  slow.  The  pupils  are  more 
frequently  contracted  than  dilated,  and  there  may  be  oscillation  of  the 
eyeballs.  In  large  haemorrhages  there  is  marked  bulging  of  the  fontanel, 
and  often  separation  of  the  sutures.  If  the  ha3morrhage  covers  one  hemi- 
sphere, there  is  hemiplegia  of  the  opposite  side.  Small  localized  cortical 
haemorrhages  may  cause  paralysis  of  the  face,  arm,  or  leg,  according  to 
the  position  of  the  lesion,  or  localized  convulsions.  In  large  haemorrhages 
at  the  base  convulsions  are  rare,  and  death  occurs  early,  usually  in  the  first 
two  days.  In  extensive  cortical  haemorrhages  convulsions  and  rigidity  of 
the  extremities  are  frequent,  and  life  is  prolonged  indefinitely. 

The  majority  of  the  fatal  cases  die  within  the  first  four  days.  In  those 
lasting  a  longer  time  the  symptoms  are  tonic  spasm  of  the  trunk,  or  of  one 
or  more  of  the  extremities,  localized  paralysis — monoplegia,  diplegia,  or 
hemiplegia,  according  to  the  lesion — with  localized  or  general  convulsions 
often  continuing  for  two  or  three  weeks  and  gradually  subsiding.  There 
is  frequently  a  slight  rise  in  temperature  due  to  secondary  infiammation. 
The  mildest  cases  may  show  no  symptoms  at  birth,  and  nothing  abnormal 
may  be  noticed  until  the  child  is  old  enough  to  walk  or  talk.  In  those 
more  severe  there  may  be  gradual  and  continuous  improvement  of  the 
early  symptoms,  and  the  case  may  go  on  to  complete  recovery,  but  more 
frequently  there  results  some  permanent  damage  to  the  brain.  The  fol- 
lowing observation  of  JMcNutt  illustrates  the  course  and  termination  of 
one  of  the  severe  cases  of  meningeal  haimorrhage  : 

Breech  presentation,  tedious  labour,  head  delivered  by  forceps,  almost 
continuous  convulsions  for  the  first  nine  days.  After  the  convulsions 
there  was  complete  paralysis  of  both  sides  of  the  body,  not  involving  the 
face.     The  child  never  walked  or  spoke ;  the  physical  development  was 


108  DISEASES   OF  THE   NEWLY  BORN. 

very  backward  ;  the  limbs  became  contractnred  ;  death  occurred  at  two 
and  a  half  years,  from  pneumonia.  The  autopsy  showed  atrophy  of  the 
brain  on  both  sides  about  the  fissure  of  Rolando. 

The  main  diagnostic  symptoms  in  recent  cases  are  stupor,  rigidity, 
convulsions,  paralysis,  and  opisthotonus.  These  vary  with  the  extent  and 
situation  of  the  lesion.  The  minor  symptoms  are  changes  in  the  pupils, 
oscillation  of  the  eyes,  and  bulging  of  the  fontanels. 

Prognosis. — Large  hemorrhages  at  the  base  are  usually  fatal.  Quite  an 
extensive  hasmorrhage  over  the  convexity  is  compatible  with  life.  The 
case  may  recover,  as  far  as  the  immediate  symptoms  are  concerned,  but 
with  serious  damage  to  the  brain.  Smaller  haemorrhages  over  the  con- 
vexity may*be  followed  by  complete  recovery,  but  in  the  majority  of  cases 
more  or  less  injury  to  the  brain  results,  the  full  extent  of  which  may  not 
be  seen  for  many  years. 

Treatment. — This  is  mainly  prophylactic,  the  chief  indication  being  to 
shorten  tedious  labours  by  the  early  use  of  the  forceps.  In  a  large  num- 
ber of  cases  where  the  haemorrhage  has  been  attributed  to  the  forceps,  the 
damage  has  rather  been  the  result  of  the  long-continued  pressure  before 
they  were  used.  Nothing  can  be  done  after  delivery  to  limit  the  amount 
of  the  hsemorrhage,  except  to  keep  the  child  as  quiet  as  possible  and  to 
relieve  individual  symptoms  as  they  arise. 

FACIAL   PARALYSIS. 

The  usual  cause  of  facial  paralysis  is  the  use  of  the  forceps,  but  this 
does  not  explain  all  the  cases.  The  etiology  of  those  in  which  the  forceps, 
have  not  been  used  is  still  somewhat  obscure.  In  peripheral  facial  palsy 
the  nerve  is  pressed  upon  either  near  its  exit  from  the  stylo-mastoid  fora- 
men, or  where  it  crosses  the  ramus  of  the  jaw,  at  which  point  the  parotid 
gland  gives  it  but  little  protection  in  the  newly  born.  If  the  lesion  is  in 
front  of  this  point,  any  one  of  the  terminal  branches  may  be  affected  ; 
most  frequently  it  is  the  temporo-facial  branch.  As  only  one  blade  of  the 
forceps  commonly  touches  the  face  in  this  region,  the  paralysis  is,  as  a 
rule,  unilateral. 

Roulland  has  reported  several  cases  not  due  to  the  forceps.  In  these 
the  pressure  is  believed  to  have  been  produced  by  the  promontory  of  the 
sacrum  at  the  superior  strait,  or  by  the  ischium  at  the  inferior  strait,  as 
paralysis  followed  when  the  head  was  long  arrested  at  one  of  these  points. 
It  was  not  seen  with  face  or  breech  presentations.  When  facial  paralysis 
is  of  central  origin  it  depends  generally  upon  a  meningeal  haemorrhage, 
and  the  arm  and  leg  of  the  same  side  as  the  face  are  involved.  It  is,  how- 
ever, possible  for  a  very  small  cortical  haemorrhage  to  produce  paralysis  of 
the  face  only.     This  occurred  in  a  case  reported  by  McNutt. 

In  repose,  the  only  symptom  noticed  may  be  that  the  eye  remains  open 
upon  the  affected  side,  owing  to  paralysis  of  the  orbicularis  palpebrarum. 


PARALYSIS   OF  THE   UPPER   EXTREMITY.  1(j9 

When  the  muscles  are  called  into  action,  as  in  crying,  the  whole  side  of 
the  face  is  seen  to  be  affected.  The  paralyzed  side  is  smooth,  full,  and 
often  appears  to  be  somewhat  swollen.  The  mouth  is  drawn  to  the  side 
not  affected.  In  this  paralysis,  the  tongue,  of  course,  is  not  implicated.  It 
is  therefore  rare  that  nursing  is  seriously  interfered  with.*  If  the  pa- 
ralysis is  of  central  origin,  only  the  lower  half  of  the  face  is  involved, 
while  in  peripheral  paralysis,  as  the  trunk  of  the  nerve  is  injured,  the 
upper  half  of  the  face,  including  the  orbicularis  palpebrarum,  is  also 
affected. 

The  paralysis  is  generally  noticed  on  the  first  or  second  day  of  life, 
and  does  not  increase  in  severity.  Its  course  and  termination  depend 
upon  the  extent  of  the  injury  done  to  the  nerve.  Some  idea  of  this  may 
often  be  gained  by  the  amount  of  injury  to  the  soft  parts,  although  this 
is  not  an  infallible  guide.  In  cases  not  due  to  the  forceps,  the  paralysis  is 
slight  and  disappears  in  a  few  days ;  the  great  majority  of  the  forceps 
cases  follow  the  same  favourable  course,  the  paralysis  gradually  disappear- 
ing without  treatment  in  about  two  weeks.  In  more  serious  cases  it  may 
last  for  months,  or  it  may  even  be  permanent.  The  reaction  of  degenera- 
tion is  present  in  these  severe  cases,  and  there  may  even  be  perceptible 
atrophy  of  the  muscles.     This  symptom  is  fortunately  extremely  rare. 

Treatment. — Nothing  should  be  done  for  the  first  ten  days  except  to 
protect  the  eye  and  keep  it  clean.  If  improvement  has  begun  by  the  end 
of  this  time,  the  probabilities  are  that  the  case  will  require  no  treatment. 
If  no  improvement  has  taken  place  by  the  end  of  the  third  or  fourth  week, 
electricity  should  be  used  regularly  and  systematically.  If  the  muscles 
respond  to  it,  the  faradic  current  may  be  employed  ;  if  not,  galvanism 
should  be  used.  The  electrical  treatment  should  be  continued  for  several 
months,  or  until  recovery  has  taken  place. 

PARALYSIS  OF  THE  UPPER  EXTREMITY. 

When  this  is  due  to  a  peripheral  lesion  it  probably  never  involves  the 
entire  arm,  but  affects  only  certain  muscles  or  groups  of  muscles.  Al- 
though commonly  occurring  after  an  artificial  delivery,  it  may  be  seen  in 
cases  where  the  labour  has  terminated  naturally.  Roullaud  f  has  reported 
a  case  in  which  deltoid  paralysis,  occurring  in  a  large  child,  was  attributed 
to  pressure  upon  the  shoulder  during  labour.  In  vertex  presentations, 
paralysis  is  most  frequently  due  to  the  forceps  where  one  of  the  blades 
has  extended  down  upon  the  neck,  injuring  the  lower  cervical  nerves.  It 
may  be  produced  by  traction  with  the  finger  in  the  axilla.  Roulland 
reports  a  unique  case  of  paralysis  of  both  extremities,  apparently  due  to 

*  In  this  connection  it  is  to  be  remembered  that  the  principal  part  in  nursing  is 
done  by  the  tongue,  and  not  by  the  lips, 
f  Paralysies  des  nouveau-nes,  Paris,  1887. 


110 


DISEASES  OF  THE   NEWLY  BORN. 


the  cord  being  very  tightly  wouml  around  tlie  neck.  The  great  propor- 
tion of  all  cases  of  paralysis  of  the  upper  extremity  follow  extraction  in 
breech  presentations.  The  injury  is  usually  inflicted  by  traction  upon  the 
shoulder  in  the  delivery  of  the  head,  or  in  bringing  down  the  arms  when 
they  are  above  the  head.  In  the  latter  case  the  paralysis  may  be  double 
and  associated  with  fracture  of  the  clavicle  or  humerus.  In  shoulder 
presentations,  paralysis  may  be  produced  by  traction  upon  the  arm  itself. 

The  most  common  form  of  peripheral  paralysis  is  that  known  as  the 
"upper-arm  type,"  or  Erb's  paralysis,  in  which  the  injury  is  inflicted  at 
the  anterior  border  of  the  trapezius  muscle  at  the  lower  part  of  the  neck, 

usually  in  such  a  position 
as  to  affect  the  fifth  and 
sixth  cervical  nerves.  The 
muscles  paralyzed  are  the 
deltoid,  biceps,  brachialis  an- 
ticus,  supinator  longus,  and 
sometimes  the  supra-  and  in- 
fra-spinatus.  All  these  mus- 
cles may  be  involved,  or  only 
part  of  them,  and  in  varying 
degrees.  In  case  the  injury 
is  slight,  the  paralysis  may 
not  be  noticed  for  some 
weeks.  If  severe,  it  is  evi- 
dent in  the  first  few  days. 
The  arm  hangs  lifeless  by 
the  side ;  it  is  rotated  in- 
ward, the  forearm  pronated, 
the  palm  looking  outward 
(Fig.  19).  The  forearm  and 
hand  are  not  affected.  In 
severe  cases  there  may  be 
anesthesia  of  the  outer  surface  of  the  arm,  in  the  region  supplied  by 
the  circumflex  and  external  cutaneous  nerves.  This  is  rarely  marked, 
and  in  its  slighter  degrees  it  is  very  difficult  to  determine.  It  is  char- 
acteristic of  this  paralysis  that  the  triceps  is  not  affected,  so  that  power 
to  extend  the  forearm  remains,  although  it  cannot  be  flexed.  Atrophy 
of  the  paralyzed  muscles  occurs  after  a  few  weeks,  but  the  muscles  are 
so  small  and  so  covered  with  fat  that  it  is  rarely  noticeable  before 
the  second  year.  It  is  most  conspicuous  in  the  deltoid.  In  all  severe 
cases  the  reaction  of  degeneration  is  present.  In  some  of  the  cases  of 
long  standing  there  occurs  a  shortening  of  the  tendon  of  the  subscapu- 
laris  muscle,  often  associated  with  subluxation  of  the  humerus.  The 
paralysis  may  be  complicated  with  fracture  of  the  clavicle,  the  neck  of 


Fig.  19. — Erb's  paralysis,  infant  two  months  old. 


TUMOURS  OF  THE  UMBILICUS,   MASTITIS,  ETC.  m 

the  scapula,  or  the  shaft  of  the  humerus,  or  with  epiphyseal  separation  of 
its  head. 

The  prognosis  depends  upon  the  severity  of  tlie  injury  and  also  upon 
the  time  when  treatment  is  begun.  The  great  majority  of  cases  recover 
spontaneously  in  two  or  three  months,  improvement  being  observed  within 
a  few  weeks,  first  in  the  biceps  and  last  in  the  deltoid.  Spontaneous  re- 
covery is  not  to  be  looked  for  unless  it  occurs  within  the  first  three 
months.  Not  infrequently  some  degree  of  paralysis  persists  until  the 
third  or  fourth  year,  and  in  some  of  the  muscles,  usually  the  deltoid,  it 
may  even  be  permanent.  If  the  muscles  respond  to  faradism,  rapid  im- 
provement can  generally  be  prophesied.  If  the  reaction  of  degeneration 
is  present,  improvement  will  be  slow  and  the  paralysis  may  be  permanent. 

The  diafffiosis  is  usually  not  difficult,  since  the  great  majority  of  cases 
are  of  the  "  upper-arm  type  "  with  classical  symptoms.  Peripheral  palsy 
of  the  arm  can  scarcely  be  confounded  with  that  of  cerebral  origin.  If 
the  lesion  is  central  it  is  one  of  the  rarest  occurrences  for  the  arm  alone  to 
be  involved ;  either  the  leg  or  face,  or  both,  are  generally  likewise  affected. 
If  the  case  does  not  come  under  observation  until  the  child  is  a  year  old, 
it  may  be  difficult,  or  without  a  good  history,  it  may  be  impossible  to  dis- 
tinguish peripheral  paralysis  from  that  due  to  polio-myelitis.  The  peculiar 
group  of  muscles  involved  in  Erb's  paralysis  is  the  only  diagnostic  point. 

In  recent  cases  the  disability  resulting  from  the  tenderness  or  pain  of 
syphilitic  epiphysitis  may  simulate  paralysis,  but  there  is  lacking  the 
characteristic  position  of  the  arm,  and  a  careful  examination  discloses  the 
fact  that  the  paralysis  is  only  apparent.  This  may  affect  both  sides. 
Fracture  of  the  clavicle  or  epiphyseal  separation  of  the  head  of  the  hu- 
merus may  also  be  mistaken  for  paralysis.  In  cases  of  long  standing, 
paralysis  of  the  deltoid  may  resemble  dislocation  of  the  humerus.  The 
reaction  of  degeneration  differentiates  paralysis  from  surgical  injuries 
with  similar  deformities. 

The  treatment  consists  in  the  use  of  electricity,  which  should  be  begun 
at  the  end  of  the  first  month  at  the  latest,  and  used  regularly.  If  the  mus- 
cles respond  to  faradism  this  may  be  employed,  but  in  most  severe  cases 
they  do  not,  and  galvanism  must  be  used,  according  to  the  rules  laid  down 
for  facial  paralysis. 


CHAPTER  VII. 
TUMOURS  OF  THE  UMBILICUS,  MASTITIS,  ETC. 

Orannloina. — This  is  nothing  more  than  a  mass  of  exuberant  granula- 
tions at  the  umbilical  stump.  The  mass  is  generally  about  the  size  of  a 
pea — sometimes  larger — bleeds  readily,  and  has  a  thin,  purulent  discharge. 


112 


DISEASES   OP  THE   NEWLY  BORN. 


It  is  promptly  cured  by  the  application  of  any  simple  astringent ;  pow- 
dered alum  is  probably  the  best.  In  case  this  is  not  successful,  the  granu- 
lations may  be  touched  Avith  nitrate  of  silver  or  snipped  off  with  scissors. 

Adenoma,  Mucous  Polypus,  or  Diverticulum  Tumour — Umbilical  Fis- 
tula.— The  first  three  terms  are  used  synonymously  to  describe  an  um- 
bilical tumour  covered  with  a  mucous  membrane  which  is  similar  in 
structure  to  that  of  the  small  intestine.  It  is  usually  associated  with  an 
umbilical  fistula.  This  tumour  is  formed  by  a  prolapse  at  the  navel  of  the 
mucous  membrane  of  Meckel's  diverticulum.  This  diverticulum  is  the 
remains  of  the  omphalo-mesenteric  duct.  When  it  is  present  in  infants, 
it  is  found  in  various  stages  of  development.     Most  frequently  there  is  a 


ABC  D 

Fig.  20. — Umbilical  fistula  and  tumours  produced  by  prolapse  of  Meckel's  diverticulum  (Barth.) 

blind  pouch  a  few  inches  long  given  off  from  the  lower  part  of  the  ileum. 
In  other  cases  it  may  remain  patent  quite  to  the  umbilicus,  causing  a 
faical  fistula  (Fig.  20,  A).  As  the  intestine  below  it  is  generally  normal, 
this  fistula  may  persist  for  months  or  even  years,  giving  rise  to  no  symp- 
toms except  a  slight  faecal  discharge  from  the  umbilicus.  In  certain  cases 
intestinal  worms  have  been  discharged  through  it.  It  may  close  sponta- 
neously or  be  closed  by  operation. 

A  prolapse  of  the  mucous  membrane  lining  the  diverticulum  produces 
an  umbilical  tumour  with  a  fistula  at  its  summit  (Fig.  20,  B).  This  is  the 
most  common  form.  A  cross-section  shows  under  the  microscope  the 
structure  of  the  intestinal  mucous  membrane  both  as  an  external  covering 
and  lining  of  the  fistulous  tract.  The  prolapse  may  involve  not  only  the 
mucous  membrane  but  the  entire  intestinal  wall.  There  then  exists  a 
conical  tumour  with  a  fistula  which  has  but  one  external  opening,  but  at 
a  short  distance  from  the  surface  it  bifurcates,  one  branch  leading  upward 
and  one  downward  (Fig.  20,  C).  A  continuation  of  the  prolapse  gives  a 
broad  pedunculated  tumour  (Fig.  20,  D),  which  may  reach  the  size  of  a 
man's  fist.  Its  covering  is  the  same  as  in  the  other  forms.  It  may  con- 
tain several  coils  of  intestine.  In  this  form  there  are  usually  two  fistulous 
openings  {a,  b)  which  communicate  with  the  intestine. 

In  all  of  these  cases  the  tumour  is  smooth,  irreducible,  of  a  rosy  pink 


UMBILICAL   HERNIA.  II3 

colour,  and  from  its  surface  there  oozes  a  mucous  discharge.  Microscop- 
ical examination  shows  the  external  covering  to  be  the  same  in  structure 
as  the  intestinal  mucous  membrane.  These  tumours  are  generally  small, 
varying  in  size  from  a  pea  to  a  small  cherry,  but  they  may  be  very  much 
larger.  A  tsecal  fistula  usually,  but  not  invariably,  coexists.*  In  the  con- 
dition represented  in  Fig.  20,  B,  it  is  easy  to  see  how  an  obliteration  of  the 
fistula  may  occur.  The  small  tumours  are  readily  cured  by  the  ligature. 
The  larger  ones  are  usually  associated  with  other  serious  malformations 
of  the  intestines,  which  make  the  outlook  bad  in  almost  every  instance. 

UMBILICAL  HERNIA. 

This  is  exceedingly  common,  and  while  not  often  serious  it  is  a  source 
of  great  annoyance.  Umbilical  hernia  is  much  more  common  in  female 
children  than  in  males,  and  more  frequent  in  those  who  are  thin  and 
poorly  nourished  than  in  plump,  healthy  infants.  In  the  majority  of  in- 
stances the  tumour  is  from  one  fourth  to  one  half  an  inch  in  diameter ;  it 
may,  however,  be  very  large,  and  may  even  become  strangulated.  Cases 
of  congenital  umbilical  hernia  sometimes  require  surgical  operation  be- 
cause of  strangulation.  Tlie  ordinary  cases  require  only  mechanical  treat- 
ment. The  most  important  thing  is  prevention.  For  this  purpose  it  is 
necessary,  after  the  cord  has  separated,  to  place  a  firm  pad  over  the  navel, 
and  to  use  a  snug  abdominal  band  for  the  first  two  or  three  months.  After 
this  period  it  is  uncommon  for  hernia  to  develop.  In  cases  coming  un- 
der observation  after  the  third  or  fourth  month,  the  pad  and  abdominal 
bandage  are  inadequate,  and  other  means  must  be  employed  to  retain  the 
hernia.  The  best  of  these  consists  in  the  use  of  two  adhesive  strips 
applied  obliquely  over  the  abdomen,  crossing  at  the  umbilicus,  the  skin 
along  the  median  line  being  folded  inward  so  as  to  overlap  the  tumour, 
this  forming  the  retention  pad.  Another  method  often  successful  is 
the  use  of  a  common  wooden  button  or  a  piece  of  lead  covered  with  kid 
and  held  in  position  either  by  rubber  plaster  or  an  abdominal  band. 
These  must  be  worn  constantly  for  several  months  at  least.  The  treat- 
ment of  these  cases  after  the  first  year,  is  extremely  unsatisfactory.  There 
is  no  truss  or  other  apparatus  for  retention  which  I  have  ever  seen  which 
was  wholly  satisfactory.  In  a  small  hernia  where  the  tumour  is  less  than 
half  an  inch  in  diameter  it  is  really  unnecessary  to  use  any  form  of  appa- 
ratus, since  these  cases  ordinarily  show  little  or  no  tendency  to  increase  in 
size,  and  the  retention  apparatus  causes  more  annoyance  than  the  hernia. 
These  small  hernige  seem  to  disappear  spontaneously  during  childhood,  as 
they  certainly  are  not  often  seen  in  children  over  seven  years  of  age. 

*  For  report  of  such  a  case,  and  a  fuller  description,  see  article  by  the  author,  New 
York  Medical  Record,  April  21,  1888. 


114  DISEASES  OF  THE  NEWLY  BORN. 


MASTITIS. 


According  to  Guillot,  a  certain  amount  of  secretion  in  the  breasts  of 
the  newly  bor.n  is  physiological.  It  is  certainly  very  common.  It  is  most 
abundant  between  the  eighth  and  fifteenth  days,  but  may  continue  in 
small  quantities  as  late  as  the  third  month.  It  is  seen  with  equal  fre- 
quency in  both  sexes.  The  quantity  of  the  secretion  amounts  in  most 
cases  only  to  a  few  drops;  in  some,  however,  as  much  as  a  drachm  has 
been  obtained.  Chemical  analysis  has  shown  this  secretion  to  be  essen- 
tially the  same  as  the  adult  milk — containing  fat,  sugar,  proteids,  and 
salts.  In  gross  appearance  it  resembles  colostrum.  The  researches  of 
Sinety  *  have  shown  that  the  mammary  gland  of  the  newly  born  contains 
cul-de-sacs  lined  with  secreting  cells,  resembling  those  of  the  adult.  Dur- 
ing the  period  of  secretion  the  gland  is  slightly  reddened,  its  vessels  turgid, 
and  all  the  signs  of  functional  activity  are  present.  This  condition  in  it- 
self is  of  no  practical  importance,  and  in  most  cases,  if  left  alone,  the 
secretion  ceases  spontaneously  after  a  week  or  ten  days.  If  abundant,  it 
can  usually  be  dried  up  by  painting  the  gland  with  tincture  of  belladonna. 
It  sometimes  happens,  however,  that  the  presence  of  this  secretion  tempts 
the  nurse  or  attendant  to  rub  or  squeeze  the  breast.  Such  manipulation 
occasionally  leads  to  serious  results  by  exciting  a  mastitis  which  may  ter- 
minate in  abscess.  Mastitis  is  not  a  very  rare  condition,  and  although 
the  inflammation  is  not  usually  severe,  it  may  be  serious  and  even  fatal. 
The  predisposing  cause  is  the  congestion  which  accompanies  functional 
activity,  usually  in  the  second  week.  The  exciting  cause  is  most  often 
some  form  of  traumatism — undue  pressure,  the  squeezing  of  the  breasts, 
or  rough  handling  by  the  nurse.  Through  abrasions  or  fissures  thus  pro- 
duced, micro-organisms  find  a  ready  entrance  with  the  same  result  as  in 
the  adult.  It  seems  possible  that  the  germs  may  enter  through  the  lactif- 
erous ducts  without  any  abrasion  of  the  skin.  Want  of  cleanliness  is  al- 
ways a  favourable  condition  for  such  infection. 

The  symptoms  of  mastitis  usually  begin  during  the  second  week  of 
life.  There  are  redness,  swelling,  and  the  usual  signs  of  inflammation, 
which  may  terminate  in  resolution  or  in  suppuration.  The  process  may 
be  limited  to  the  mammary  region,  or  a  diffuse  phlegmonous  inflammation 
may  be  set  up,  as  in  a  case  reported  by  Bush,f  in  which  there  was  ex- 
tensive sloughing  of  the  tissues  of  the  whole  of  one  side  of  the  chest,  with 
a  fatal  result.  In  the  great  majority  of  cases  the  process  does  not  reach 
this  degree  of  intensity,  but  suppuration  with  the  formation  of  single  or 
multiple  abscesses  is  not  uncommon.  In  the  female  it  is  possible  for  the 
cicatrization  which  follows  such  an  inflammation  to  interfere  with  the  sub- 

*  Gazette  Medicale,  No.  17,  1885. 

f  New  York  Medical  Journal,  March,  1881. 


INTESTINAL  OBSTRUCTION.  115 

sequent  development  of  the  gland.  The  general  symptoms  are  restlessness, 
loss  of  sleep,  disinclination  to  nurse,  and  loss  of  weight.  In  cases  of  diffuse 
phlegmonous  inflammation  the  general  symptoms  are  those  of  pyogenic 
infection.  Jourda  *  has  collected  fifteen  cases  of  mammary  abscess,  twelve 
of  which  recovered.  They  began  between  the  fourth  and  the  forty-second 
days.     In  eleven  cases,  only  one  side  was  involved  ;  in  four,  both  sides. 

Mastitis  is  usually  due  to  want  of  cleanliness  or  to  meddlesome  inter- 
ference ;  the  parts  should  therefore  be  kept  scrupulously  clean,  and  on  no 
account  should  squeezing  of  the  breasts  be  permitted.  They  should  be  pro- 
tected by  a  simple  cotton  pad.  If  acute  inflammation  develops,  it  should  be 
treated  in  the  beginning  by  hot  applications.  Should  pus  form,  early  in- 
cision with  free  drainage  and  general  tonic  and  stimulant  treatment  are 

indicated. 

INTESTINAL   OBSTRUCTION. 

The  most  frequent  causes  of  intestinal  obstruction  in  the  newly  born 
are  malformations  of  the  intestine ;  rarely  it  may  be  due  to  pressure  from 
tumours,  or  from  a  persistent  omphalo-mesenteric  duct  or  artery.  The  vari- 
ous pathological  conditions  present  in  intestinal  malformations  are  consid- 
ered in  the  chapter  on  Diseases  of  the  Intestines.  The  most  common  seat 
of  obstruction  is  at  the  anus,  the  bowel  being  normally  formed  through- 
out, lacking  only  the  external  orifice.  The  next  most  frequent  condition 
is  obstruction  in  the  rectum,  which  may  be  due  either  to  a  membranous 
septum  in  the  gut,  or  to  obliteration  of  the  tube  for  some  distance. 
These  rectal  obstructions  are  readily  recognised.  By  the  examining  finger 
or  a  bougie  the  lower  limit  of  the  obstruction  can  be  made  out,  but  there 
is  no  means  by  which  the  upper  limit  can  be  determined  except  by  open- 
ing the  abdomen.  AYhen  the  obstruction  is  above  the  rectum,  localization 
is  more  difficult;  but  the  most  frequent  seat  is  the  duodenum.  Of  38 
cases  collected  by  Gaertner,  the  seat  of  obstruction  was  the  duodenum  in 
19  cases,  the  jejunum  in  3,  the  ileum  in  11,  the  colon  in  G,  the  ileum  and 
colon  in  1.     There  is  often  obstruction  at  more  than  one  point. 

The  symptoms  vary  with  the  seat  and  the  degree  of  the  obstruction. 
In  atresia  of  the  anus  or  rectum  there  is  at  first  simply  an  absence  of  all 
discharges  from  the  bowel.  Later  there  is  abdominal  distention  from 
dilatation  of  the  sigmoid  flexure  and  colon.  After  several  days  vomiting 
begins.  If  there  is  atresia  of  the  duodenum  or  any  part  of  the  small 
intestine,  vomiting  begins  early — usually  by  the  second  day  of  life — and  it 
is  persistent.  Nothing  is  passed  from  the  bowels  after  the  first  dark  dis- 
charge of  the  contents  of  the  colon,  which  is  chiefly  mucus.  There  is 
rapid  asthenia,  and  death  from  inanition  usually  occurs  in  four  or  five  days. 
The  higher  the  obstruction  the  shorter  the  duration  of  life.  If  the  con- 
dition is  one  of  stenosis  only,  the  symptoms  are  similar  to  those  described 

*  These,  Paris,  1889. 


116  DISEASES  OF  THE   NEWLY  BORN. 

but  less  severe,  and  life  may  be  prolonged  for  several  weeks,  or  even 
months.  The  constipation  in  these  cases  is  not  absolute.  When  the 
cause  of  obstruction  is  external  pressure,  the  symptoms  do  not  always  be- 
gin immediately  after  birth.  I  have  recently  seen  a  child  in  whom  noth- 
ing abnormal  was  noticed  for  the  first  three  weeks,  but  at  the  end  of  that 
time  there  developed  all  the  signs  of  acute  intestinal  obstruction.  Lapa- 
rotomy revealed  a  loop  of  intestine  constricted  by  a  tiny  cord,  which  was 
probably  the  remains  of  the  omphalo-mesenteric  duct. 

Cases  of  imperforate  anus  and  membranous  septum  in  the  rectum  are 
readily  relieved  by  proper  surgical  treatment.  In  the  other  varieties  of 
obstruction,  whether  in  the  rectum,  in  the  colon,  or  in  the  small  intestine, 
although  life  may  be  prolonged  by  the  formation  of  an  artificial  anus,  the 
ultimate  result  is  almost  invariably  fatal,  death  usually  resulting  from 
marasmus  during  the  early  weeks  of  life. 

DIAPHRAGMATIC   HERNIA. 

This  is  due  to  a  congenital  deficiency  in  the  diaphragm,  which  in  nearly 
all  the  reported  cases  has  occurred  on  the  left  side  at  its  anterior  portion. 
The  opening  may  be  so  small  as  to  allow  the  passage  of  only  a  single  coil 
of  intestine,  or  so  large  that  a  considerable  part  of  the  abdominal  contents 
find  their  way  into  the  thoracic  cavity.  This  causes  displacement  of  the 
heart  to  the  right,  prevents  the  expansion  of  the  left  lung,  and  if  it  occur 
in  intra-uterine  life  may  prevent  the  development  of  the  lung.  In  Gau- 
tier's  case  the  left  half  of  the  diaphragm  was  deficient,  and  nearly  all  of 
the  small  intestine,  the  stomach,  spleen,  and  pancreas  were  found  in  the 
left  chest.     The  left  lung  was  rudimentary. 

If  inflation  of  the  lungs  by  the  catheter  or  otherwise  is  attempted,  a 
sense  of  resistance  is  experienced.  A  physical  examination  of  the  chest 
shows  that  movement  is  limited  to  one  side,  the  apex  beat  is  far  to  the 
right,  and  usually  there  is  tympanitic  resonance  over  the  left  side.  If  a 
large  deficiency  in  the  diaphragm  exists,  infants  usually  survive  but  a  few 
hours ;  if  a  smaller  one,  life  may  be  prolonged  indefinitely.  Northrup  * 
has  reported  a  case  in  a  child  who  lived  to  the  age  of  three  years  and  pre- 
sented very  obscure  physical  signs.  It  died  from  intercurrent  disease,  the 
only  local  symptom  being  marked  dyspnoea.  In  this  case  several  loops  of 
the  ileum,  the  caecum,  and  the  vermiform  appendix  were  found  in  the 

thoracic  cavity. 

SCLEREMA. 

Sclerema  is  a  condition  characterized  by  hardening  of  the  skin  and 
subcutaneous  tissues.  It  may  occur  in  circumscribed  areas  or  extend  over 
nearly  the  entire  body.  It  affects  infants  who  are  very  feeble  and  usually 
terminates  fatally.     Although  sclerema  is  chiefly  seen  in  the  first  days  of 

*  Archives  of  Paediatrics,  vol.  ix,  p.  130. 


SCLEREMA.  12  7 

life,  it  is  not  limited  to  the  newly  born,  but  may  ocenr  at  any  time  during 
the  first  few  months.  It  is  not  to  be  confounded  with  oedema  of  the 
newly  born,  with  which  condition  it  is,  however,  sometimes  associated. 
From  published  reports  it  appears  to  be  of  not  very  infrequent  occur- 
rence in  Europe,  chiefly  in  large  foundling  asylums.  In  America,  sclerema 
is  an  extremely  rare  disease.  In  a  discussion  in  the  American  Psediatric 
Society,  in  1889,  following  the  report  of  a  case  by  Northrup,  scarcely  a 
dozen  cases  could  be  recalled  by  the  members  present.  I  have  seen  but 
five  cases.  In  the  newly  born,  sclerema  affects  those  who  are  premature 
or  very  feeble,  sometimes  those  who  are  syphilitic.  Later  it  may  follow 
any  condition  leading  to  extreme  exhaustion,  especially  the  different  forms 
of  diarrhoeal  disease. 

The  first  thing  to  attract  attention  is  nsnally  the  induration  of  the 
skin.  It  is  often  seen  first  in  the  calves  or  the  dorsum  of  the  feet,  some- 
times first  in  the  cheeks,  but  soon  extends  over  the  greater  part  of  the 
body.  It  is  especially  marked  in  the  cheeks,  buttocks,  thighs  and  back, 
and  regions  where  adipose  tissue  is  abundant.  It  may  affect  the  body  uni- 
formly or  in  circumscribed  areas.  The  skin  may  be  smooth  or  it  may  ap- 
pear somewhat  lobulated.  The  colour  is  normal  or  slightly  bluish,  often 
tinged  with  yellow.  The  lips  are  blue,  and  the  capillary  circulation  so 
feeble  that  after  pressure  upon  the  nails  the  blood  returns  slowly  or  not 
at  all.  The  limbs  are  stiff  and  board-like.  The  skin  is  cold  to  the  touch, 
and  often  the  thermometer  in  the  axilla  will  not  rise  above  90°  F.  In 
cases  reported  by  Roger  and  Parrot,  an  axillary  temperature  of  71°  F.  was 
recorded.  The  general  feeling  of  the  body  has  been  well  likened  by 
Northrup  to  that  of  a  half-frozen  cadaver.  The  tongue  and  the  mucous 
membrane  of  the  mouth  are  cold;  no  radial  pulse  can  be  felt;  the  respira- 
tion is  slow,  irregular,  embarrassed,  and  at  times  the  movements  of  the 
thorax  are  scarcely  perceptible.  The  cry  is  a  feeble  whine,  scarcely  au- 
dible. The  duration  of  the  disease  is  usually  from  three  to  four  days. 
Death  occurs  slowly  and  quietly.  If  recovery  takes  place  there  is  gradual 
improvement  in  the  circulation  and  nutrition,  and,  later,  a  disappearance 
of  the  areas  of  induration. 

The  causes  of  sclerema  are  general,  not  local,  the  most  important  etio- 
logical factors  being  great  feeblenesss,  with  lowering  of  the  body  tempera- 
ture, and,  in  consequence,  hardening  of  the  subcutaneous  fat.  If  it  be 
true,  as  stated  by  Langer,  that  the  fat  of  childhood  contains  more  pal- 
mitine  and  stearine  than  that  of  adults,  it  is  easy  to  see  how  this  may  oc- 
cur. There  are  no  essential  lesions  in  this  disease.  Atelectasis  is  often 
present,  and  may  have  something  more  than  an  accidental  association,  as 
incomplete  aeration  of  the  blood  is  no  doubt  a  factor  in  the  production 
of  the  symptoms.  In  Northrup's  case,  the  skin  after  being  injected  was 
studied  with  great  care  microscopically,  with  absolutely  negative  results. 

The  prognosis  is  very  bad,  because  of  the  grave  conditions  of  which  it 


118  DISEASES  OF  THE  NEWLY  BORN. 

is  the  expression,  but  it  is  not  invariably  fatal.  In  its  milder  forms, 
where  treatment  is  begun  early,  recovery  may  take  place.  The  diagnosis 
is  to  be  made  from  oedema  by  the  fact  that  there  is  no  pitting  upon  pres- 
sure, by  the  rigidity  of  the  body,  and  by  the  great  reduction  in  the  tem- 
perature. The  most  important  thing  in  treatment  is  artificial  heat ;  noth- 
ino-  but  the  incubator  is  efficient.  In  addition  to  this,  care  should  be  taken 
to  promote  "the  general  nutrition  by  careful  feeding  and  by  all   other 

means  possible. 

(EDEMA. 

(Edema  has  often  been  confounded  with  sclerema,  but,  although  they 
may  sometimes  exist  together,  the  conditions  are  quite  distinct,  a^]dema 
occurs  in  delicate  infants,  and  is  associated  with  a  feeble  heart,  especially 
of  the  right  side,  in  consequence  of  which  there  are  insufficient  aeration  of 
the  blood,  overfilling  of  the  veins,  and  often  a  lowering  of  the  body  tem- 
perature. It  also  depends  upon  poor  blood  states,  like  severe  anaemia,  and 
I  have  seen  it  occur  after  hasmorrhages.     The  kidneys  are  unaffected. 

The  swelling  is  first  noticed  in  the  eyelids,  the  dorsum  of  the  feet,  the 
hands,  or  in  dependent  parts  of  the  body.  It  may  come  on  quite  sud- 
denly. In  severe  cases  there  may  be  general  anasarca,  but  dropsy  into  the 
serous  cavities  is  rare.  Sometimes  the  first  thing  observed  may  be  a  sud- 
den increase  in  weight  before  the  oedema  of  any  part  is  striking  enough 
to  be  noticed.  The  general  condition  is  feeble ;  the  surface  of  the  body 
cool ;  the  temperature  often  subnormal ;  the  cry  weak  ;  the  urine  often 
scanty,  but  rarely  albuminous.  The  diagnosis  of  oedema  is  quite  easy,  the 
parts  having  the  same  appearance  as  in  older  patients.  They  are  soft  and 
waxy-looking,  and  pit  upon  pressure.  While  in  most  cases  the  prognosis 
is  unfavourable,  the  disease  is  not  necessarily  fatal,  since  some  even  of  the 
severe  cases  recover.  The  usual  duration  is  five  or  six  days ;  but  there  are 
frequently  relapses. 

The  object  of  treatment  is  first  to  promote  the  general  nutrition  by  all 
available  means,  and  then  to  improve  the  circulation  by  the  administra- 
tion of  heart  stimulants,  particularly  digitalis  and  alcohol.  In  cases  of 
extensive  oedema,  alkaline  diuretics,  like  the  citrate  of  potash,  may  be 
combined  with  digitalis.  The  body-temperature  must  be  carefully  main- 
tained by  artificial  heat.  The  principal  complications  are  diseases  of  the 
lungs  and  of  the  intestines. 

INANITION  FEVER. 

The  term  inanition  fever  is  not  altogether  a  satisfactory  one ;  but, 
until  these  cases  are  better  understood,  it  is  adopted  because  it  empha- 
sizes the  very  close  connection  which  exists  between  the  rise  of  tem- 
perature and  the  condition  of  inanition  or  starvation.  Under  this  head- 
ing are  included  cases  seen  during  the  first  five  days  of  life — generally 
from  the  second  to  the  fourth  day — in  which  there  is  an  elevation  of  tem- 


INANITION  FEVER.  II9 

perature,  apparently  due  to  tlie  fact  that  the  infant  gets  very  little,  fre- 
quently nothing  at  all  from  the  breast  at  which  it  is  being  suckled.  It 
is  further  characteristic  of  these  cases  that  the  temperature  falls  when  the 
milk  is  secreted  in  abundance,  or  when  the  child  is  put  upon  a  full  breast, 
or  when  artificial  feeding  is  begun,  or  even  when  v/ater  is  administered,  if 
freely  given. 

So  far  as  my  knowledge  goes,  the  first  to  call  attention  to  this  condi- 
tion was  McLane  (New  York),  who  in  1890  reported  to  one  of  the  med- 
ical societies  an  extraordinary  case  of  hyperpyrexia  in  a  newly-born  child. 
The  infant  was  found  on  the  sixth  day  with  a  temperature  of  106°  F., 
near  which  point  it  had  remained  for  three  days.  The  child  was  being 
suckled  at  a  breast  which  was  found  to  be  absolutely  dry.  A  wet-nurse 
was  procured,  the  temperature  fell  to  normal  in  a  few  hours,  and  the  child, 
which  when  first  seen  was  apparently  in  a  hopeless  condition,  was  soon 
perfectly  well. 

Since  that  time  very  extensive  observations,  extending  to  upward  of 
three  thousand  cases,  have  been  made  at  the  Sloane  Maternity  and  Nurs- 
ery and  Child's  Hospitals,  which  have  established  the  fact  that  a  rise  of 
temperature  to  102°  or  even  104°  P.  is  quite  common  in  newly-born  in- 
fants during  the  first  few  days.  This  fever  is  accompanied  by  no  evi- 
dences of  local  disease,  and  ceases  in  nursing  infants  with  the  establish- 
ment of  the  free  secretion  of  milk.  The  fall  in  temperature  is  often 
rapid,  dropping  to  the  normal  in  a  few  hours  after  having  continued  for- 
three  or  four  days,  and  in  a  large  number  of  cases  it  does  not  rise  again. 

The  following  case  is  a  fairly  typical  one  of  the  more  severe  form : 
The  patient  was  the  second  child,  the  first  having  died  at  the  age  of 
ten  days,  from  no  disease  it  was  said,  but  simply  from  exhaustion.  At 
birth  the  infant,  a  boy,  weighed  eight  and  a  quarter  pounds  and  was 
apparently  vigorous.  During  the  first  forty-eight  hours  his  loss  in  weight 
was  five  and  a  half  ounces  and  his  condition  good.  I  saw  him  on  the 
evening  of  the  third  day.  In  the  preceding  twenty-four  hours  he  had  lost 
eight  ounces  in  weight,  and  the  temperature  had  gradually  risen,  until 
at  the  time  of  my  visit  it  was  103-8°  F.  The  body  was  limp,  the  child 
making  no  resistance  to  examination.  He  cried  with  a  feeble  whine ; 
the  restlessness  of  the  early  part  of  the  day  having  given  place  to  complete 
apathy.  The  lips  and  skin  were  very  dry,  the  fontanel  sunken,  the  pulse 
weak.  As  the  father,  a  physician,  expressed  it,  "  he  had  been  wilting 
through  the  day  like  a  flower  in  the  sun."  Although  put  to  the  breast 
regularly,  the  child  had  apparently  got  very  little.  It  was,  in  fact,  impos- 
sible to  squeeze  any  milk  from  the  mother's  breasts.  Water  was  freely 
given  and  a  wet-nurse  secured  in  a  few  hours.  The  first  milk  was  taken 
from  the  wet-nurse  at  11  P.  M.,  and  the  temperature,  which  fell  gradually 
during  the  night,  was  normal  the  next  morning  and  did  not  rise  again. 
(See  chart,  Fig.  21).     During  the  succeeding  four  days  the  child  gained 


120 


DISEASES  OF   THE  NEWLY  BORN. 


103° 


eighteen  ounces  in  weight,  and  at  the  end  of  a  week  was  as  well  as  an 
average  infant  of  his  age. 

The  symptoms  are  so  uniform  and  so  characteristic  that  they  make 
for  these  cases  of  fever  a  class  by  themselves.  The  frequency  with  which 
this  is  seen  is  shown  by  the  following  statistics  :  Among  200  infants  taken 
successively  at  the  Nursery  and  Child's  Hospital,  20  had  fever  during  the 
first  five  days,  reaching  101°  F.  or  over,  which  was  not  explained  by 
ordinary  causes  and  followed  the  course  above  described.  In  500  suc- 
cessive children  born  at  the  Sloane  Maternity  Hospital,  there  were  135 
with  a  similar  fever.     It  was  seen  in  vigorous  infants  as  well  as  in  those 

who  were  delicate.  The  usual 
duration  of  the  fever  was  three 
days,  the  temperature  generally 
touching  the  highest  point  upon 
the  third  or  fourth  day  of  life. 
In  about  two  thirds  of  the  cases 
the  temperature  did  not  rise  above 
102°  F. ;  in  9  it  was  104°  F.  or 
over,  the  highest  recorded  being 
106°  F.  The  fall  was  generally 
quite  abrupt,  although  not  always 
so.  Daily  weighings,  which  were 
made  in  these  cases,  showed  that 
the  infants  continued  to  lose 
weight  while  the  fever  continued, 
and  that  the  loss  almost  invariably 
exceeded  by  several  ounces  that  of 
the  children  who  had  no  fever. 
(See  p.  16.)  The  maximum  loss 
noted  was  twenty-eight  ounces.  In  quite  a  large  number  of  cases  it  ex- 
ceeded twenty  ounces.  As  a  rule  the  infants  began  to  gain  in  weight  when 
the  temperature  remained  at  the  normal  point,  but  not  until  then. 

The  symptoms  presented  by  these  infants  were  a  hot,  dry  skin,  marked 
restlessness,  dry  lips,  and  a  disposition  to  suck  vigorously  anything  within 
reach.  With  very  high  temperature  there  were  considerable  prostration 
and  weakened  pulse.  In  the  less  severe  cases  there  were  only  crying  and 
restlessness.  The  rapidity  with  which  the  symptoms  disappeared  when 
the  children  were  wet-nursed  or  properly  fed,  was  very  striking. 

It  is  important  that  this  fever  should  be  recognised,  because  it  gives  at 
times  the  first  warning  of  a  condition  which  may  prove  fatal.  The  extra 
loss  of  ten  or  fifteen  ounces  in  the  first  week,  is  a  serious  handicap  to 
newly-born  infants,  the  effect  of  which  may  last  for  several  weeks.  The 
temperature  of  every  child  should  be  taken  during  the  first  week.  All  the 
usual  local  causes  of  fever  are  first  to  be  excluded  by  a  physical  examina- 


101° 


100 


99° 


1 

i    \ 

3 

i 

5 

" 

7 

S      1 

n 

n 

' 

/ 

/ 

/ 

1 

,  \ 

1 

/ 

/ 

f 

i 

J 

- 

^ 

P 

S 

^ 

-^^ 

"V,, 

/^ 

f 

V 

... 

Fio.  21. — Temperature  chart.     Inanition  fever. 


INANITION  FEVER.  121 

tion.  This  fever  can  hardly  be  confounded  with  that  due  to  pyogenic 
infection,  whicli  rarely  begins  before  the  fifth  or  sixth  day. 

The  treatment  is  sim2:)le — viz.,  to  give  water  regularly  every  two  hours, 
in  quantities  up  to  an  ounce  at  a  time  if  required  by  the  thirst  of  the 
child.  This  should  be  done  in  every  case  where  the  temperature  reaches 
101°  F.  When  the  temperature  does  not  at  once  begin  to  fall,  the  infant 
should  be  put  upon  another  breast  or  artificial  feeding  should  be  begun. 
Examination  of  the  breasts  from  which  the  child  has  been  nursing  will 
usually  reveal  the  fact  that  the  secretion  of  milk  is  very  scanty  and  often 
entirely  absent. 

Such  a  fever  I  have  occasionally  seen  in  older  infants,  usually  in  those 
who  are  nursing  dry  breasts  or  where  fluid  food  and  water  have  been  with- 
held because  of  some  gastric  disturbance.  It  yields  as  promptly  to  treat- 
ment as  does  the  same  condition  in  the  newly  born. 


SECTION   II. 
NUTEITION. 

CHAPTER   I. 

INTRODUCTORY. 

NuTRiTioisr  in  its  broadest  sense  is  the  most  important  branch  of 
paediatrics.  At  no  time  of  life  does  prophyhixis  give  such  results  as  in 
infancy,  and  no  part  of  prophylaxis  is  worthy  of  more  attention  than  the 
conditions  of  nutrition.  This  study  is  the  first  duty  of  physicians  who 
practise  among  children.  The  importance  of  correct  ideas  regarding  it 
can  hardly  be  overestimated.  The  problem  is  not  simply  to  save  the 
child's  life  during  the  perilous  first  year,  but  to  adopt  those  means  which 
shall,  during  the  plastic  period  of  infancy,  tend  to  the  healthy  and  normal 
growth  of  the  child,  so  that  all  the  organs  of  the  body  shall  have  their 
normal  development  instead  of  impaired  structure  and  deranged  func- 
tion, the  effects  of  which  may  last  throughout  childhood  or  even  through- 
out life. 

The  question  whether  a  child  shall  be  strong  and  robust  or  a  weakling, 
is  often  decided  by  its  food  during  the  first  three  months.  The  largest 
part  of  the  immense  mortality  of  the  first  year  is  traceable  directly  to  dis- 
orders of  nutrition.  The  child  must  be  fed  so  as  to  avoid  not  only  the 
immediate  dangers  of  acute  indigestion,  diarrhoea,  and  marasmus,  but  the 
more  remote  ones  of  chronic  indigestion,  rickets,  scurvy,  and  general  mal- 
nutrition with  all  its  varied  manifestations,  since  these  conditions  are  the 
most  important  predisposing  causes  of  acute  disease  in  infancy. 

One  of  the  difficulties  has  always  been  that  temporary  success  may 
mean  ultimate  failure.  If  the  injurious  effects  of  improper  feeding  were 
immediately  manifest,  there  would  be  very  much  less  of  it  than  exists  at 
the  present  time.  It  is  because  many  things  are  valuable  as  temporary 
foods,  which  when  used  permanently  are  injurious.  No  better  illustration 
is  seen  than  in  the  too  exclusive  use  of  carbohydrates,  like  most  of  the 
proprietary  foods.  Infants  so  fed  grow  very  fat,  and  for  the  time  appear 
to  be  properly  nourished.  The  absence  from  the  food  of  some  of  those 
elements  which  are  of  vital  importance  may  not  be  evident  for  months ; 
hence  the  mistakes  so  often  made  by  the  laity,  and  even  by  the  profession. 

123 


THE   FOOD  CONSTITUENTS— PROTEIDS.  123 

There  are  certain  plain  rules  regarding  the  requirements  of  the  growing 
organism  which  can  not  be  ignored  without  serious  consequences,  which 
will  sooner  or  later  be  evident.  Another  common  mistake  is  in  the  pro- 
longed use  of  predigested  foods.  These  are  sometimes  continued  until,  as 
in  a  case  under  my  observation,  a  healthy  child  at  two-and-a-half  years  was 
totally  unable  to  digest  the  casein  of  cow's  milk.  A  great  stumbling-block 
to  many  is  the  fact  that  there  are  some  infants  of  robust  constitution  who, 
in  good  surroundings,  have  thriven  exceptionally  well  in  spite  of  very  bad 
methods  of  feeding.  But  it  should  not  be  forgotten  that  there  are  a  very 
much  larger  number  of  perfectly  healthy  infants  whose  lives  are  sacrificed 
every  year,  both  directly  and  indirectly,  as  a  result  of  improper  feeding.  A 
method  of  feeding  is  to  be  judged  not  by  the  few  exceptional  cases  which 
may  do  well,  but  by  the  results  obtained  in  the  majority  of  cases. 

Let  no  one  think  that  he  can  secure  the  best  results  in  infant-feeding 
without  devoting  both  time  and  study  to  the  problem.  Close  attention 
to  details  is  indispensable  to  success  in  this  as  in  all  branches  of  medicine  ; 
but  in  none  are  more  satisfactory  results  obtained. 

THE  FOOD   CONSTITUENTS  AND  THE   PURPOSES  THEY  SUBSERVE  IN 

NUTRITION. 

In  infancy  and  childhood,  as  in  adult  life,  the  elements  of  the  food 
are  five  in  number :  proteids,  fat,  carbohydrates,  mineral  salts,  and  water. 
The  form  in  which  they  must  be  furnished  to  the  child,  and  the  relative 
quantities  in  which  they  are  demanded,  are  different  from  those  required 
by  the  adult.  One  of  the  reasons  for  this  difference  is  the  delicate  condi- 
tion of  the  organs  of  digestion  in  infancy,  and  the  inability  to  assimilate 
certain  forms  of  food.  Another  reason  is  that  provision  must  be  made 
not  only  for  the  natural  waste  of  the  body,  but  for  its  rapid  growth,  nearly 
trebling  in  size,  as  it  does,  during  the  first  twelve  months. 

Proteids. — The  proteids  are  essential  to  life,  since  they  constitute  the 
only  kind  of  food  which  is  capable  of  replacing  the  continuous  nitroge- 
nous waste  of  the  cells  of  the  body,  upon  the  healthy  condition  of  which 
the  digestion  and  assimilation  of  the  other  elements  of  the  food  depend. 
Without  the  aid  either  of  the  fats  or  the  carbohydrates,  the  proteids  may 
sustain  life  and  may  even  prevent  a  loss  of  weight  for  a  time  ;  but  in  so 
doing  a  great  excess  of  such  food  is  required,  as  twenty-two  parts  of  pro- 
teids can  do  the  work  of  only  ten  parts  of  fat.  Such  a  diet  taxes  severely 
the  digestive  organs  and  the  kidneys.  When,  however,  fat  and  carbohy- 
drates are  added  to  the  food,  only  one-half  or  one-third  as  much  proteids 
are  required  to  replace  the  nitrogenous  waste,  as  in  the  case  of  an  exclusive 
proteid  diet  (Munk). 

The  proteids  are  furnished  by  the  casein  and  the  other  albuminoids 
present  both  in  woman's  milk  and  cow's  milk,  in  the  white  of  egg,  muscle- 


124  NUTRITION. 

fibre,  gluten  of  wheat,  etc.  The  proteids  easiest  of  digestion  by  infants 
are  those  of  woman's  milk.  The  greatest  difficulty  in  artificial  feeding 
has  been  to  supply  other  proteids  which  can  take  their  place.  It  is  the 
difference  in  the  digestibility  of  the  proteids  that  causes  most  of  the 
trouble  in  the  substitution  of  cow's  milk  for  woman's  milk. 

The  average  amount  of  proteids  furnished  in  a  good  sample  of  woman's 
milk  is  1-5  per  cent.  During  the  first  few  months,  infants  fed  upon  cow's 
milk  should  not  receive  a  larger  proportion  than  this,  and  on  account  of 
the  difference  in  the  digestibility  of  the  two,  the  proteids  of  cow's  milk 
must  at  first  be  reduced  below  this  point,  usually  to  1  per  cent,  and  in 
some  instances  to  0-5  per  cent.  Some  infants  fed  upon  milk  appear  to 
thrive  normally  for  a  considerable  period,  even  with  so  small  a  proportion 
of  proteids  as  0'5  per  cent,  provided  the  other  elements  of  the  food  are 
supi^lied  in  abundance.  But  all  children  fed  on  low  proteids  must  be  very 
closely  watched.  It  is  always  hazardous  to  keep  an  infant  long  upon  a 
food  which  is  low  both  in  proteids  and  fat. 

The  most  constant  symptom  following  insulficient  proteids  in  the 
food  is  angemia.  Besides  this,  there  may  be  feeble  circulation,  loss  of 
strength,  flabbiness  of  the  tissues,  and  general  failure  of  nutrition.  Later 
there  may  follow  difficulty  in  the  digestion  of  other  elements  of  the  food. 
The  vegetable  proteids  can  not  permanently  take  the  place  of  the  animal 
proteids  in  the  food  of  young  infants. 

Fats. — As  has  already  been  hinted  on  the  previous  page,  the  uses  of 
fat  in  the  body  are  intimately  associated  with  those  of  the  proteids.  Fat 
possesses  the  important  property  of  saving  nitrogenous  waste,  so  that 
when  this  is  supplied  in  the  food  in  proper  proportions,  the  entire  energy 
of  the  proteids  may  be  expended  upon  the  growth  and  nutrition  of  the 
cells  of  the  body  without  being  used  ujj  in  the  production  of  animal  heat. 
The  demands  made  upon  the  proteids  by  the  rapid  growth  of  the  body  in 
infancy,  make  it  desirable  that,  whenever  possible,  the  fats  should  do  the 
work  of  the  proteids. 

In  addition  to  their  use  as  a  source  of  animal  heat,  the  fats  add  to  the 
body-weight  by  storing  up  fat  in  the  body.  They  are  needed  for  the 
growth  of  the  nerve  cells  and  fibres,  and  are  essential  to  the  proper  growth 
of  bone.  Exactly  what  the  part  is  which  the  fats  take  in  the  development 
of  the  osseous  system  is  not  altogether  understood,  but  it  is  probable  that 
their  effect  is  due  to  their  well-known  and  important  function  in  aiding 
the  absoriDtion  from  the  intestines  of  inorganic  salts,  especially  the  earthy 
phosphates.  In  a  patient  upon  a  milk  diet,  when  the  fats  are  withheld  or 
greatly  reduced,  these  salts  appear  in  large  quantities  in  the  faeces.  More 
fat  is  supplied  in  the  food  of  the  nursing  infant  than  is  used  up  in  the 
body,  as  a  very  large  amount  is  normally  discharged  in  the  stools.  To 
this  is  due  the  soft  consistence  of  the  stools  of  the  nursing  infant.  Fats 
thus  seem  to  fill  the  role  of  a  natural  laxative  ;  constipation  being  one  of 


CARBOHYDRATES.  125 

the  first  and  most  striking  symptoms  following  the  reduction  of  fat  in  the 
milk. 

The  proportion  of  fat  required  in  infancy,  is  therefore  very  much 
greater  than  at  any  other  period  of  life.  Probably  the  most  common  mis- 
take in  artificial  feeding  has  been  to  give  too  little  fat.  The  chief  reason 
for  the  failure  of  most  of  the  proprietary  infant-foods  is  that  they  are  too 
low  in  fat ;  but  an  excess  of  carbohydrates  can  not  supply  this  deficiency. 

Woman's  milk  of  a  good  quality  contains  from  3  to  5  per  cent  fat,  and 
this  may  be  taken  as  representing  the  needs  of  the  body  under  normal 
conditions.  Infants  who  are  fed  upon  cow's  milk  should  get,  on  the 
average,  3  per  cent  fat  for  the  first  few  months  and  4  per  cent  during  the 
latter  part  of  the  first  year.  Infants  who  are  fed  for  a  long  time  upon  a 
food  low  in  fat  are  very  prone  to  develop  rickets.  Clinical  experience 
also  teaches  that  if  the  food  at  the  same  time  is  low  in  proteids  this  result 
follows  much  more  readily.  As  such  a  diet  is  in  most  cases  excessive  in 
carbohydrates,  children  so  fed  are  apt  to  be  very  fat,  but  usually  ansemic. 
The  importance  of  fats  in  nutrition  does  not  end  with  the  first  year ; 
they  should  be  supplied  liberally  throughout  childhood.  The  most  con- 
venient form  of  administration  is  cream,  and  next  to  this  cod-liver  oil. 

Carbohydrates. — Although  these,  like  the  fats,  can  not  replace  the 
nitrogenous  waste  of  the  body,  they  are  important  aids  to  the  proteids, 
and  in  this  respect  they  are  even  more  valuable  than  the  fats.  The  car- 
bohydrates are  partly  converted  into  fat,  and  may  thus  increase  the  body- 
weight.  They  are  capable  of  replacing  the  fat- waste  of  the  body.  They 
are  one  of  the  most  important  sources  of  animal  heat. 

Carbohydrates  are  the  most  abundant  of  the  solid  elements  of  the  food, 
although  they  form  a  smaller  percentage  of  the  entire  quantity  of  food  in 
infancy  than  in  adult  life.  The  form  in  which  carbohydrates  are  fur- 
nished to  the  infant,  and  in  fact  to  all  young  mammals,  is  milk-sugar. 
While  this  form  of  sugar  is  to  be  preferred,  it  is  by  no  means  so  essential 
that  it  be  given  as  that  the  fat  and  proteids  of  the  food  should  be  those  of 
milk.  Other  forms  of  sugar  may  often  take  its  place  without  interfering 
willi  nutrition.  Sometimes,  when  there  is  difficulty  in  the  digestion  of 
milk-sugar,  a  temporary  change  to  cane-sugar  or  to  maltose  may  even  bo 
advantageous.  The  carbohydrates  required  by  young  infants  can  not,  ex- 
cept to  a  very  small  extent,  be  supplied  in  the  form  of  starch,  owing  to 
the  feeble  diastatic  power  of  the  digestive  fluids  during  the  early  months, 
and  in  fact  during  the  greater  part  of  the  first  year.  As  a  rule,  there  is 
less  difficulty  in  the  digestion  of  the  carbohydrates  in  the  form  of  sugar 
than  of  any  other  part  of  the  food.  A  diet  consisting  too  exclusively  of 
carbohydrates  leads  often  to  a  rapid  increase  in  weight,  but  it  is  not  ac- 
companied by  a  proportionate  increase  in  strength.  Such  infants  have 
but  little  resistance,  and  many  of  them  become  rachitic.  The  easy  diges- 
tion of  a  food  consisting  chiefly  of  soluble  carbohydrates,  and  the  rapidity 


126  NUTRITION. 

with  which  children  so  fed  gain  in  weight,  lead  to  a  great  misapprehen- 
sion in  regard  to  their  value  as  foods.  The  ultimate  results  of  such  one- 
sided feeding,  if  long  continued,  are  almost  invariably  disastrous. 

In  building  up  the  cells  of  the  body  the  proteids  are  first  in  impor- 
tance, the  carbohydrates  second,  and  the  fats  third.  In  the  production  of 
animal  heat  the  fats  come  first,  the  carbohydrates  second ;  practically  the 
proteids  should  never  be  called  upon  for  this  purpose.  In  a  proper  diet, 
all  of  these  elements  are  represented. 

Mineral  Salts. — These  are  of  greater  importance  in  infancy  than  later 
in  life,  because  of  the  building  up  of  the  osseous  system  which  is  going  on 
with  such  rapidity  during  infancy  and  early  childhood.  The  most  im- 
portant for  this  purpose  are  the  phosphates  of  lime  and  magnesium. 
These  are  furnished  in  abundance  both  in  woman's  and  cow's  milk. 
These  salts  are  also  necessary  for  cell  growth.  Other  inorganic  salts  fur- 
nish the  elements  from  which  the  mineral  constituents  of  the  blood  and 
digestive  fluids  are  formed,  and  still  others  facilitate  absorption,  excretion, 
and  secretion. 

Water. — The  food  of  all  young  mammals  consists  of  from  eighty  to 
ninety  per  cent  of  water.  This  is  needed  for  the  solution  of  certain  parts 
of  the  food,  such  as  the  sugar  and  some  of  the  proteids,  and  for  the  sus- 
pension of  the  other  proteids  and  the  emulsified  fat.  All  the  food  is  thus 
dissolved  or  very  finely  divided  so  as  to  be  more  readily  acted  upon  by  the 
feeble  digestive  organs  of  the  infant.  Water  is  needed  also  in  large  quan- 
tities for  the  rapid  elimination  of  the  waste  of  the  body.  In  proportion 
to  its  weight,  an  average  infant  during  the  first  year  requires  a  little  more 
than  six  times  as  much  water  as  an  adult.  During  the  time  when  the 
child  is  upon  an  entirely  fluid  diet,  the  addition  of  water  other  than  that 
supplied  by  the  food  is  unnecessary ;  but  when  the  number  of  feedings 
becomes  less  frequent,  and  solid  food  is  given  in  larger  quantities,  water 
should  be  given  freely  between  the  feedings  at  all  seasons,  but  especially 
in  the  summer. 


CHAPTEE  II. 
THE  INFANT'S  DIETARY. 

WOMAN'S   MILK. 

Woman's  milk  is  the  ideal  infant-food.  A  thorough  knowledge  of 
its  character,  exact  composition,  and  variations  is  indispensable,  for  upon 
this  knowledge  are  based  all  our  rules  for  the  preparation  of  foods  used 
as  substitutes  for  woman's  milk  when  this  can  not  be  obtained. 


WOMAN'S   MILK. 


127 


"Woman's  milk  is  a  secretion  of  the  mammary  glands  and  not  a  mere 
transudation  from  the  blood-vessels ;  although  under  abnormal  conditions 
it  may  partake  more  of  the  character  of  a  transudation  than  a  secretion. 
A  few  drops  may  be  squeezed  from  the  breasts  before  parturition ;  gener- 
ally speaking,  however,  it  is  only  present  after  delivery.  During  the  first 
two  days  the  secretion  is  scanty.  Usually  upon  the  third  or  fourth  day  it 
becomes  well  established,  although  it  may  be  delayed  until  the  fifth  or 
sixth  day.  During  the  period  of  lactation,  milk  is  constantly  formed  in 
the  mammary  glands,  but  the  process  is  more  active  while  the  child  is  at 
the  breast. 

Physical  Characters. — Woman's  milk  is  of  a  bluish-white  colour  and 
quite  sweet  to  the  taste.  When  freshly  drawn  its  reaction  is  usually  alka- 
line, sometimes  neutral,  but  under  healthy  conditions  never  acid.  The 
specific  gravity  varies  between  1,027  and  1,032,  the  average  being  1,031  at 
60°  F.  On  the  addition  of  acetic  acid  only  a  slight  coagulation  is  seen, 
this  being  in  the  form  of  small  flocculi,  and  never  in  large  masses  as  is  the 
case  in  cow's  milk.  Microscopically,  there  are  seen  great  numbers  of 
fat-globules  nearly  uniform  in  size  and  some  granular  matter.  Occasion- 
ally there  are  present  epithelial  cells  from  the  milk-ducts  or  from  the 
nipple. 

Colostrum. — The  secretion  of  the  first  two  or  three  days  differs  quite 
markedly  from  the  later  milk.  To  this  the  name  colostrum  has  been 
given.    It  is  of  a  deep  yellow  colour,  which  is  chiefly  due  to  the  colostrum- 


0     B\^^^^     bf»"^    ®©     Q 


Fig.  22.— Colostrum.     (Funke.) 


Fig.  23. — Woman's  milk  at  a  late  period. 
(Funke.) 


corpuscles.     It  is  not  so  sweet  as  the  later  milk.     It  has  a  specific  gravity 

of  1,040  to  1,046,  a  strongly  alkaline  reaction,  and  is  coagulated  into  solid 

masses  by  heat,  and  sometimes  coagulates  spontaneously.     It  is  very  rich 

in  proteids  and  in  salts.     Microscopically  the  fat-globules  are  of  unequal 

size,  and  there  are  present  large  numbers  of  granular  bodies  known  as 

colostrum-corpuscles  (Fig.  22).     These  are  four  or  five  times  the  size'of 
10 


128  NUTRITION. 

the  milk-globules  (Fig.  23),  and  they  are  probably  epithelial  cells  which 
have  undergone  fatty  degeneration. 

Composition  of  Colostrum* 

Proteids 5-71 

Fat 2-04 

Sugar 3  •  74 

Salts 0-28 

Water 88-23 

100-00 

The  colostrum-corpuscles  are  very  abundant  during  the  first  few  days, 
but  under  normal  conditions  they  are  not  found  after  the  tenth  or 
twelfth  day. 

Daily  Quantity. — Exact  information  upon  this  point  is  difficult  to 
obtain.  There  are  recorded,  however,  extended  observations  made  with 
great  care  upon  five  cases,f  from  which  some  deductions  may  safely  be 
drawn.  All  were  healthy  infants,  nursing  exclusively  and  gaining  steadily 
in  weight. 

From  these  observations,  and  others  less  extended,  the  average  daily 


*  From  five  analyses  by  Pfeiffer  of  milk  obtained  during  the  first  three  days. 

•j- Haehner's' cases  (Jahrb.  f.  Kinderh.,  xv,  23 ;  xxi,  314).  Case  I.  Female;  birth- 
weight  7  pounds  14  ounces  (3,100  grammes).  First  week,  lost  1^  ounce  (41  grammes); 
after  this  gained  steadily  during  the  twenty-three  weeks  of  observation  ;  from  second 
to  ninth  week,  average  weekly  gain  8  ounces  (241  grammes) ;  from  tenth  to  eighteenth 
week,  average  gain  4|  ounces  (138  grammes) ;  from  nineteenth  to  twenty-third  week, 
average  gain  4  ounces  (130  grammes);  weight  at  the  end  of  twenty-third  week,  14| 
pounds  (6,690  grammes). 

Case  II.  Male ;  birth-weight  6-J  pounds  (2,950  grammes).  Loss,  first  week,  3  ounces 
(80  grammes);  after  this  gained  steadily  during  the  eleven  weeks  of  observation  ;  from 
second  to  eleventh  week,  average  weekly  gain  7^  ounces  (214  grammes) ;  weight  at  end 
of  eleventh  week,  11  pounds  2  ounces  (5,045  grammes). 

Case  III.  Female;  birth-weight  3  pounds  9  ounces  (1,620  grammes).  Gain,  first 
week,  1-J  ounce  (40  grammes) ;  during  the  succeeding  twenty-one  weeks  of  observation, 
average  weekly  gain  of  5  ounces  (141  grammes) ;  weight  at  the  end  of  twenty-second 
week,  10  pounds  3  ounces  (4,620  grammes). 

Laure's case  (These,  Paris,  1889).  Female;  birth-weight  8  pounds  13  ounces  (4,000 
grammes) ;  loss,  first  week,  8  ounces  (225  grammes) ;  after  this  gained  steadily  during 
the  nine  weeks  of  observation,  on  an  average  9^  ounces  (268  grammes)  weekly;  at  the 
end  of  ninth  week,  weight  13  pounds  3-J^  ounces  (6,000  grammes). 

Ahlf eld's  case  (Deutsch.  Ztschr.  f.  Prakt.  Med.,  1878).  Birth-weight  7  pounds  14 
ounces  (3,100  grammes).  Observations  continued  from  fourth  to  thirtieth  week.  Dur- 
ing first  ten  weeks,  average  weekly  gain  5f  ounces  (161  grammes) ;  from  eleventh  to 
twentieth  week,  7^  ounces  (214  grammes) ;  from  twenty-first  to  thirtieth  week,  6  ounces 
(168  grammes) ;  at  the  end  of  thirtieth  week,  weight  18  pounds  9^  ounces  (8,435 
grammes). 

In  all  these  cases  the  amount  of  milk  was  determined  by  weighing  the  infant  upon 


WOMAN'S  MILK. 


129 


quantity  of  milk  secreted  under  normal  conditions  of  healtii  may  be  as- 
sumed to  be  pretty  nearly  as  follows  : 

Approximately. 

At  the  end  of  the  first  week 10  to  10  oz.  (300  to     500  grm.). 

During  the  second  week 13  to  18  oz.  (400  to     550  grm.). 

During  the  third  week 14  to  24  oz.  (430  to     720  grm.). 

During  the  fourth  week 10  to  20  oz.  (500  to     800  grm.). 

From  the  fifth  to  the  thirteentli  week  ...  20  to  34  oz.  (GOO  to  1,030  grm.). 

From  the  fourth  to  the  sixth  month 24  to  38  oz.  (720  to  1,150  grm.). 

From  the  sixth  to  the  ninth  month 30  to  40  oz.  (900  to  1,220  grm.). 

It  will  be  noted  that  the  amount  increases  very  rapidly  up  to  about 
the  eighth  week,  and  after  this  much  more  slowly.  The  amount  of  milk 
varies  also  with  the  demands  of  the  child  in  a  very  striking  and  uniform 
way, 

A  comparison  of  the  daily  amount  of  milk  taken  with  the  weight  of 
the  child  at  the  different  periods,  shows  that  during  the  first  ten  weeks 
large  children  take  on  an  average  an  amount  equal  to  from  fifteen  to 
nineteen  per  cent  of  the  body- weight ;  while  smaller  children,  during  the 
same  period,  take  only  from  twelve  to  fourteen  per  cent  of  the  body- 
weight.  From  the  eleventh  to  the  thirteenth  week  the  large  children 
take  daily  from  thirteen  to  seventeen  per  cent  of  the  body-weight,  and 
the  small  ones  from  eleven  to  thirteen  i^er  cent,  showing  that  the  larger 

very  delicate  scales  both  before  and  after  every  nursing  during  the  entire  period  of  ob- 
servation. 

The  following  table  gives  in  a  condensed  form  the  daily  quantity  of  milk  in  these 
cases : 


Time. 

Haehner's 
1st  case. 

Haehner's 
2d  case. 

Haehner's 
3d  case. 

Laures 
case. 

Ahlfeld'8 
case. 

1st  dav 

Granimes. 

20 
170 

2(;5 

420 
300 
374 
423 
497 
550 
594 
003 
740 
880 
835 
700 
790 
807 
870 

Gramnies. 

75 
135 
325 
295 
290 
340 
350 
423 
408 
531 
501 
001 
081 
730 
005 

Grammes. 

20 
45 
70 
99 
124 
130 
150 
229 
314 
379 
447 
472 
525 
508 
584 
000 
073 
709 

Graramea. 

125 

222 

400 

475 

500 

550 

730. 

810 

944 

978 

1,038 

1.024 

1.085 

GramiDM. 

2d  day 

3d  dav 

4th  dav  

5th  day  

0th  day  

7th  day 

Average  2d  week 

Average  3d  week 

Average  4th  week 

576 

Average  5th  week 

055 

Average  0th  week 

791 

Average  7th  week 

811 

Average  8th  week 

845 

Average  9th  week 

810 

Average  10th  to  13th  week.. 
Average  14th  to  17th  week.. 
Average  18th  to  23d  week..  . 
Average  24th  to  30th  week . . 

1,< 
1, 

^69 
)83 
329 
145 

130 


NUTRITION. 


children  take  not  only  more  food,  but  more  in  proportion  to  their  size 
than  the  smaller  ones. 

The  average  quantity  taken  at  one  nursing  by  the  five  children  previ- 
ously mentioned  was  as  follows : 

Approximately. 

During  the  first  week f  to  1|  oz.    (18  to    50  grin.). 

During  the  second  week 1    to  3    oz.    (30  to    90  grm.). 

During  the  third  week li  to  4    oz.    (4.5  to  120  grm.). 

During  the  fourth  week 1^  to  4^  oz.    (45  to  140  grm.). 

From  the  fifth  to  the  seventh  week 2    to  5    oz.    (64  to  150  grm.). 

From  the  eighth  to  the  eleventh  week 2i^  to  5^  oz.    (75  to  160  grm.). 

During  the  fourth  month 3    to  6    oz.    (90  to  180  grm.). 

During  the  fifth  month 3^  to  6^  oz.  (110  to  200  grm.). 

During  the  'sixth  month 4    to  7    oz.  (120  to  220  grm.). 

Between  the  limits  mentioned  the  greater  number  of  cases  will  un- 
doubtedly fall.  The  amount  taken  at  one  time  is,  however,  modified 
by  the  frequency  of  nursing,  and  is  therefore  not  so  good  a  guide  to  the 
amount  of  food  required,  as  is  the  quantity  taken  in  twenty-four  hours. 

Composition. — Many  of  the  older  analyses  of  milk  gave  erroneous  re- 
sults because  of  imperfect  methods  of  examination.  According  to  the 
most  recent  analyses  of  Pfeiffer,  Koenig,  Leeds,  Harrington,  and  others, 
the  composition  of  human  milk  is  as  follows : 


Average. 

Common  healthy  variations. 

Fat 

Su'^ar 

Per  cent. 

4-00 
7-00 
1-.50 
0-20 
87-30 

Per 

3-00 
6-00 
1-00 
0-18 

89-82 

cent. 

to    5-00 
"     7-00 

Proteids 

"     2-25 

Salts 

"     0-25 

W  ater 

"  85-50 

100-00 

100-00 

100-00 

In  the  older  analyses,  the  percentage  of  proteids  is  almost  invariably 
too  high  and  the  sugar  too  low. 

There  are  certain  variations  in  composition  depending  upon  the  age 
of  the  milk.  Nearly  all  these  changes  take  place  during  the  first  month, 
and  principally  during  the  first  two  weeks.  During  this  period  there  is, 
according  to  Pfeififer,  a  fall  in  the  proteids  from  nearly  4  to  below  2  per 
cent,  in  the  salts  from  0-45  to  0-20  per  cent,  a  rise  in  the  sugar  from  2  to 
6  per  cent,  and  a  very  slight  increase  in  the  fat.  After  the  first  month 
the  regular  variations  in  composition  are  so  slight  that  they  may  be  prac- 
tically ignored. 

Proteids. — The  proteids  are  not  yet  fully  understood.  Their  separa- 
tion is  somewhat  difficult,  and  they  are  usually  considered  together.  The 
most  abundant  and  the  most  important  ones  are  casein  and  lactalbumin, 
although  Hammarsten  gives  a  third — lactoglobulin — and  some  other  au- 


WOMAN'S  MILK.  131 

thors  even  a  fourth.  The  casein  is  not  in  solution  but  in  suspension,  by 
virtue  of  the  presence  in  the  milk  of  lime  phosphate,  with  which  it  is 
probably  in  combination.  The  lactalbumin  is  in  solution ;  it  resembles 
serum-albumin.  It  is  present  in  a  larger  proportion  than  in  other  varieties 
of  milk.    According  to  Koenig,  lactalbumin  is  twice  as  abundant  as  casein. 

The  proteids  are  usually  present  in  the  proportion  of  1  to  2  per  cent 
in  woman's  milk,  although  the  variations  are  quite  wide  (0-7  to  4-5  per 
cent).  The  amount  of  proteids  is  larger  in  the  milk  of  the  first  few  days. 
After  the  third  week  the  proportion  changes  but  little  until  near  the  end 
of  lactation,  when  it  falls  very  markedly. 

Fat. — This  exists  in  the  form  of  minute  globules,  which  are  held  in  a 
state  of  permanent  emulsion  by  the  albuminous  solution  in  which  they 
are  suspended.  The  old  view,  that  the  globules  had  an  investing  mem- 
brane, is  now  generally  discarded.  Like  the  proteids,  the  proportion  of 
fat  is  subject  to  wide  variations — 4  per  cent  being  taken  as  the  average. 
In  thirty-four  analyses  made  for  me  at  the  laboratory  of  the  College  of 
Physicians  and  Surgeons,  the  fat  varied  between  1-12  and  6-66  per  cent. 
In  forty-three  analyses  by  Leeds,  the  variations  were  between  2-11  and  6-89 
per  cent.    The  proportion  is  very  little  affected  by  the  period  of  lactation. 

Sugar. — The  sugar  is  in  complete  solution.  Its  proportion  is  very 
constant,  the  average  being  seven  per  cent.  The  ordinary  variations  are 
usually  within  the  limits  of  G  and  7  per  cent.  The  sugar  being  so  im- 
portant as  a  heat-producing  element,  Nature  has  wisely  provided  that  this 
shall  be  the  most  constant  ingredient  of  the  milk.  The  amount  of  sugar 
is  smallest  in  the  milk  of  the  first  week ;  after  the  first  month,  however, 
the  variations  are  sliglit. 

Salts. — The  average  proportion  of  inorganic  salts  is  020  per  cent,  or 
about  one  fourth  that  of  cow's  milk.  According  to  Rotch's  analysis,  the 
inorganic  salts  exist  in  the  following  jiroportions : 

Salts  in  Woman's  Milk. 

Calcium  phosphate 23'87 

Calcium  silicate 1-27 

Calcium  sulphate 2-25 

Calcium  carbonate 2  •  85 

Magnesium  carbonate 3  •  77 

Potassium  carbonate 23-47 

Potassium  sulphate 8 '33 

Potassium  chloride 12-05 

Sodium  chloride 21-77 

Iron  oxide  and  alumina 0-37 

10000 

With  the  exception  of  calcium  phosphate  nearly  all  the  salts  are  in 
solution.    The  milk  of  the  first  few  days  is  very  rich  in  salts — the  proper- 


132 


NUTRITION. 


^" 


cE:? 


1,010 


\ 


tion  being  fully  twice  that  of  auy  later  period.     After  the  first  month  the 
variations  are  slight. 

The  Examination  of  Milk. — The  exact  composition  of  human  milk  is 
to  be  determined  only  by  a  complete  chemical  analysis.  There  are,  how- 
ever, many  variations  which 
the  physician  may  readily 
ascertain  for  himself  by  sim- 
ple methods  of  examination. 
The  quantity  of  milk  se- 
creted by  the  breasts  may  be 
estimated  by  the  quantity 
which  may  be  drawn  by  a 
breast-pump,  although  this 
is  not  a  very  reliable  test. 
If  the  child  nurses  habitu- 
ally forty  or  fifty  minutes, 
the  probabilities  are  very 
strong  that  the  quantity  of 
milk  is  small.  If  the  breasts 
at  nursing  time  are  full,  hard, 
and  tense,  the  supply  is  prob- 
ably abundant.  If  they  are 
soft  and  flabby,  and  the 
milk  appears  to  run  in  only 
while  the  child  is  nursing,  it 
is  almost  certain  that  the 
quantity  is  small.  The  most 
reliable  of  all  tests  is  weigh- 
ing the  infant  before  and 
after  nursing,  upon  an  accu- 
rate pair  of  scales,  sufficient- 
ly sensitive  to  indicate  half- 
ounces.  Two  or  three  weighings  will  suffice  to  show  conclusively  whether 
an  infant  at  three  months,  for  instance,  is  getting  habitually  four  or  five, 
or  only  one  or  two  ounces  at  a  nursing. 

The  reaction  of  milk  may  be  taken  with  ordinary  litmus  paper.  When 
freshly  drawn  it  should  be  alkaline  or  neutral,  never  acid. 

The  specific  gravity  may  be  taken  with  any  small  hydrometer  gradu- 
ated from  1,010  to  1,040  (Fig.  24,  B).  The  specific  gravity  is  lowered  by 
the  fat,  but  increased  by  the  other  solids.  An  ordinary  urinometer  will 
answer  every  purpose,  the  only  difficulty  being  the  quantity  which  is  re- 
quired to  float  the  instrument. 

3JicroscopicaI  examination. — The  microscope  reveals  the  presence  of 
colostrum-corpuscles,  blood,  pus,  epithelium,  and  granular  matter.    Colos- 


A  B  C 

Fig.  24. — Apparatus  for  examination  of  woman's  milk. 
A,  Marchand's  tube ;  B,  C,  the  author's  lactometer 
and  cream-gauge. 


WOMAN'S  MILK.  X33 

trum-corpuscles  are  abnormal  after  the  twelfth  day ;  pus  and  blood  are 
always  abnormal.  All  of  these  conditions  necessitate  the  suspension  of 
nursing,  at  least  temporarily.  But  little  importance  can  be  attached  to 
the  size  and  appearance  of  the  fat-globules  as  affecting  the  nutritive  prop- 
erties of  the  milk. 

The  determination  of  fat. — The  simplest  method  is  by  the  cream-gauge 
(Fig.  24,  C),  which  is  sufficiently  accurate  for  ordinary  clinical  purposes. 
The  glass  cylinder  holding  ten  cubic  centimetres  is  filled  to  the  zero  mark 
with  freshly  drawn  milk.  This  is  allowed  to  stand  at  the  temperature  of 
the  room  (66°  to  72°  F.)  for  twenty-four  hours,  and  the  percentage  of 
cream  is  then  read  off.  Under  these  conditions,  the  relation  of  the  per- 
centage of  cream  to  that  of  fat  is  very  nearly  as  five  to  three ;  thus  five 
per  cent  of  cream  will  indicate  that  the  milk  contains  three  per  cent  of 
fat,  etc.  When  an  immediate  determination  of  fat  is  desired,  the  most 
accurate  instrument  is  the  Babcock  centrifugal  machine.  (See  page  140.) 
Marchand's  tube  (Fig.  24,  A)  may  also  be  employed.  In  this  test  the  fat 
is  extracted  by  ether  and  then  precipitated  by  alcohol.*  The  various 
optical  tests  which  have  been  suggested  are  much  less  satisfactory. 

Sugar. — The  proportion  of  sugar  is  so  nearly  constant  that  it  may  be 
ignored  in  clinical  examinations. 

Proteidn. — We  have  no  direct  method  for  determining  clinically  the 
amount  of  proteids.  If  we  regard  the  sugar  and  salts  as  practically  uni- 
form, or  so  nearly  so  as  not  to  affect  the  specific  gravity,  we  may  form  an 
approximate  idea  of  the  proteids  from  a  knowledge  of  the  specific  gravity 
and  the  percentage  of  fat.  We  may  thus  determine  pretty  positively 
whether  they  are  greatly  in  excess  or  very  scanty.  The  specific  gravity 
will  then  vary  directly  with  the  proportion  of  proteids,  and  inversely  with 
the  proportion  of  fat — i.  e.,  high  proteids,  high  specific  gravity ;  high  fat, 

*  Marchand's  test :  First  put  in  five  cubic  centimetres  of  milk,  up  to  the  line  M ; 
then  four  or  five  drops  of  liquor  sodae  ;  shake  ;  add  five  cubic  centimetres  of  ether,  up  to 
the  line  E;  cork, and  shake  fifteen  or  twenty  times;  add  ninety-per-cent  alcohol,  up  to 
the  line  A.  The  tube  is  now  tightly  corked,  shaken  thoroughly,  and  placed  upright  in 
a  tall  bottle  containing  water  at  a  temperature  of  120°  to  150°  F.  The  fat  separates 
and  forms  a  distinct  layer  at  the  top,  and  after  half  an  hour  the  amount  is  read  off  in 
degrees.    By  reference  to  the  following  table  the  exact  percentage  of  fat  is  shown: 


Degrees  Percentage 

Marcband.  of  fat. 


Degrees  Percentage 

Marchand.  of  fat. 


1 1-49 

3 1-96 

5 2-43 

7 2-89 

9 3-36 

11 3-83 

Each  additional  degree  on  the  tube  corresponds  to  0-23  per  cent  of  fat.    To  insure 
accuracy  the  test  should  be  repeated  two  or  three  times  with  the  same  specimen. 
These  tubes  may  be  obtained  from  E.  Greiner,  51  William  Street,  New  York. 


13 4-29 

lo 4-75 

17 ...  5-22 

19 5-(.i8 

21 614 


134 


NUTRITION. 


low  specific  gravity.     The  aiiplication  of  this  principle  will  be  seen  by 
reference  to  the  accompanying  table.* 

Woman's  Milk. 


Specific  gravity  70°  F. 


Average 1*031 

Normal  variations.. .       1-028  -  1  -029 
Normal  variations.. .  1-032 

Abnormal  variations.  Low  (below  1*028). 
Abnormal  variations.  Low  (below  1*028). 
Abnormal  variations.  High  (above  1*032). 
Abnormal  variations.  High  (above  1*032). 


Cream — 24  hours. 


8%  -  12% 

0%  —  i3% 

High  (above  10^), 

Low  (below  0%). 

High. 

Low, 


Proteids  (calculated). 


1-5% 

Normal  (rich  milk). 

Normal  (fair  milk). 

Normal  or  slightly  below. 

Very  low  (very  poor  milk). 

Very  high  (very  rich  milk). 

Normal  (or  nearly  so). 


The  specimen  taken  for  examination  should  be  either  the  middle  por- 
tion of  the  milk — i.  e.,  after  nursing  two  or  three  minutes — or,  better,  the 
entire  quantity  from  one  breast,  since  the  composition  of  the  milk  will 
differ  very  much  according  to  the  time  when  it  is  drawn.  The  first  milk 
is  slightly  richer  in  proteids  and  much  poorer  in  fat.  The  last  drawn 
from  the  breasts  is  low  in  proteids  and  high  in  fat.  The  following  analy- 
ses from  Forster  illustrate  these  differences  : 


First  portion. 

Second  portion. 

Third  portion. 

Fat 

Per  cent. 

1*71 
1*13 

Per  cent. 

2*77 
0*94 

Per  cent. 

5*51 

Proteids  

0*71 

Conditions  Aflfecting  the  Composition  ofWoman's  Milk. — TJieage  of  the 
nurse. — This  has  no  constant  influence.  Other  things  being  equal,  the  milk 
of  very  young  women,  and  also  of  those  over  thirty-five  years  of  age,  is  likely 
to  be  lower  in  fat  than  that  of  women  between  twenty  and  thirty-five  years. 

Number  of  pregnancies. — This  has  no  constant  influence  except  such 
as  results  from  the  effect  w^o^  the  general  health  of  the  nurse. 

Acute  illness. — In  the  majority  of  cases  of  acute  illness  of  a  minor 
character  and  of  short  duration  there  is  no  perceptible  effect  upon  the 
milk.  In  the  acute  febrile  diseases  of  a  severe  type  the  quantity  of 
milk  is  reduced,  the  fat  is  low,  and  the  proteids  are  apt  to  be  high.  In 
septic  conditions  bacteria  may  appear  in  the  milk. 

Menstruation. — The  effect  of  this  is  exceedingly  variable,  depending 
much  ujion  the  individual  and  the  ease  of  menstruation.  From  observa- 
tions upon  685  cases,  Meyer  noted  disturbances  in  the  child  in  over  one 
half  the    number.      My    own    experience  accords    rather   with    that  of 

*  The  authors  apparatus  for  this  examination,  consisting  of  lactometer  (Fig.  24,  B) 
and  two  cylindrical  graduated  glasses  (Fig.  24,  C),  may  be  obtained  from  Eimer  and 
Amend,  Eighteenth  Street  and  Third  Avenue,  New  York,  With  these  the  test  can  be 
made  with  half  an  ounce  of  milk.  For  a  fuller  discussion  of  the  subject,  see  article  by 
the  author  in  Archives  of  Pfediatrics,  March,  1893. 


WOMAN'S  MILK. 


135 


Pfeiffer  and  Schlichter,  who  consider  it  quite  exceptional  for  the  child  to 
be  visibly  affected.  Schlichter  made  observations  upon  infants  during 
233  menstrual  days,  noting  the  condition  of  the  stools  and  digestion  both 
before  and  after  menstruation.  In  ninety  per  cent  of  the  cases  there  was 
no  perceptible  influence.  In  only  eight  per  cent  were  the  stools  bad,  and 
in  only  three  per  cent  was  there  disturbance  of  the  stomach  with  vomiting. 
The  nature  of  the  changes  in  milk  produced  by  menstruation  is  illus- 
trated by  the  following  case  taken  from  Eotch  : 


Second  day  of  men- 
struation.    Bowels  of 
child  loose. 

Seven  days  after 

menstruation. 

Bowels  regular. 

Forty  days  after  men- 
struation.   Child 
gaining  rapidly. 

Fat 

Per  cent. 

1-37 
610 
2-78 
0-15 
89-60 

Per  cent. 

2-02 
6-55 
2-12 
0-15 
89-16 

Per  cent. 

2-74 

Sugar 

6-35 

Proteids 

0-98 

Salts 

0-14 

Water 

89-79 

At  the  present  time  sufficient  observations  have  not  been  made  to  show 
whether  the  differences  noted  in  the  above  case — low  fat  and  high  proteids 
— are  the  rule  where  disturbances  are  produced  during  menstruation. 
Monti's  examinations  lead  him  to  the  conclusion  that  the  fat  is  not  con- 
stantly affected.  It  is  safe  to  say  that  the  changes  are  not  uniform,  and 
that  in  very  many  cases  none  of  importance  are  produced  by  menstruation. 

Diet. — The  fat  and  the  proteids  of  the  milk  are  much  influenced  by 
diet,  the  sugar  but  very  little.  A  nitrogenous  diet  increases  quite  uni- 
formly both  the  fat  and  the  proteids.  A  vegetable  diet  diminishes  both 
the  fat  and  the  proteids.  A  starvation  diet  diminishes  the  fat,  while  the 
proteids  may  be  diminished  or  increased  ;  if  the  latter,  they  are  generally 
changed  in  character.  An  excessively  rich  diet  increases  the  fat  and  usu- 
ally the  proteids  also.  .  All  fluids  tend  to  increase  the  quantity  of  milk. 
Alcohol  in  the  form  of  malted  drinks,  and  malt-extracts  increase  the  quan- 
tity of  milk  and  the  amount  of  fat.  The  effect  of  alcohol  upon  the  proteids 
is  not  constant,  but  they  are  usually  increased.  The  following  table  gives 
the  result  of  analyses  of  the  milk  of  two  women  in  the  New  York  Infant 
Asylum  before,  while  taking,  and  after  taking  an  alcoholic  extract  of  malt : 


I. 

Without  malt. 

Case  I : 

Fat 

Per  cent. 

1-74 
1-93 
7-02 
0-20 

1-12 
1-57 
7-11 
0-19 

Proteids 

Suear 

Salts 

Case  II : 

Fat 

Proteids 

Sugar 

Salts 

After  taking  8  oz.  malt 
daily  for  10  days. 


Per  cent. 

'3-83 
1-58 
7-43 

0-17 

2-75 
2-34 
6-77 
0-17 


III. 
No  malt  for  7  days. 


Per  cent. 

2-41 
2-95 
6-59 
0-19 

1-70 
1-26 
604 
0-18 


136  NUTRITION. 

The  child  of  Case  I  gained  one  ounce  and  a  half  during  the  four  days 
preceding  the  first  analysis  ;  that  of  Case  II  did  not  gain  at  all.  During 
the  ten  days  while  taking  the  malt,  the  first  child  gained  twelve  ounces, 
the  second  child  eight  ounces.  During  the  seven  days  after  the  malt  was 
discontinued,  the  first  child  gained  eight  ounces,  the  second  child  one 
ounce.  There  was  a  notable  increase  in  the  quantity  of  milk  in  both 
cases  while  taking  the  malt. 

Klingemann  has  shown  that  the  taking  of  alcohol  of  a  poor  quality 
(especially  amylic  alcohol)  may  cause  it  to  appear  in  the  milk,  and  may 
produce  symptoms  in  the  nursing  infant,  particularly  if  the  amount  taken 
is  large.  Seibert  has  called  attention  to  very  grave  symptoms  in  infants 
produced  by  the  ingestion  of  stale  beer  by  nurses. 

The  nursing  woman  should  have  a  generous  diet  of  simple  food,  and 
should  drink  largely  of  milk  or  gruels  made  with  milk.  The  diet  should 
be  a  varied  one,  not  excessive  in  nitrogenous  food  nor  in  vegetables.  All 
salads  and  highly  seasoned  dishes  should  be  avoided,  not  so  much  because 
they  upset  the  child,  although  this  may  happen,  as  because  they  are  likely 
to  disturb  the  digestion  of  the  nurse.  All  the  common  vegetables  and 
fruits  in  season  may  be  allowed  in  moderation.  Strong  tea  and  coffee 
should  be  prohibited,  although  weak  tea  or  coffee  may  be  allowed,  each 
but  once  a  day.  Cocoa  is  less  objectionable  than  either  tea  or  coffee.  In 
addition  to  her  regular  meals  the  nurse  should  have  milk  or  gruel  at  bed- 
time. The  diet  should  in  all  cases  be  adapted  to  her  digestion.  Great 
harm  often  results  from  over-feeding  with  its  consequent  indigestion. 
The  taking  of  alcohol  should  be  discouraged  and  its  routine  use  for- 
bidden. 

Drugs. — The  elimination  of  drugs  through  the  milk  is  somewhat  un- 
certain and  variable.  A  large  proportion  of  those  popularly  supposed  to 
influence  the  child  when  taken  by  the  nurse,  have  no  effect  whatever. 
The  effect  of  drugs  is  more  noticeable  when  the  milk  is  very  poor  in 
quality ;  it  being  at  such  times  more  of  an  excretion  than  a  secretion. 
This  is  seen  during  the  early  colostrum  period,  also  during  the  illness  of 
the  nurse  or  when  from  various  causes,  mental  or  physical,  the  secretion 
becomes  disturbed.  The  more  important  drugs  affecting  the  child  through 
the  milk  are  the  following  : 

Belladonna :  Effect  quite  constant  under  all  circumstances  when  given 
in  full  doses. 

Opium :  Effect  inconstant,  although  it  is  possible,  when  the  milk  is 
poor,  for  toxic  symptoms  to  be  produced  when  full  doses  are  given  to  the 
mother.     A  fatal  case  is  on  record  in  a  child  a  few  days  old. 

Potassium  iodide :  Effect  not  uniform,  particularly  seen  when  the  ad- 
ministration is  long  continued.  Koplik  and  others  have  reported  the  pro- 
duction of  iodism  in  nursing  infants  while  the  drug  was  taken  by  the 
mother. 


COW'S  MILK.  137 

Bromides :  Effect  similar  to  that  of  the  iodides. 

Mercury :  Effect  veiy  feeble,  and  only  after  prolonged  administra- 
tion.* 

Drugs  occasionally  eliminated  in  milk  in  sufficient  amount  to  produce 
visible  effects  are  the  saline  cathartics,  arsenic,  and  the  salicylates.  Acids, 
chloral,  and  most  other  drugs  are  without  effect. 

Pregnancy. — The  milk  of  pregnant  women  is  generally  small  in 
quantity  and  poor  in  quality,  especially  in  fat.  (See  chart,  p.  1G8.)  It  is 
not  known,  however,  that  there  are  any  other  differences. 

Bacteria. — Under  normal  conditions  human  milk  is  practically  sterile. 
In  disease  of  the  mammary  gland  of  a  suppurative  character,  bacteria  are 
frequently  found  in  the  milk.  They  may  also  appear  in  considerable  num- 
bers during  puerperal  sepsis.  In  the  milk  of  women  suffering  from  acute 
fevers  not  of  septic  origin,  Escherich  found  no  bacteria.  It  has  been 
shown  that  the  bacilli  of  anthrax  and  tuberculosis  may  appear  in  cow's 
milk  apart  from  any  disease  of  the  udder  itself.  This  may  fairly  be  as- 
sumed to  be  true  in  the  case  of  human  milk. 

Nervous  impressions. — These,  when  of  a  marked  character,  have  a  very 
decided  and  immediate  effect  upon  the  milk.  Fatigue,  exhaustion,  great 
excitement,  sudden  fright,  grief,  or  passion  are  likely  to  affect  the  secre- 
tion in  a  most  marked  manner.  An  infant  who  takes  the  breast  under 
such  circumstances  may  exhibit  only  the  ordinary  signs  of  acute  indiges- 
tion, such  as  vomiting  and  undigested  stools,  or  there  may  be  in  addition 
high  temperature,  great  prostration,  toxic  symptoms,  and  sometimes  even 
convulsions.  The  nature  of  the  changes  in  milk  from  such  causes  is  as 
yet  but  little  understood.  The  probability  is,  however,  that  it  is  the  pro- 
teids  which  are  at  fault,  as  these  are  very  unstable  and  easily  affected,  and 
that  instead  of  the  normal  proteids  others  are  produced  which  possess 
toxic  properties.  In  certain  cases  the  secretion  of  milk  may  be  almost 
entirely  arrested  by  nervous  influences. 

COWS  MILK. 

The  only  one  of  the  lower  animals  whose  milk  is  practically  available 
for  infant-feeding  is  the  cow.  Cow's  milk  being  our  main  reliance  in  the 
artificial  feeding  of  infants  and  the  staple  food  of  nearly  all  young  chil- 
dren, it  follows  that  everything  relating  to  its  production  and  handling  is 
of  great  importance  to  the  physician.  In  the  feeding  of  children  no  one 
thing  is  more  essential  than  a  supply  of  pure  cow's  milk.  Milk  undergoes 
changes  from  such  slight  causes,  that  the  physician  should  insist  upon  it 
that  those  who  furnish  milk  for  infant-feeding,  whether  in  city  or  country, 
should  be  fully  informed  regarding  this  subject.     In  towns  and  cities  phy- 

*  See  Fehling,  Arch,  fiir  Gvnak.,  Bd.  xxvii,  H.  3. 


138 


NUTRITION. 


sicians  should  co-operate  to  secure  it  for  their  patients  in  its  best  form.* 
The  conditions  to  be  fulfilled  in  good  cow's  milk  are : 

1.  It  must  be  fresh.  There  are  certain  changes  which  take  place  in 
cow's  milk,  even  when  handled  in  the  best  manner,  during  the  twenty- 
four  or  seventy-two  hours  which  often  elapse  between  the  time  it  is  drawn 
from  the  cows  and  its  consumption.  These  changes,  although  perhaps 
not  actually  causing  disease,  may  still  interfere  with  the  digestibility  of 
milk,  particularly  for  very  young  infants.  It  is  entirely  practicable  in 
every  city  and  town  for  milk  to  be  obtained  for  young  infants  before  it  is 
twelve  hours  old,  and  this  should  be  insisted  upon. 

2.  It  must  be  from  healthy  animals.  All  herds  furnishing  milk  for 
infant-feeding  should  receive  the  tuberculin  test ;  they  should  be  subjected 
to  careful  and  regular  medical  inspection. 

3.  Preferably  it  should  be  the  milk  from  a  mixed  herd  rather  than 
from  a  single  cow.  A  milk  is  thus  secured  which  is  practically  uniform 
in  its  composition,  while  that  from  a  single  cow  may  be  subject  to  a  con- 
siderable variation  from  day  to  day.  A  child  fed  upon  the  milk  of  a  sin- 
gle cow  is  not  infrequently  made  ill  from  changes  in  the  milk,  the  result 
of  food,  temporary  indisposition  or  other  disturbance  of  the  animal. f  If 
the  milk  is  the  mixed  product  of  several  cows  such  a  result  is  very  much 
less  likely  to  occur. 

4.  The  milk  must  be  clean.  This  is  only  to  be  accomplished  by  a 
dissemination  of  knowledge  among  dairymen  in  regard  to  the  common 
sources  of  milk  contamination.  It  is  to  be  secured  by  more  rigid  cleanli- 
ness in  the  stables,  in  the  animals  themselves,  in  the  hands  of  the  milker, 
in  pails,  cans,  bottles,  and  all  utensils  with  which  the  milk  comes  in  con- 
tact.    The  amount  of  filth— dirt,  hair,  etc. — which  is  removed  from  ordi- 


*  As  an  illustration  of  what  can  be  accomplished  in  the  way  of  securing  a  proper 
milk  supply  for  the  use  of  infants,  the  work  of  the  Medical  Commission  of  Newark, 
N.  J.,  may  be  cited.  This  commission,  organized  largely  through  the  efforts  of  Dr. 
H.  L.  Coit,  has  entered  into  an  agreement  with  a  dairyman,  the  terms  of  which  are 
that  the  selection  of  the  cows,  the  details  regarding  their  food  and  care,  and  the 
handling  of  the  milk  shall  be  under  the  supervision  of  the  Medical  Commission.  All 
these  matters  are  carried  out  according  to  the  most  improved  methods.  The  animals  are 
subjected  to  a  regular  inspection  by  a  competent  veterinary  surgeon ;  a  chemist  and 
bacteriologist  are  employed  to  see  that  the  milk  is  kept  up  to  the  standard  both  as  re- 
gards composition  and  purity.  In  return,  the  milk,  which  is  delivered  only  in  bottles, 
is  stamped  with  the  approval  of  the  commission  as  "  certified  milk,"  and  is  sold  at  a 
slightly  higher  price  than  ordinary  milk.  Although  in  operation  now  but  a  short  time, 
this  plan  has  proved  eminently  successful  both  from  a  medical  and  commercial  stand- 
point. If  in  every  city  and  large  town  physicians  would  co-operate  in  this  or  some 
similar  way,  great  good  would  be  accomplished. 

f  It  is  well  known  that  the  milk  of  a  cow  during  the  "  bulling  "  period  may  be  the 
cause  of  very  severe  attacks  of  indigestion  in  infants  who  get  such  milk  as  their  prin- 
cipal or  only  food.     Such  milk  apparently  contains  some  toxic  products. 


COW'S  MILK. 


139 


nary  milk  by  passing  it  through  a  separator  is  simply  appalling,  and 
shows  how  carelessly  most  of  our  milk  is  handled  at  the  present  time. 
Bacterial  contamination  will  be  considered  later. 

5.  The  animals  should  have  fresh  food,  and  not  brewer's  grains,  which 
they  are  so  likely  to  have  in  the  neighbourhood  of  large  cities. 

6.  Transportation  should  be  as  short  as  possible,  in  order  to  secure 
freshness  and  to  diminish  the  liability  to  the  other  changes  which  occur 
when  milk  is  carried  long  distances.*  The  milk  should  be  cooled,  then 
bottled  and  sealed  at  the  dairy,  and  kept  at  a  temperature  at  or  below 
45°  F.,  until  it  reaches  the  consumer.  In  this  way  all  chances  of  con- 
tamination by  handling  after  the  milk  leaves  the  dairy  are  avoided. 

Composition. — The  following  table  f  gives  the  composition  of  milk  from 
different  breeds  of  cows : 


Durham. 

Ayrshire. 

Holstein. 

Jersey. 

American 
grades. 

Common 
natives. 

Fat 

Per  cent. 
4-04 
4-34 
4-17 
0-73 

86-73 

Per  cent. 
3-89 
4-41 
4-01 
0-73 

86-96 

Per  cent. 
2-88 
4-33 
3-99 
0-74 

88-06 

Per  cent. 
5-21 
4-53 
3-99 
0-71 

85-57 

Per  cent. 
4-01 
4-36 
4-06 
0-74 

86-83 

Per  cent. 
3-69 

Sugar 

4-35 

Proteids 

Salts 

4-09 
0-73 

Water 

84-14 

It  will  be  seen  that  the  averages  are  remarkably  uniform  in  all  the  con- 
stituents except  the  fat,  the  variations  here  being  between  2-88  and  5-21 
per  cent.  Leaving  out  the  Jerseys,  the  following  represents  very  closely 
the  average  composition  of  cow's  milk,  as  the  pliysician  has  to  do  with  it 
in  infant-feeding : 

Average  Coiv''s  Milk.  Per  cent. 

Fat 3-50 

Sugar 4-30 

Proteids 4-00 

Salts 0-70 

Water 87-00 

100-00 

As  to  the  relative  advantages  of  the  different  breeds  for  infant-feeding, 
the  difference  has  not  seemed  to  me  to  be  very  great,  provided  all  are 
equally  healthy.  It  should  be  remembered  that  tuberculosis  is  rather 
more  common  in  Jerseys  than  in  other  breeds.  Practically  it  is  necessary 
that  the  physician  should  know  only  the  amount  of  fat  in  the  milk  he  is 
using,  as  this  is  the  variable  factor. 


*  Very  much  of  the  milk  consumed  in  New  York  has  been  transported  one  hundred 
miles,  and  some  is  even  brought  three  hundred  miles. 

f  These  figures  are  compiled  from  over  one  hundred  and  forty  thousand  analyses, 
and  have  been  collected  by  Mr.  Gordon,  of  the  Walker-Gordon  Milk  Laboratory;  sixty 
thousand  of  these  analyses  refer  to  the  American  grades  and  the  common  natives. 


14:0 


NUTRITION, 


Fat: 

7 


4  cc. 


The  Examination  of  Cow's  Milk. — For  clinical  purposes  the  reaction, 

specific  gravity,  and  percentage  of  fat  should  be  determined.    The  normal 

reaction  of  cow's  milk  is  neutral  or  slightly  acid ;  it  should  never  be 

strongly  acid.     If  it  is  strongly  alkaline  it  is  pretty  certain  that  something 

has  been  added  to  it.     The  sjDccific  gravity  is  from 

J] ^  1,028  to  1,033.     If  the  milk  has  been  falsified  by 

the  removal  of  cream,  the  specific  gravity  is  raised. 
The  best  of  all  ready  methods  of  determining  fat 
is  the  Babcock  centrifugal  machine.*  By  this  the 
fat  is  brought  to  the  surface  by  the  centrifugal 
process  after  destroying  the  nitrogenous  matter  by 
sulphuric  acid.  This  test  is  very  accurate  and  can 
be  made  in  five  minutes.  For  institutions  such  an 
apparatus  is  indispensable ;  several  sj^ecimens  can 
be  examined  at  the  same  time,  and  the  composition 
of  the  milk  and  cream  used  can  be  determined  each 
day.  The  optical  test  by  means  of  Feser's  lacto- 
scope  (Fig.  'is))  is  a  good  one,  and  with  a  little  ex- 
perience in  the  use  of  the  instrument  is  quite  ac- 
curate, f 

The  cream-gauge  (Fig.  24,  C)  may  be  used  as 
for  woman's  milk,  but  it  is  not  very  accurate.  The 
milk  while  warm  from  the  cow  should  be  put  into 
the  cylinder  and  cooled  rapidly  by  being  placed  in 
ice  water.  Under  these  conditions,  if  the  reading 
is  made  at  the  end  of  eight  or  ten  hours  the  per- 
centage of  cream  to  that  of  fat  is  about  four  to  one. 
If  the  milk  has  been  first  cooled  and  afterward 
handled  two  or  three  times  before  the  test  is  made, 
the  cream  rises  much  less  regularly  and  the  above 
ratio  is  not  maintained. 
The  Differences  between  Cow's  Milk  and  Woman's  Milk. — The  colour 
of  cow's  milk  is  more  opaque  than  woman's  milk,  although  the  latter  may 


/ 


Fig.  25. 


—Feser's  lacto- 
scope. 


*  This  can  be  obtained  of  any  dairy-supply  house  in  the  country. 

f  The  test  is  applied  as  follows :  Four  cubic  centimetres  of  milk  measured  in  a 
pipette  is  put  into  the  tube  and  water  slowly  added,  shaking  from  time  to  time 
until  the  black  lines  on  the  porcelain  stem  "A  "  are  faintly  visible  through  the  milky 
water.  The  percentage  of  fat  is  then  read  off  on  the  glass  cylinder  at  the  level  of 
the  water  added.  Thus,  water  up  to  the  mark  "  4  "  indicates  four  per  cent  fat,  etc. 
This  test  is  not  to  be  applied  to  human  milk.  For  cow's  milk  it  is  pretty  satisfac- 
tory if  the  instrument  is  carefully  made.  A  little  experience  is  necessary  in  order 
to  know  exactly  at  what  point  of  translucency  the  reading  is  to  be  taken.  The  lacto- 
scope  may  be  obtained  from  Eimer  &  Amend,  Eighteenth  Street  and  Third  Avenue, 
New  York. 


COW'S  MILK.  141 

contain  the  larger  proportion  of  fat.  This  is  clue  to  the  fact  that  the 
colour  of  the  milk  depends  not  only  upon  the  fat  but  also  upon  the  cal- 
cium phosphate  -with  which  the  casein  is  combined.  This  is  so  much 
more  abundant  in  cow's  milk  than  in  woman's  milk  that  even  after  the 
fat  has  been  removed  from  the  former,  it  is  still  of  a  deep  white  colour, 
while  woman's  milk  under  the  same  conditions  is  almost  transparent. 
The  total  solids  are  usually  greater  in  cow's  milk,  but  the  difference  is 
slight.  The  sugar,  as  in  woman's  milk,  is  lactose  in  complete  solution. 
At  the  present  time  there  are  not  known  to  be  any  important  differences 
in  the  fat. 

The  most  striking  variation  is  seen  in  the  proteids.  Not  only  are  the 
proteid  substances  in  cow's  milk  from  two  to  three  times  as  great  in 
amount,  but  they  differ  also  in  their  character.  The  amount  of  proteid 
substances  in  cow's  milk  coagulable  by  acid  is  about  four  times  as  great  as 
the  non-coagulable  portion ;  while  in  woman's  milk  the  non-coagulable 
portion  is  twice  as  great  as  the  coagulable  portion  (Leeds).  This  is  due 
to  the  fact  that  in  cow's  milk  there  is  much  more  casein  than  lactalbumin, 
while  in  woman's  milk  there  is  less.  This  variation  is  shown  most  strik- 
ingly by  the  physiological  test — its  digestibility  by  the  infant's  stomach. 
Cow's  milk  in  the  stomach  is  coagulated  into  larger,  firm>er  clots  which 
dissolve  slowly;  woman's  milk  into  loose,  flocculent  curds,  which  dissolve 
readily. 

The  inorganic  salts  of  cow's  milk  are  more  than  three  times  as  abun- 
dant as  those  of  woman's  milk.  In  the  composition  of  these  salts  the  most 
important  difference  is  that  there  is  present  in  cow's  milk  a  relatively 
larger  proportion  of  calcium  phosphate  and  sodium  chloride  with  a 
smaller  proportion  of  potassium  chloride. 

The  Salts  of  Coic's  Milk  (Weber  and  Fleischmann). 

Potassium 17-34  to  24-50 

Sodium 7-00  to  11-00 

Calcium 17-30  to  27-00 

Magnesia 1-90  to    4-07 

Iron  oxide 0-33  to    0-G3 

Phosphoric  acid 26-00  to  29-13 

Sulphuric  acid 0  •  05  to    1-00 

Chlorine 15-6    to  1034 

The  reaction  of  cow's  milk  is  neutral  or  slightly  acid,  practically  never 
alkaline  ;  woman's  milk  is  neutral  or  alkaline. 

Cow's  milk  as  used  always  contains  a  large  number  of  bacteria,  which 
increase  directly  in  proportion  to  the  age  of  the  milk  ;  the  milk  of  healthy 
women  is  practically  sterile. 

Cream. — A  great  misapprehension  exists  as  to  its  composition.  It  is 
often  spoken  of  as  if  it  were  entirely  different  from  milk.  It  should 
rather  be  regarded  as  a  milk  which  contains  an  excess  of  fat. 


142 


NUTRITION. 


Cream  is  obtained  either  by  skimming — the  gravity  process — or  by  the 
use  of  a  centrifugal  machine  known  as  a  separator.  The  latter  pro- 
cess has  the  advantage  in  point  of  time,  as  centrifugal  cream  can  be 
put  upon  the  market  from  twenty-four  to  thirty-six  hours  earlier  than 
gravity  cream.  It  is,  however,  attended  by  a  slight  disadvantage,  as  it 
may  break  up  mechanically  some  of  the  fat-globules,  so  that  after  heating 
they  may  form  a  thin  oily  layer  at  the  top  of  the  bottle.  This  is  more 
likely  to  occur  where  centrifugal  cream  has  been  transported  a  long  dis- 
tance. 

The  following  table  gives  the  composition  of  an  average  milk  and  of 
centrifugal  cream  of  different  densities  removed  from  the  same  milk  : 


Whole  milk. 

Cream. 

I. 

II. 

III. 

IV. 

Fat  

4-00 
4-30 
4-00 
0-70 

8-00 
4-30 
3-90 
0-70 

12-00 
4-20 
3-80 
0-64 

16-00 
4-00 
3-60 
0-60 

20-00 

Sugar 

3-80 

Proteids 

3-20 

Salts 

0-55 

These  will  be  spoken  of  hereafter  as  8-per-cent  cream,  12-per-cent  cream, 
16-per-cent  cream,  etc.,  as  indicating  the  amount  of  fat  which  they 
contain.  The  richest  centrifugal  cream  contains  from  35  to  40  per 
cent  fat. 

From  the  table  it  will  be  seen  that  cream  differs  from  the  milk  from 
which  it  is  taken  mainly  in  containing  more  fat.  The  reduction  in  the 
proteids,  even  in  the  20-per-cent  cream,  is  less  than  1 
per  cent.  The  changes  in  the  other  constituents  are  so 
slight  that  they  may  be  ignored.  In  common  speech  the 
term  cream  is  applied  to  any  of  these.  The  physician 
should  know,  if  he  is  using  cream  for  infant-feeding,  the 
approximate  amount  of  fat  it  contains.  The  40-per-cent 
cream  is  the  very  thick,  centrifugal  cream  sold  in  cities ; 
20-per-cent  cream  is  the  ordinary  centrifugal  cream ;  16- 
per-cent  cream  is  the  common  skimmed  or  gravity  cream. 
In  infant-feeding  it  is  convenient  to  make  use  of  a  cream 
containing  12  per  cent  fat,  and  one  containing  8  per  cent 
fat.  They  may  be  obtained  directly  from  fresh  milk  by 
the  gravity  process.  If  one  quart  of  average  milk  is  put  into  a  glass 
jar  and  this  into  ice  water  or  upon  ice,  after  four  or  five  hours  there 
may  be  taken  from  the  top  about  ten  ounces  of  8-per-cent  cream ; 
after  six  hours,  about  six  ounces  of  12-per-cent  cream  (Fig.  26).  Both 
of  these  may  be  removed  by  skimming,  or,  better  still,  the  milk  from 
the  bottom  of  the  jar  may  be  siphoned  off,  leaving  the  amount  men- 


FiG.  26.— Twelve- 
per-ceut  cream. 


COW'S  MILK. 


143 


tioned.*  If  the  milk  is  richer  than  the  average  the  time  may  be  short- 
ened to  three  and  five  hours  respectively.  If  it  is  poorer  than  the  average 
the  time  must  be  lengthened. 

None  of  the  methods  described  for  determining  the  quantity  of  fat  in 
milk  are  applicable  to  cream,  except  the  Babcock  centrifugal  machine. 

Milk  Sterilization. — The  term  sterilization  is  widely  and  rather 
loosely  used  to  signify  the  heating  of  milk  for  the  destruction  of  germs. 
It  should,  however,  be  borne  in  mind  that  none  of  the  methods  commonly 
employed  render  milk  sterile  in  the  bacteriological  sense  of  the  word, 
although  this  can  be  done  by  heating  milk  on  two  or  three  successive  days 
as  in  preparing  culture  media.  What  is  accomplished  by  the  means  com- 
monly employed,  is  the  destruction  of  such  pathogenic  germs  as  may  be 
present,  and  a  large  number  of  the  other  bacteria,  so  as  to  retard  for 
several  days  the  ordinary  fermentative  changes.  The  preservation  of  milk 
for  infant-feeding,  by  boiling  it  in  small  bottles,  was  advocated  by  Jacobi 


*  A  similar  plan  on  a  large  scale  may  be  followed  in  institutions  by  using  an  appa- 
ratus known  as  the  "  Cooley  creamer."  This  consists  of  a  wooden  tank  lined  with 
metal,  made  of  different  sizes,  holding  two,  four,  or  more  cans  of  milk.  The  cans  (Fig. 
27)  hold  eighteen  quarts,  and  are 
so  covered  that  they  can  be  sub- 
merged. The  bottom  of  the  can 
is  inclined,  and  at  the  lowest 
point  is  placed  a  faucet.  In  the 
side  is  a  glass  window,  so  that 
the  cream  level  can  be  distinctly 
seen.  The  cans  are  filled  and 
placed  in  the  tank  of  ice  water ; 
after  six  or  twelve  hours  the 
lower  portion  is  drawn  off  and 
the  upper  creamy  layer  left  be- 
hind. In  this  way  a  cream  of  8, 
13,  or  16  per  cent  may  be  ob- 
tained. The  8  and  12  per  cent 
are  those  most  convenient  to 
use.  If  the  milk  is  put  in  before 
the  cream  has  risen  once,  after 
twelve  hours  from  six  to  nine 
quarts  of  8-per-cent  cream  may  be  obtained,  and  from  four  to  six  quarts  of  12-per-cent 
cream ;  the  variation  being  due  to  the  difference  in  the  milk  employed.  After  six 
hours  about  two-thirds  of  the  quantities  mentioned  can  be  obtained.  The  exact  amount 
can  be  determined  after  a  few  experiments  with  any  given  milk  by  testing  the  strength 
of  the  cream  each  day  with  the  Babcock  machine.  Then,  with  the  same  conditions  of 
time,  temperature,  etc.,  the  results  will  be  quite  uniform.  If  the  milk  is  so  old  that 
the  cream  has  already  risen  once,  different  results  from  those  mentioned  will  be  ob- 
tained. The  plan  is  a  simple  one,  involves  very  little  trouble,  and  the  milk  during  the 
time  the  cream  is  rising  is  kept  at  a  low  temperature. 

The  Cooley  creamer  may  be  obtained  at  Bellows  Falls,  Vt. 
11 


Fig.  27. — Cans  of  the  Cooley  creamer.    A,  external  view ; 
B,  section  view. 


144 


NUTRITION. 


many  years  ago.  The  adoption  of  systematic  means  for  the  destruction 
of  germs  in  milk  for  infant-feeding  has  been  largely  due  to  the  work  of 
Soxhlet. 

The  most  important  of  the  germs  in  milk  are  the  various  saprophytic 
bacteria  upon  which  are  believed  to  depend  a  very  large  proportion  of 

our  diarrhoeal  diseases,  the  bacillus  tuber- 
culosis, which  may  be  derived  from  the 
cow  or  may  be  an  accidental  contamina- 
tion, and  the  germs  of  cholera,  diphtheria, 
typhoid,  and  scarlet  fever.  All  these 
flourish  in  milk  at  its  ordinary  tempera- 
ture. There  is  pretty  conclusive  evidence 
that  outbreaks  of  all  ,  the  diseases  men- 
tioned have  in  certain  cases  been  due  to 
contaminated  milk.* 

Following  Soxhlet,  all  the  earlier  ex- 
periments in  sterilization  were  made  at  a 
temperature  of  212°  F.,  continued  for  an 
hour  and  a  half.  So  far  as  destroying 
germs  was  concerned  this  was  quite  enough. 
Such  milk  will  keep  for  more  than  a  week 
at  ordinary  room-temperatures.  But  it 
was  soon  found  that  some  objectionable 
changes  take  place.  The  taste  is  that 
of  boiled  milk,  to  which  many  children 
strongly  object ;  a  certain  proportion  of 
the  sugar  is  converted  into  caramel,  causing  a  change  in  colour  to  a 
light  brown ;  the  casein  is  rendered  less  coagulable  by  rennet,  and  is 
acted  upon  more  slowly  and  imperfectly  both  by  pepsin  and  pancrea- 
tin.     Certain  changes  probably  take  place  in  the  fat  also.     Children  fed 


Fig.  28  — The  Arnold  sterilizer. 


*  The  degree  to  which  contamination  takes  place  under  ordinary  circumstances 
may  be  judged  from  the  investigations  of  Sedgewiek  and  Batchelder  in  Boston  in  1893. 
In  fifteen  specimens  of  ordinary  country  milk  which  were  handled  in  the  usual  way 
and  examined  a  few  hours  after  it  was  drawn  from  the  cow,  the  average  number  of 
bacteria  to  each  cubic  centimetre  (about  fifteen  minims)  was  69,143.  The  average 
number  in  fifty-seven  samples  of  market  milk  as  delivered  from  wagons  in  the  spring 
of  the  year  was  2,355,500.  In  sixteen  samples  of  milk  as  sold  by  grocers — this  being 
several  hours  older  than  the  milk  delivered  from  wagons — the  average  number  of 
bacteria  to  each  cubic  centimetre  was  4,577,000. 

The  principal  source  of  contamination  is  undoubtedly  from  the  cow  and  the  stable 
during  the  process  of  milking.  Dr.  R.  G.  Freeman  exposed  for  two  minutes  a  Petri 
gelatin  plate  under  a  cow  during  milking  and  obtained  1,800  colonies.  No  doubt  a 
great  proportion  of  these  germs  are  harmless,  but  with  them  others  are  often  found 
which,  if  not  strictly  pathogenic,  hasten  fermentative  changes  in  milk  and  greatly 
interfere  with  its  digestibility. 


cows  MILK.  145 

upon  ."  sterilized "  milk  are  certainly  more  prone  to  constipation  than 
others,  this  probably  depending  upon  the  difficulty  in  digesting  the 
casein.  There  seems  now  to  be  little  doubt  that  the  nutritive  properties 
of  the  milk  are,  to  a  certain  degree  at  least,  impaired  by  heating  to  212° 
F.  for  an  hour  and  a  half.  In  a  large  city,  with  the  milk  supply  which  is 
available,  it  may  be  in  summer  a  choice  of  evils  whether  infants  shall  be 
fed  upon  "  sterilized  "  milk,  with  the  disadvantages  mentioned,  or  whether 
Dy  giving  contaminated  raw  milk  we  shall  run  the  risk  of  introducing 
germs  which  produce  diarrhoeal  diseases.  The  latter  is  certainly  by  far 
the  greater  danger. 

The  changes  mentioned  as  occurring  in  milk  are  believed  to  begin  at 
or  about  180°  F.,  and  to  be  more  marked  the  higher  the  temperature  is 
carried  and  the  longer  it  is  maintained.  Heating  milk  to  212°  F.  for  an 
hour  or  an  hour  and  a  half,  should  be  employed  only  in  the  hot  weather 
and  when  it  is  necessary  to  keep  the  milk  for  a  considerable  time  as  in 
travelling,  or  when  ice  is  out  of  the  question,  as  among  the  very  poor. 

This  method  of  heating  milk  is  accomplished  by  the  use  of  some  ap- 
paratus by  which  steam  is  produced,  the  bottles  being  exposed  on  all 
sides  in  a  close  vessel.  Probably  the  simplest  and  most  satisfactory  ster- 
ilizer is  the  "  Arnold  "  (Fig.  28). 

"  Sterilizing  "  at  a  Low  Temperature — Pasteurizing  Milk. — To  obviate 
the  objections  above  referred  to,  the  practice  has  come  largely  into  use  of 
raising  the  temperature  only  to  167°  F.  This  is  known  as  "  Pasteurizing," 
and  has  been  extensively  used  in  and  about  New  York  and  in  Boston. 
The  temperature  of  167"  F.,  maintained  for  twenty  minutes,  has  been 
shown  to  be  sufficient  to  destroy  the  bacilli  of  cholera,  typhoid  fever, 
diphtheria,  tuberculosis,  bacterium  coli  commune,  and  the  ordinary  pyo- 
genic germs.  It  does  not,  however,  destroy  spores,  and  milk  thus  treated 
will  keep  at  ordinary  room-temperatures  for  two  or  three  days  only,  but 
on  ice  for  several  days.  A  simple  apparatus  for  this  purpose  (Fig.  29)  * 
has  been  devised  by  Freeman,  of  New  York.     In  this  the  temperature  is 

♦Freeman's  apparatus  is  used  as  follows:  The  pail  is  filled  to  the  groove  with 
water,  which  is  then  raised  to  the  boiling  point.  The  bottles  of  milk  are  dropped  into 
their  places  in  the  cylindrical  cups,  suflicient  water  being  poured  into  each  cup  to  sur- 
round the  bottle,  this  water  acting  as  the  conductor  of  heat.  The  pail  is  now  removed 
from  the  stove  and  placed  upon  a  board  or  other  non-conductor,  and  the  receptacle  con- 
taining the  bottles  of  milk  is  set  inside  and  the  cover  replaced.  The  volumes  of  milk 
and  water  have  been  so  calculated  that  in  ten  minutes  they  are  both  at  a  temperature 
of  about  167°  F.  The  water  contains  heat  enough  to  maintain  this,  with  very  slight 
variations,  for  twenty  minutes.  In  half  an  hour  the  bottles  of  milk  are  removed  and 
cooled  rapidly  by  being  placed  in  a  water-bath,  the  water  being  changed  once  or  twice; 
or,  better,  by  setting  the  pail  in  a  sink  and  allowing  the  cold  water  to  run  from  a  faucet 
through  a  piece  of  rubber  pipe  into  the  pail,  overflowing  into  the  sink.  This  rapid 
cooling  is  very  important.  They  are  then  put  in  the  refrigerator.  This  apparatus  may 
be  obtained  from  James  Dougherty,  411  West  Fifty-ninth  Street,  New  York. 


146 


NUTRITION. 


raised  by  hot  water,  while  cold  water  is  used  as  the  conducting  medium. 
Milk  heated  to  167°  F.  has  no  objectionable  taste,  and  according  to  Free- 
man's experiments  with  artificial  digestion,  the  character  of  the  curd  and 
its  digestibility  do  not  differ  from  that  of  ordinary  milk.  This  seems  to 
be  borne  oat  by  clinical  observation. 

The  objections  urged  against  heating  to  212°  F.  do  not  hold  against 
heating  to  167°  F.,  as  most  of  the  changes  are  thus  avoided.  However, 
the  real  question  is  whether  there  are  any  changes  produced  in  milk  so 
treated  which  detract  from  its  value  as  an  infant-food.  Upon  this  point 
we  must  as  yet  speak  somewhat  guardedly,  for  experience  with  it  is  limited 


Fig.  29. — Freeinaii's  l^tsteurizcr.     A,  bottles  in  position  for  Iieatinic;   B,  method  of  cooling. 

to  a  few  years.  To  my  knowledge,  no  sufficient  evidence  has  yet  been 
adduced  to  establish  the  fact  that  milk  so  heated  has  lost  any  of  its  essen- 
tial nutritive  properties,  or  that  children  fed  exclusively  upon  it  exhibit 
siffns  of  either  of  the  two  most  marked  disorders  of  nutrition — rickets  or 

o 

scurvy;  although  I  have  seen  two  cases  in  which  scurvy  seemed  to  be 
clearly  due  to  the  use  of  milk  heated  to  212°  F.  for  over  an  hour. 

It  should  be  distinctly  understood  that  sterilized  milk  requires  the 
same  modifications  for  infant-feeding  as  plain  milk.  There  is  no  evidence 
to  show  that  its  nutritive  properties  or  its  digestibility  are  in  any  way 
enhanced  by  the  process  of  heating.  A  great  misapprehension  seems  to 
exist  in  the  minds  of  many  physicians  with  reference  to  this  point.  The 
opinion  has  gained  a  certain  amount  of  currency  that,  if  milk  has  only 
been  "sterilized,"  it  may  be  fed  to  a  young  infant  without  any  further 
modification. 

Sterilized  milk  can  not  be  said  to  have  any  special  therapeutic  value 
in  the  gastro-enteric  diseases  of  infancy.  It  is  capable  of  causing  just 
about  as  much  disturbance  as  plain  milk  given  in  the  same  circumstances. 
Its  chief  value — and  I  think  I  may  say  almost  its  only  value — is  in  pre- 
venting disease,  first,  by  enabling  us  to  feed  infants  upon  milk  in  which, 
although  it  may  be  forty-eight  hours  old,  no  considerable  fermentative 


COW'S  MILK.  147 

changes  have  taken  place,  and,  secondly,  by  destroying  pathogenic  germs 
with  which  the  milk  may  have  become  accidentally  contaminated. 

The  danger  of  transmitting  tuberculosis  to  the  infant  by  means  of 
cow's  milk  is  one  that  has,  I  think,  been  very  greatly  exaggerated.  Ani- 
mal experiments  show  that  this  is  certainly  possible,  and  there  are  a  few 
isolated  instances  on  record  in  which  this  seems  to  have  been  the  mode 
of  infection  in  children,  but  these  cases  are  extremely  rare.  In  one  hun- 
dred and  nineteen  autopsies  of  my  own  upon  tuberculous  patients,  nearly 
all  of  them  infants,  there  was  not  found  one  with  the  primary  lesion  in 
the  gastro-enteric  tract.  Northrup,  in  his  large  post-mortem  experience, 
has  seen  but  a  single  case.  The  danger  of  transmitting  diphtheria,  scarlet 
fever,  and  especially  typhoid  fever,  by  means  of  milk,  is  very  much  greater. 

Summary. — Prolonged  heating  to  212°  F.  is  objectionable  and  is  not 
to  be  recommended  for  general  use.  It  may  be  necessary  especially  in 
cities  and  in  very  hot  weather,  where  ice  is  scarce  and  the  milk  very 
highly  contaminated,  also  when  the  milk  is  to  be  kept  for  several  days,  as 
while  travelling ;  for  prolonged  journeys,  however,  such  as  crossing  the 
ocean,  the  milk  should  be  heated  to  212°  F.  for  one  hour  on  three  suc- 
cessive days.  Heating  to  167°  F.  is  quite  sufficient  for  ordinary  purposes. 
It  is  desirable  that  milk  thus  treated  should  be  prepared  daily,  although 
it  will  keep  on  ice  for  four  or  five  days.  The  fewer  the  germs  in  the 
milk  at  the  time  of  heating,  the  shorter  the  time  and  the  lower  the  tem- 
perature which  will  be  necessary,  hence  the  desirability  of  having  the 
milk  as  clean  and  as  fresh  as  possible.  For  the  best  results,  the  heating 
should  be  done  at  the  dairy,  so  that  the  antecedent  changes  shall  be  reduced 
to  the  minimum.  Without  this  precaution  these  changes  are  sometimes 
so  great  as  to  render  the  milk  unfit  for  use.  Heating  milk  for  purposes 
of  sterilization  is  at  present  imperative  in  cities  during  the  warm  months, 
as  ordinary  milk  is  from  twelve  to  thirty-six  hours  old  when  received, 
and  from  twenty-four  to  seventy-two  hours  old  before  it  is  consumed. 
In  the  country  it  is  a  safeguard  to  be  used  w^hen  doubt  exists  in  regard  to 
the  health  of  the  cows  or  the  handling  of  the  milk ;  but  where  clean  milk 
can  be  obtained  fresh  every  morning  from  healthy  cows,  it  is  unnecessary. 
"Sterilized"  milk  requires  the  same  modification  -for  infant-feeding  as 
plain  milk.  "  Sterilization  "  is  not  to  be  regarded  as  a  therapeutic  meas- 
ure ;  its  value  consisting  in  the  prevention  of  disease.  While  I  advise  and 
constantly  use  milk  which  has  been  heated,  my  preference  is  strongly  for 
that  which  is  sufficiently  pure,  clean,  and  fresh  to  render  this  unnecessary. 
I  believe  that  the  direction  in  which  we  are  to  work  is  toward  securing 
the  greatest  attention  to  the  care  and  feeding  of  cows  and  to  the  handling 
of  milk  in  order  to  prevent  every  possible  contamination  ;  and  at  the  same 
time  to  have  all  cows  whose  milk  is  to  be  used  for  infant-feeding  under 
close  medical  supervision.  Until  such  a  condition  of  things  is  realized, 
the  heating  of  milk  used  for  infant-feeding  will  be  necessary. 


148 


NUTRITION. 


Peptonized  Milk. — Milk  is  peptonized  through  the  agency  of  a  sub- 
stance derived  from  the  pancreas,  usually  of  the  pig.  This  is  known  in 
the  market  as  "extractum  pancreatis,"  the  active  ferment  being  the  tryp-" 
sine.  As  this  acts  only  in  an  alkaline  medium,  bicarbonate  of  soda  should 
first  be  added  to  the  milk.  The  purpose  of  peptonizing  is  a  partial  or 
complete  digestion  of  the  casein  of  milk  before  feeding. 

Partially  Peptonized  Milk. — This  is  done  as  follows :  *  One  pint  of 
fresh  cow's  m.ilk  and  four  ounces  of  water  are  put  into  a  bottle,  and  a 
powder  added  containing  five  grains  of  extractum  pancreatis  and  fifteen 
grains  of  bicarbonate  of  soda.  This  is  kept  at  a  temperature  of  105°  to 
115°  F.  best  by  placing  the  bottle  in  water  about  as  warm  as  the  hand 
can  bear  comfortably.  It  should  be  shaken  from  time  to  time.  For 
partial  peptonization,  the  process  is  continued  for  from  six  to  twenty 
minutes.  The  peptonizing  powder  is  sold  in  glass  tubes  and  in  tab- 
lets. The  tubes  are  to  be  preferred,  as  being  less  liable  to  deteriorate 
with  age.  Milk  which  has  been  peptonized  ten  minutes  is  not  altered 
in  taste;  if,  however,  the  process  is  continued  for  twenty  minutes,  a 
slightly  bitter  taste  is  noticed  from  the  formation  of  peptone.  This  in- 
creases with  the  duration  of  the  process  of  artificial  digestion.  If  it  is 
desired  to  arrest  this  after  ten  minutes,  the  milk  may  be  raised  to  the 
boiling  point,  which  destroys  the  ferment,  or  its  activity  may  be  stopped 
by  placing  the  milk  upon  ice.  If  the  milk  is  to  be  fed  at  once,  neither 
of  these  procedures  is  necessary.  If  it  is  to  be  kept  for  several  hours, 
scalding  is  more  certain  to  arrest  the  change  than  lowering  the  tempera- 
ture. 

Completely  Peptonized  Milk. — The  process  is  exactly  the  same  as  the 
above,  except  that  it  is  continued  for  two  hours,  which  is  generally  re- 
quired for  the  conversion  of  all  the  proteids  into  peptones.  The  addi- 
tion of  acetic  acid  to  such  milk  produces  no  coagulation.  Although  com- 
pletely peptonized  milk  is  quite  bitter,  this  is  not  an  obstacle  to  its  use 
for  young  infants,  who  after  the  first  or  second  bottle  do  not  usually 
object  to  its  taste.  For  those  who  are  a  little  older,  the  bitter  taste  may 
be  covered  by  lemon-juice  and  sugar — one  even  teaspoonful  of  cane  sugar 
and  two  teaspoonfuls  of  lemon-juice  being  added  to  each  four  ounces  of 
the  milk. 

Peptonized  milk  is  to  be  diluted  according  to  the  age  of  the  child. 
It  is  usually  better  to  peptonize  a  milk-and-cream  mixture  which  has 
previously  been  diluted  with  the  proper  amount  of  water.  Peptonized 
milk  is  a  valuable  resource  in  chronic  cases  where  there  is  feeble  casein- 
digestion,  and  during  attacks  of  acute  indigestion  in  infancy.  In  acute 
attacks,  completely  peptonized  milk  is  usually  preferable  to  that  which 
has  been  partially  peptonized.     It  is  not  advisable  to  continue  its  use  in- 

*  Fairchild's  process. 


CONDENSED   MILK. 


149 


definitely;  if  this  is  done  the  stomach  gradually  becomes  less  and  less  able 
to  do  this  work.  At  most,  peptonization  should  be  used  only  for  a  month 
or  two  at  a  time,  as  the  case  improves  being  gradually  diminished  by 
lessening  the  amount  of  the  powder  used  and  the  time  of  peptonizing. 

CoxDEXSED  Milk. — This  is  prepared  by  heating  fresh  cow's  milk  to 
212°  F.  to  destroy  the  bacteria  and  then  evaporating  in  vacuo  at  a  low 
temperature  to  a  little  less  than  one  fourth  its  volume.*  It  is  preserved 
in  tin  cans,  usually  with  the  addition  of  cane  sugar  in  the  proportion  of 
about  six  ounces  to  a  pint.  The  changes,  therefore,  to  which  the  milk 
has  been  subjected  are  evaporation  of  a  part  of  the  water,  partial  or  com- 
plete sterilization,  and  the  addition  of  cane  sugar.  Fresh  condensed  milk 
to  which  no  sugar  had  been  added  is  delivered  daily  in  New  York  and 
in  other  large  cities. 

The  composition  of  condensed  milk  is  shown  in  the  following  table; 
also  the  results  obtained  when  it  is  diluted  with  six,  twelve,  and  eighteen 
parts  of  water,  as  usually  fed  : 


Fat 

Proteids 

o  \  Cane,  40-44  > 

S^^'^nMilk,  10-25  S 

Salts 

Water 


Condensed 
milk.t 


6-94 
8-43 

50-69 

1-39 
31-30 


With  6  parts 
of  water 
added. 


Per  cent. 

0-99 
1-20 

7-23 

0-17 
90-49 


With  12 
parts  of 
water. 


Per  cent. 

0-53 
0-G5 

3-90 

0-10 
94-82 


With  18 
parts  of 
water. 


The  dilution  with  twelve  parts  of  water  is  that  most  frequently  em- 
ployed, although  eighteen  is  often  used  for  very  young  infants. 

The  reasons  both  for  the  success  and  for  the  failure  of  condensed  milk 
as  an  infant-food,  are  apparent  from  a  study  of  its  composition  as  it  is 
ordinarily  used.  As  a  temporary  food  it  is  often  useful,  first  because 
it  has  been  sterilized,  but  chiefly  because  the  casein  of  the  cow's  milk 
has  been  reduced  by  the  usual  dilution  to  such  a  point  (about  0-6  per 
cent)  that  an  infant  with  a  very  weak  digestion  can  manage  it,  while  it 
furnishes  an  abundance  of  sugar,  the  easiest  thing  for  an  infant  to  digest. 
During  the  first  few  months  of  life  it  is  often  apparently  very  successful 
for  these  reasons,  but  it  can  not  be  continued  indefinitely  without  hazard. 
I  have  seen  many  infants  reared  exclusively  upon  it,  but  as  yet  not  one 
who  did  not  show,  on  careful  examination,  more  or  less  evidence  of  rickets. 
Condensed  milk  fails  as  a  permanent  food,  partly  because  it  consists  too 
largely  of  carbohydrates,  but  chiefly  because  it  is  lacking  in  fat.     It  is 


*  Process  followed  by  the  Borden  Condensed  Milk  Company. 

t  Analysis  made  for  the  author  by  E.  E.  Smith,  Ph.  D.,  of  Borden's  Eagle-brand 
condensed  milk. 


150  NUTRITION. 

admissible  only  for  temporary  use  during  attacks  of  indigestion,  for  very 
young  infants  during  the  first  two  or  three  months,  or  among  the  very 
poor,  Avhere  the  cow's  milk  which  is  available  is  still  more  objectionable. 
It  should  never  be  continued  as  a  permanent  food  where  good,  fresh  cow's 
milk  can  be  obtained,  nor  should  it  be  used  as  a  permanent  food  without 
the  addition  of  fat  (cream).  In  travelling  it  is  often  the  most  convenient 
as  well  as  the  safest  food  to  use.  It  should  then  be  diluted  twelve  times 
for  an  infant  under  one  month,  and  from  six  to  ten  times  for  those  who 
are  older. 

The  fresh  condensed  milk  has  not  the  disadvantage  of  the  addition  of 
a  large  amount  of  cane  sugar,  and  requires  essentially  the  same  modifi- 
cation as  ordinary  cow's  milk.  For  the  poor  in  cities  it  is  often  the  best 
infant-food  available.  For  routine  use  it  should  be  diluted  with  from 
eight  to  twelve  parts  of  water,  with  the  addition  of  sugar — jireferably 
milk  sugar — and  if  possible  fresh  cream. 

KuMYSS. — The  original  kumyss  was  fermented  mare's  milk,  and  has 
been  extensively  used  by  the  Tartars  for  centuries  both  as  a  food  and  a 
beverage.  In  this  country  kumyss  is  made  from  cow's  milk.  The  fer- 
ment used  by  the  Tartars  was  kefir  grains,  consisting  of  two  forms  of  the 
ordinary  yeast  plant  and  great  numbers  of  lactic-acid  bacilli.  The  first 
kumyss  made  in  the  country  was  fermented  by  these  grains,  but  they 
have  now  been  discarded  by  most  manufacturers  of  kumyss,  as  it  is  true 
that  the  bacteria  which  they  contain  are  of  no  advantage  and  their  eifect 
may  possibly  be  deleterioixs.  Kumyss  was  formerly  made  chiefly  from 
skimmed  milk,  but  at  present  many  manufacturers  use  the  whole  milk, 
with  the  addition  of  cane-sugar  and  a  small  proportion  (about  one  six- 
teenth) of  water.  The  process  now  most  commonly  employed  is  started 
with  ordinary  yeast,  causing  a  vinous  fermentation.  This  is  carried  on 
at  a  temperature  of  from  60°  to  70°  F.  in  corked  bottles.  At  a  little 
higher  temperature  the  fermentation  proceeds  more  rapidly,  and  may  be 
completed  in  two  or  three  days ;  but  better  results  are  obtained  with  the 
slower  process,  which  requires  a  week  or  ten  days.* 

As  thus  manufactured,  kumyss  contains  alcohol,  carbon  dioxide,  lactic 
acid,  and  traces  of  butyric  and  acetic  acids.  The  casein  is  first  coagu- 
lated, and  then  broken  up  into  minute  particles  by  the  agitation  to  which 
the  kumyss  is  subjected  during  manufacture.  Some  of  the  casein  is 
probably  converted  into  albumoses  or  similar  compounds. 

Kumyss  has  an  acid  reaction  and  a  peculiar  taste  somewhat  resembling 


*  The  following  is  perhaps  the  best  formula  for  the  domestic  manufacture  of 
kumyss :  One  quart  of  fresh  milk,  half  an  ounce  of  sugar,  two  ounces  of  water,  a  piece 
of  fresh  yeast  cake  half  an  inch  square ;  put  into  wired  bottles,  keep  at  a  temperature 
between  60°  and  70°  F.  for  one  week,  shaking  five  or  six  times  a  day,  and  then  put 
upon  ice. 


KUMYSS— MATZOOX. 


151 


buttermilk ;  at  first  often  disagreeable,  but  a  fondness  for  it  is  soon  ac- 
quired by  the  majority  of  those  who  take  it.  Its  composition  is  as 
follows  : 

Kumyss. 


Made  from 

mare's  milk 

(Koenig). 

Made  from 
cow's  milk 
(Koenig). 

Made  from 

skimmed  milk 

(Koenig). 

Brush's  kumyss 
(Doremus). 

Fat 

Proteids 

Sugar 

Alcohol 

Lactic  acid 

Acid 

Carbon  dioxide 

Salts 

1-46 
2-24 
1-47 
1-91 
0-91 

6 -'42 

1-83 
2-66 
4-09 
1-14 
0-55 

6-43 
89-30 

0-88 
2-89 
3-95     . 
1-38 

0-82 

6-53 
89-55 

1-91 
2-04 
3-26 
0-62 

6-36 

0-44 

0-44 

90-99 

Water 

91-29 

The  advantages  of  kumyss  are  due  to  the  alcohol,  carbon  dioxide,  and 
lactic  acid  which  it  contains,  and  to  the  changes  which  have  taken  place 
in  the  casein  of  the  milk  by  which  its  digestibility  is  very  much  facili- 
tated. It  is  more  useful  for  older  children  than  for  young  infants.  It  is 
a  very  valuable  resource  in  many  forms  of  acute  and  chronic  indigestion. 
Kumyss  is  often  retained  when  milk  in  any  other  form  is  vomited.  In 
chronic  cases  it  frequently  stimulates  the  appetite  and  improves  diges- 
tion. 

For  infants,  kumyss  should  be  diluted,  generally  with  an  equal  quantity 
of  water.  Many  take  it  better  if  the  gas  has  been  allowed  to  escape  by 
standing  a  few  minutes.  "When  the  stomach  is  very  irritable  it  should  be 
given,  preferably  cold,  in  small  quantities  and  frequently — e.  g.,  a  table- 
spoonful  every  twenty  or  thirty  minutes.  It  is  important  to  secure  a  reli- 
able article  and  one  that  is  reasonably  fresh. 

Matzoox. — Matzoon  is  a  form  of  fermented  milk  first  used  in  Asia 
Minor.  The  process  of  the  manufacture  of  matzoon  is  given  by  Dadirrian 
as  follows  :  Cow's  milk  is  employed,  with  the  addition  only  of  an  imported 
ferment  which  consists  probably  of  a  form  of  yeast.  The  milk  is  first 
boiled  half  an  hour  for  sterilization.  The  fermentation  is  begun  at  a 
temperature  of  about  105°  F.  and  continued  in  an  open  vessel  for  twelve 
hours,  the  temperature  being  gradually  reduced  to  about  70®  F.,  after 
which  it  is  cooled,  bottled,  and  kept  on  ice.  It  is  ready  for  use  in 
twenty-four  hours.  A  very  slow  fermentation  continues  after  bottling, 
so  that  the  older  matzoon  is  more  sour  than  that  freshly  made ;  older 
specimens  contain  also  a  little  carboa  dioxide.  Matzoon  keeps  on  ice 
for  two  or  three  weeks.  It  is  a  thick,  curdy  fluid  with  a  taste  some- 
what resembling  sour  cream.  For  infant-feeding  it  should  be  diluted 
with  water  and  fed  with  a  spoon,  as  it  is  too  thick  to  be  drawn  from  a 
bottle. 


152  NUTRITION. 

The  composition  of  Dadirrian's  matzoou  is  as  follows  :  * 

Matzoon. 

Proteids 3-48 

Fat 3-49 

Milk  sugar 3-68 

Lactic  acid 0-90 

Alcohol  and  other  products  of  fermentation 0- 13_ 

Mineral  salts 0  •  G9 

Water 87-63 

100-00 

By  the  process  to  which  the  milk  is  subjected  there  is,  as  in  the  manu- 
facture of  kumyss,  a  decomposition  of  the  milk-sugar  into  alcohol,  lactic 
and  carbonic  acids.  The  changes  in  the  proteids  are  quite  similar  to  those 
in  kumyss.  In  kumyss  the  fermentation  goes  on  in  the  bottle,  and  conse- 
quently the  carbonic  acid  is  retained,  while  in  matzoon  the  greater  part 
of  the  gas  escapes.  The  indications  for  the  use  of  matzoon  are  the  same 
as  for  kumyss. 

Junket,  Curds  and  Whey. — Junket  is  made  as  follows :  To  one 
pint  of  fresh  lukewarm  cow's  milk  is  added  two  teaspoonfuls  of  essence  of 
pepsin  or  liquid  rennet.  It  is  stirred  for  a  moment  and  then  allowed  to 
stand  until  firmly  coagulated.  It  may  be  flavoured  with  wine,  which 
should  be  added  to  it  before  coagulation.  It  is  given  cold.  The  only 
change  which  has  taken  place  is  the  coagulation  of  the  casein,  such  as 
occurs  in  the  stomach  as  the  first  step  in  digestion.  Junket  is  useful  in 
the  feeding  of  older  children,  but  should  not  be  given  to  infants. 

Whey. — The  milk  is  coagulated  as  above  directed,  the  curd  is  then 
broken  up  with  a  fork,  and  the  whey  strained  off  through  coarse  muslin. 
To  this  whey  may  be  added  wine  or  brandy.  From  forty-six  analyses 
Koenig  gives  the  composition  of  whey  as  follows  : 

Whey. 

Proteids 0-86 

Fat 0-33 

Sugar 4-79 

Salts 0-65 

Water. 93  -  38 

100-00 

Whey  is  especially  valuable  for  infants  suffering  from  acute  indiges- 
tion. It  may  be  given  in  small  amounts  frequently,  and  will  often  be 
retained  when  everything  else  is  vomited.  It  should  be  given  cold.  Wine 
whey  is  made  by  the  addition  of  sherry  wine,  usually  in  the  proportion  of 
one  part  to  sixteen. 

*  Analysis  of  Leeds. 


BEEP   PREPARATIONS. 


153 


BEEP   PREPARATIONS. 

.The  nutrieut  properties  of  these  preparations  are  to  be  measured  by 
the  amount  of  albumin  they  contain,  their  stimulant  properties  by  the 
proportion  of  extractives. 

Beef  Juice. — Expressed  beef  juice  is  made  as  follows  :  A  piece  of  lean 
steak  is  slightly  broiled,  and  the  juice  pressed  out  by  a  meat-press  or  a 
lemon-squeezer.  Two  or  three  ounces  can  ordinarily  be  obtained  from 
one  pound  of  steak.  This  is  seasoned  with  salt  and  given  cold  or  warm, 
but  not  heated  sufficiently  to  coagulate  the  albumin  in  solution. 

Another  excellent  method  of  making  beef  juice  without  cooking,  is 
by  taking  one  pound  of  finely  chopped  lean  beef  and  eiglit  ounces  of 
water  and  allowing  this  to  stand  in  a  covered  jar  upon  ice  from  six  to 
twelve  hours.  The  juice  is  then  squeezed  out  by  twisting  the  meat  in 
coarse  muslin.  It  is  seasoned  with  salt  and  given  like  the  above.  This 
is  not  quite  so  palatable  as  that  obtained  by  the  first  method,  because  it 
contains  a  smaller  proportion  of  extractives.  It  can  be  made  so,  how- 
ever, by  the  addition  of  sherry  wine  or  celery  salt.  If  the  raw  juice  is 
added  to  milk  in  the  proportion  of  two  or  three  teaspoonfuls  to  each  feed- 
ing, the  taste  will  not  be  noticed.  The  milk  should  not  be  warmed  above 
100"  F.  before  the  addition  of  the  juice. 

The  composition  of  the  two  products  is  shown  in  the  following  table  : 

Beef  Juice.* 


I. 

Expressed  juice 
from  1  lb.,  warm 
process ;  quan- 
tity, '2)4  oz. 

II. 
Cold  process, 
1  lb.  beef.  8  oz. 
water  ;  quan- 
tity, 8>>,'  oz. 

Proteids 

2-90 
0-60 
3-40 
0-20 
92-90 

3-00 

Pat 

Extractives 

190 

Salts 

0-20 

Water 

94-90 

100-00 

100-00 

The  only  difference  in  the  two  preparations  is  that  the  first  contains 
about  twice  as  much  of  the  extractives.  The  second  process  is  much  more 
economical,  as  more  than  three  times  as  much  juice  can  be  obtained  from 
a  given  quantity  of  beef.  If  a  stronger  juice  is  desired,  the  amount  of 
proteids  may  be  doubled  by  using  only  four  ounces  of  water.  This  is 
preferable  for  all  except  young  infants. 

Beef  extracts  are  not  to  be  considered  in  any  sense  as  foods.  Kem- 
merich  has  shown  that  animals  receiving  nothing  else  died  of  starvation, 

*  Analysis  made  for  the  author  by  E.  E.  Smith,  Ph.  D. 


154  NUTRITION. 

and  even  sooner  than  when  everything  was  withheld.  According  to  Chit- 
tenden, they  contain  no  nitrogen  in  the  form  of  proteids,  but  only  in  com- 
bination with  the  soluble  extractives.  They  are  stimulants,  and  as  such 
are  often  useful. 

Of  the  other  preparations  of  beef  in  the  market  probably  the  best  are 
Mosquera's  beef  jelly,  bovinine,  the  beef  peptonoids  of  the  Arlington 
Company,  and  Murdock's  liquid  food.  These  contain  from  ten  to  thirty- 
five  per  cent  of  proteids  available  for  nutrition.  They  are  valuable  addi- 
tions to  milk  in  the  artificial  feeding  of  infants.  They  also  furnish  a 
proteid  which  can  be  used  in  many  cases  of  indigestion  where  milk  is  not 
admissible.  For  infants  they  must  be  well  diluted.  They  are  valuable 
in  older  children  in  many  cases  of  general  malnutrition. 

Eaw  scraped  beef,  or  that  which  has  been  slightly  cooked,  is  easily 
digested  by  most  young  children.  There  are  many  conditions  in  which 
other  forms  of  proteid,  particularly  casein,  are  not  well  borne,  and  indeed 
can  not  be  taken  at  all,  where  children  even  as  young  as  twelve  months 
appear  to  digest  this  beef-pulp  without  any  difficulty.  It  should  be  made 
from  very  rare  or  i-aw  steak,  finely  scraped  and  well  salted.  A  table- 
spoonful  may  be  given  at  one  feeding  to  a  child  of  eighteen  months.  In 
nutrient  properties  this  far  exceeds  most  of  the  beef  preparations  in  the 
market.  The  alleged  danger  of  tapeworm  from  the  use  of  raw  meat,  is 
in  this  country  so  slight  that  it  may  be  disregarded. 

Broths. — Animal  broths  may  be  made  from  mutton,  veal,  chicken,  or 
beef.  A  good  formula  for  general  use  is  the  following  :  One  pound  of 
lean  meat,  one  pint  of  water ;  stand  for  four  or  five  hours,  then  cook  over 
a  slow  fire  for  one  hour  down  to  half  a  pint.  After  it  has  cooled,  skim 
off  the  fat  and  strain  through  a  cloth.  The  composition  of  a  broth  so 
made  is  given  by  Cheadle  as  follows  : 

Beef  Broth. 

Proteids 1-03 

Extractives 1 "  82 

Fat 

Salts 0-88 

Water 96-28 

100-00 

From  its  composition  it  will  be  seen  that  broths  are  not  very  nutri- 
tious ;  they  are,  however,  quite  stimulating,  and  are  at  times  useful,  par- 
ticularly where  milk  is  to  be  temporarily  withheld;  but  they  are  not 
adapted  to  prolonged  use.  Broths  which  have  been  thickened  with  either 
barley  or  rice  flour  are  useful  for  children  in  the  second  and  third  years. 

CEREALS. 

Barley  Water. — This  is  to  be  made  either  from  the  grains  or  from  the 
barley  flour.     When  the  grains  are  used,  the  following  is  the  formula 


IXFANT-FOODS.  I55 

which  I  have  been  accustomed  to  employ  :  To  two  tablespoonfuls  of  barley, 
add  one  quart  of  water,  and  boil  continuously  for  six  hours,  keeping  the 
quantity  up  to  the  quart  by  the  addition  of  water ;  strain  through  coarse 
muslin.  It  is  an  advantage  to  soak  the  barley  for  a  few  hours,  or  even 
over-night,  before  using.  The  water  in  which  it  is  soaked  is  not  used. 
When  cold  this  makes  a  rather  thin  barley  jelly.  Its  composition  by 
analysis  is  as  follows  : 

Barley  Water. 

Starch 1-63 

Fat 0-05 

Proteids 0-09 

Inorganic  salts 0  •  0-3 

Water 98  •  20 

lOO-OO 

Almost  an  identical  product  may  be  obtained  by  using  either  the  pre- 
pared barley  flour  of  the  Health  Food  Company,  New  York,  or  Eobin- 
son's  barley,  two  drachms — one  even  tablespoonful — to  each  twelve  ounces 
of  water,  and  cooking  for  fifteen  minutes.  This  is  certainly  a  simpler 
and  easier  method  of  preparation. 

Rice  Water,  Oatmeal  Water,  etc. — These  may  be  made  in  the  same 
manner  as  the  barley  water,  using  the  same  jiroportions  either  of  the 
flour  or  the  grains.  Salt  should  always  be  added  to  these  gruels  if  used 
alone.  These  substances  are  useful,  being  a  convenient  form  in  which 
starch  may  first  be  added  to  the  food  of  infants  when  old  enough  to 
digest  it,  i.  e.,  about  the  eighth  or  ninth  month.  They  may  also  be  used, 
when  more  dilute,  to  allay  thirst  when  the  stomach  is  irritable,  and  when 
milk  in  all  forms  must  be  temporarily  withheld.  Rice  water  and  barley 
water  are  usually  preferable  in  cases  of  diarrhoea,  and  oatmeal  water 
where  there  is  a  tendency  to  constipation. 

INFANT-FOODS. 

It  is  not  possible,  nor  even  desirable,  for  a  physician  to  know  all  about 
the  infant-foods  with  which  the  market  is  flooded.  He  should,  however, 
at  least  know  that  they  are  not  perfect  substitutes  for  breast-milk,  that  as 
permanent  foods  they  are  greatly  inferior  to  properly  modified  cow's  milk, 
and  that  as  often  used  by  the  laity,  and  even  by  the  medical  profession, 
they  are  capable  of  doing  and  have  done  much  positive  harm.  There  are 
two  diseases — rickets  and  scurvy — which  have  so  frequently  followed  their 
prolonged  use,  that  there  can  be  no  escaping  the  conclusion  that  they  were 
the  active  cause.  This  is  the  unanimous  verdict  of  all  physicians  whose 
experience  entitles  them  to  speak  with  authority  upon  the  subject  of 
infant-feeding.  On  the  other  hand,  there  are  times  when  some  of  these 
preparations  may  be  of  considerable  value,  but  chiefly  for  temporary  use 
in  pathological  conditions.     Here  they  are  to  be  prescribed  like  drugs, 


156 


NUTRITION. 


but  only  with  a  very  definite  knowledge  of  exactly  what  they  do  and  what 
tliey  do  not  contain.  The  most  commonly  used  infant-foods  may  be 
grouped  as  follows  : 

1.  The  Milk  Foods. — Nestle's  food  is  perhaps  the  most  widely  known. 
The  others  closely  resembling  it  in  composition  are  the  Anglo-Swiss,  the 
Franco-Swiss,  the  American-Swiss,  and  Gerber's  food.  These  foods  are 
essentially,  sweetened  condensed  milk  evaporated  to  dryness,  with  the 
addition  of  some  form  of  flour  which  has  been  partly  dextrinized ;  they 
all  contain  a  large  proportion  of  unchanged  starch. 

3.  The  Liebig  or  Malted  Foods.— Mellin's  food  may  be  taken  as  a  type 
of  the  class.  Others  which  resemble  it  more  or  less  closely  are  Liebig's, 
Horlick's  food,  Hawley's  food,  and  malted  milk.  Mellin's  food  is  com- 
posed principally  (80  per  cent)  of  soluble  carbohydrates.  They  are  de- 
rived from  malted  wheat  and  barley  flour,  and  are  composed  of  a  mixture 
of  dextrines,  dextrose,  and  maltose,  with  a  small  amount  of  cane  sugar. 

3.  The  Farinaceous  Foods. — These  are  imperial  grauum.  Ridge's  food, 
Hubbell's  prepared  wheat,  and  Robinson's  patent  barley.  The  first  con- 
sists of  wheat  flour  previously  prepared  by  baking,  by  which  a  small  pro- 
portion of  the  starch — from  one  to  six  per  cent — has  been  converted  into 
sugar.  In  chemical  composition  these  four  foods  are  very  similar  to  each 
other,  consisting  mainly  of  unchanged  starch  which  forms  from  seventy- 
five  to  eighty  per  cent  of  their  solid  constituents. 

4.  Miscellaneous  Foods. — Under  this  head  maybe  mentioned  (1)  Carn- 
rick's  soluble  food,  which  is  composed  mainly  of  carbohvdrates,  more 
than  one  half  being  unchanged  starch,  the  fat  being  chiefly  cocoa  butter ; 
(2)  lacto-preparata,  which  difiers  from  the  above  chiefly  in  the  fact  that 
the  starch  has  been  replaced  by  milk  sugar ;  (3)  lactated  food,  which  is 
composed  of  about  seventy-five  per  cent  carbohydrates,  nearly  one  half  of 
which  is  unchanged  starch. 

The  Composition  of  Infant-Foods* 


Fat 

Proteids 

Dextrines 

Dextrose  and  maltose. 

Cane  sugar 

Milk  sugar 

Total  soluble  carbo- 
hydrates   

Insoluble  carbohy- 
drates (starch) 

Inorecanic  salts 

Moisture 


.Vestl«'s  food. 

MeUm'3  food. 

Malted  milk. 

Ridge's  food. 

Per  cent. 

Per  cent. 

Per  cent. 

Per  cent. 

5-48 

0-31 

3-66 

1-11 

1104 

10-70 

15-18 

11-93 

7-38 

40-96 

31 -971 

1-23 

.37-38 

31-79 

0-.'52 

30-59 

4-23 

415 

1-16 

7-60 

45 -57 

82-57 

67-91 

2  91 

29  95 

77-96 

1-72 

3-20 

3 -.34 

0-49 

1-50 

409 

2-20 

8-58 

Imperial 
granum. 


Per  cent. 

104 
14  13 
1-38 
0-42 
Trace. 


76- 11 
0-39 
8-38 


Lacto-preps- 
rata. 


Per  cent 

14- 


63 -68 


63-68 


Camrick*8 
soluble  food. 


Per  cent, 

7-45 
10-25 


27-08 

37-37 
4-42 
3-42 


*  With  the  exception  of  lacto-preparata  and  Carnriok's  soluble  food,  which  are  taken  from 
Leeds,  all  these  analyses  were  made  for  the  author  by  E.  E.  Smith,  Ph.  D.  In  general  they  corre- 
spond with  those  previously  published  by  Leeds,  Rach,  Trimble,  Stutzer,  and  others. 

-t  Including  milk  sugar. 


PLATE    III. 


WOMAN'S   MILK. 


COW'S   MILK. 


Proteios. 

Fat 

Soluble  Carbohydrates  (sugar*. 

Salts. 

Insoluble  Carbohydrates  (starch) 


CONDENSED  MILK,    (diluted  six  times.) 


MELLIN'S  FOOD. 


I 


MALTED   MILK. 


NESTLE'S  FOOD. 

1 

1 

1                              1 

I 

CARNRICK'S 

SOLUBLE 

FOOD. 

1 

I 

1                                                  1 

IMPERIAL  GRANUM, 


Chart  showing  composition  of  various  mfant  foods  compared  with  woman's  milk. 


INFAXT-FEEDING. 


157 


A  better  idea  can  be  obtained  of  these  foods  by  the  study  of  the  fol- 
lowing table,  where  they  are  diluted  with  water  for  comparison  with  milk  : 

Infant-Foods  diluted  with  Water  to  compare  with  Milk. 


Fat 

Proteids , 

Soluble  carbohydrates  (sugars) . , 
Insoluble  i;arbohydrates  (starch) 

Inorfcanic  salts 

Water 


Bivnat 
milk. 


Per  cent. 
400 
1.50 
700 

o'so 

87-30 


Condens. 

Cov's    !     milk, 

Mellinl! 

Malted 

Nestl^'t 

RIdge'i 

Imperial 

milk.        diluted 

food. 

milk. 

food. 

food. 

Cranum. 

6  times. 

Per  cent.  Per  cent. 

Per  cent. 

Per  cent. 

Per  cent. 

Per  cent. 

Per  cent. 

3  50       0-99 

0  04 

0  39 

0-76 

016 

0-14 

4  00 

1-20 

1-50 

2-28 

1  .54 

1  67 

1-98 

4:J0 

7-23 

11-56 

10 -18 

6  38 
419 

0-41 
10-91 

0-25 
10-65 

6-70 

6  17 

0-45 

0-50 

0-24 

0  07 

0-06 

87-50 

90-41 

86-45 

86-65 

86-89 

86-78 

86-92 

Cam- 
rick". 
Bolublo 
food. 

Per  cent. 
112 
1-35 
4-06 
5-61 
0  56 
87-30 


The  accompanying  graphic  chart  (Plate  III)  shows  in  another  form 
the  same  thing  as  the  last  table.  In  it  are  seen  at  a  glance  the  essential 
features  in  the  composition  of  most  of  the  foods,  viz.,  the  large  propor- 
tion of  carbohydrates  and  the  absence  of  fat.  As  a  class  then,  infant-foods 
contain  an  excess  of  carbohydrates,  and  many  of  them  a  large  percentage 
of  unchanged  starch.  The  proteids,  though  often  sufficient  in  amount,  are 
chiefly  vegetable,  and  not  animal  proteids.  Without  exception  they  are 
lacking  in  fat,  and  therefore  they  do  not  furnish  all  that  the  growing 
organism  requires.  They  should  not  be  used  except  in  those  forms  of 
indigestion  where  we  desire  temporarily  to  withhold  fat  and  casein  and  to 
employ  as  food  only  carbohydrates.  They  can  not  be  used  as  exclusive 
foods  for  any  considerable  period  without  disastrous  results.  Their  con- 
tinued use  without  some  addition  of  fresh  milk  should  never  in  any  cir- 
cumstances be  countenanced.  While  some  of  them  may  furnish  the  addi- 
tional carbohydrates  required  by  an  infant  who  is  fed  upon  diluted  cow's 
milk,  they  can  not  do  more.  The  group  of  farinaceous  foods,  as  they  fur- 
nish starch  in  a  convenient  and  palatable  form,  may  often  be  advantage- 
ously used  as  an  addition  to  milk  after  the  ninth  month  and  during  the 
second  year. 


CHAPTER   III. 
INF  A  NT-FEEDINO. 


The  different  methods  of  feeding  which  are  available  are : 

1.  Breast-feeding,  either  by  the  mother  or  by  a  w^et-nurse. 

2.  Mixed  feeding,  or  a  combination  of  nursing  and  artificial  feeding. 

3.  Artificial  feeding  exclusively. 

In  deciding  which  one  of  these  methods  shall  be  used,  all  the  condi- 
tions, such  as  the  health  of  the  mother,  the  vigour  of  the  child,  and  its 
surroundings,  must  be  taken  into  consideration.     The  first  choice  should 


158  NUTRITION. 

always  be  maternal  nursing.  If  it  is  not  possible  for  the  mother  to  nurse 
her  infant  entirely,  nursing  may  be  supplemented  by  feeding  either  from 
the  outset  or  after  the  third  or  fourth  mouth.  If  tlie  conditions  are  such 
that  maternal  nursing  is  impossible  or  impracticable,  the  question  to  be 
decided  is  one  of 

Artificial  Feeding  vs.  Wet-nursing. — Neither  method  of  feeding  is  to 
be  used  exclusively.  While  recent  advances  made  in  artificial  feeding 
have  greatly  diminished  the  necessity  for  wet-nurses,  there  are  still  many 
instances  where,  objectionable  though  they  may  be,  they  are  indispensable 
for  saving  the  life  of  the  child,  as  the  perfect  substitute  for  good  breast 
milk  is  as  yet  undiscovered. 

If  artificial  feeding  can  be  begun  at  birth  and  carried  on  according  to 
the  most  approved  methods,  it  is  highly  successful  in  the  great  majority 
of  cases  in  which  maternal  nursing  is  impossible.  In  my  experience,  fully 
ninety  per  cent  of  the  infants  seen  in  private  practice  can  with  care  be 
so  reared.  The  remainder  of  the  cases  will  require  wet-nurses ;  these  in- 
cluding chiefly  infants  who  are  prematurely  born  or  those  who  are  deli- 
cate from  birth,  and  those  with  especially  weak  digestion,  who  are  reared 
only  with  the  greatest  difficulty  under  any  circumstances.  This  state- 
ment applies  particularly  to  infants  living  in  large  cities.  If,  however, 
artificial  feeding  has  been  badly  begun,  and  so  carried  on  for  two  or  three 
months  that,  when  the  child  comes  under  observation,  a  condition  of 
chronic  indigestion  is  established,  the  difficulties  in  the  way  of  artificial 
feeding  are  much  increased,  and  the  proportion  of  cases  in  which  wet- 
nurses  are  required  will  be  much  larger.  Whether  or  not  a  wet-nurse 
shall  be  employed  at  this  juncture  will  depend  upon  the  circumstances 
surrounding  each  case.  If  the  child  has  steadily  lost  flesh  so  that  it 
weighs  only  a  little  more  than  at  birth,  if  it  lives  in  a  large  city,  or  if  the 
season  is  midsummer,  the  necessity  for  a  wet-nurse  is  very  much  increased. 
In  these  circumstances,  the  great  danger  is  the  supervention  of  some  acute 
disease  of  the  stomach  or  intestines,  to  which  a  child  in  this  condition 
is  very  liable,  and  which  it  may  not  be  able  to  survive.  Unless  such  a 
child  begins  very  soon  to  improve  witli  proper  methods  of  artificial  feeding, 
a  wet-nurse  should  be  secured.  If  the  child  lives  in  the  country,  if  the 
weather  is  cool,  and  if  the  child  is  holding  its  own  in  weight,  a  faithful 
trial  of  proper  feeding  should  be  made  before  resorting  to  a  wet-nurse. 
If  the  child,  at  the  time  of  coming  under  observation,  is  suffering  from  an 
attack  of  acute  indigestion,  or  from  the  symptoms  of  acute  inanition,  a 
wet-nurse  should  be  obtained  at  once.  I  believe  that  the  day  will  soon 
come  when  no  physician  will  lay  before  his  patient  the  choice  of  a  wet- 
nurse  or  artificial  feeding  in  the  case  of  a  healthy  infant  whose  mother  can 
not  or  will  not  nurse  it ;  but  that  the  general  attitude  of  the  profession 
will  be,  artificial  feeding  if  possible,  wet-nursing  only  if  necessary.  I  am 
well  aware  that  this  practice  is  not  followed  by  many  of  the  leading 


ARTIFICIAL   FEEDING    VERSUS  WET-NURSING.  159 

physicians  in  New  York,  who  still  adhere  to  the  practice  of  employing 
wet-nurses  in  every  instance  in  which  maternal  nursing  is  impossible. 
This  is  largely  due  to  a  want  of  familiarity  with  the  methods  and  results 
of  the  best  artificial  feeding,  while  the  results  of  improper  artificial  feed- 
ing are  to  be  seen  on  every  hand. 

The  disadvantages  in  the  employment  of  wet-nurses  are  many,  and 
almost  as  difficult  to  overcome  as  those  attending  artificial  feeding.  In 
the  first  place,  good  ones  are  difficult  to  obtain,  and  outside  of  a  large 
city  it  is  almost  impossible  to  obtain  one  of  any  kind.  While  it  is  true 
that  good  breast  milk  is  unquestionably  the  best  infant-food,  it  is  equally 
true  that  properly  modified  cow's  milk  is  a  far  better  food  than  the  milk 
of  many  wet-nurses  who  are  employed.  The  expense  of  wet-nurses — 
twenty  to  thirty-five  dollars  a  month  in  New  York — places  them  out 
of  the  reach  of  many  who  need  them  most ;  and,  finally,  the  class  of 
women  from  which  most  of  our  wet-nurses  are  drawn,  are  very  undesirable 
inmates  of  a  household,  and  are  often  the  source  of  endless  trouble  and 
annoyance — a  nuisance  which  must  be  tolerated  for  the  sake  of  the  baby. 
The  danger  of  the  transmission  of  disease  from  the  nurse  to  the  child  is 
a  real  one.  Numerous  instances  are  on  record  of  syphilis  being  communi- 
cated in  this  way,  and  some  have  come  under  my  own  observation.  It  is 
possible  that  tuberculosis  may  be  transmitted  through  the  milk,  although, 
like  syphilis,  this  is  much  more  liable  to  result  from  other  contact  with 
the  nurse,  especially  kissing. 

The  moral  question  involved  in  the  subject  of  wet-nursing  is  one 
which  neither  the  physician  nor  the  family  who  employ  the  nurse  can 
ignore,  for  it  is  no  small  thing  to  deprive  an  infant  of  its  mother's  breast 
when,  as  statistics  show  to  be  true  of  the  children  of  wet-nurses,  this  fact 
reduces  its  chance  of  survival  to  one  in  ten.  The  family  should  be  com- 
pelled by  the  physician  to  consider  this  aspect  of  the  question,  and  to  see 
to  it  that  proper  provision  for  the  care  of  the  wet-nurse's  child  is  made,  so 
as  to  give  it  the  best  possible  chance  with  artificial  feeding.  If  the  wet- 
nurse's  child  is  two  months  old,  its  chances  of  getting  on  without  the 
mother  are  vastly  improved,  while  her  usefulness  as  a  wet-nurse  is  not 
thereby  diminished.  It  should  therefore  be  required  that,  whenever  cir- 
cumstances permit,  every  woman  who  goes  out  as  a  wet-nurse  should 
nurse  her  own  infant  for  at  least  two  months  before  she  leaves  it. 

The  unnecessary  employment  of  wet-nurses  is  no  doubt  an  evil,  and 
has  a  bad  influence  upon  those  who  make  wet-nursing  a  business,  as 
many  women  in  cities  are  tempted  to  do  on  account  of  the  large  wages 
which  they  are  able  to  earn  for  very  easy  work.  If  a  wet-nurse  were 
retained  in  her  place  only  as  long  as  the  needs  of  the  child  required — 
i.  e.,  until  it  had  arrived  at  a  sufficient  age,  and  its  digestion  had  suffi- 
ciently improved  to  enable  it  to  thrive  upon  modified  cow's  milk — she 
could  be  dispensed  with  in  a  month  or  two  months,  and  could  then 
12 


160  NUTRITION. 

seek  another  place.  lu  this  way  a  small  uumber  of  nurses  could  be 
made  to  do  duty  for  quite  a  large  number  of  children.  This  is  practi- 
cally just  what  is  done  in  several  of  our  large  institutions,  where  a  deli- 
cate child  is  wet-nursed  only  long  enough  to  give  it  a  start,  which  may 
require  two  weeks,  one  month,  or  three  months,  as  the  case  may  be.  And 
just  in  this  way  should  wet-nurses  be  used  in  private  practice,  as  furnish- 
ing an  infant-food  easy  of  digestion,  and  one  without  which  sometimes  we 

can  not  get  along. 

BREAST-FEEDING. 

I.  Maternal  Nursing. — Maternal  nursing  is  desirable  whenever  it  is 
possible.  Under  the  following  conditions,  however,  it  should  not  be  at- 
tempted : 

(1)  No  mother  who  is  the  subject  of  tuberculosis  in  any  form,  whether 
latent  or  active,  should  nurse  her  infant ;  it  can  only  hasten  the  progress 
of  the  disease  in  herself,  while  at  the  same  time  it  exposes  the  infant  to 
the  danger  of  infection.  (2)  Nursing  should  not  be  allowed  where  serious 
complications  have  been  connected  with  parturition,  such  as  severe 
haemorrhage,  puerperal  convulsions,  nephritis,  or  puerperal  septicaemia. 
(3)  If  the  mother  is  choreic  or  epileptic.  (4)  If  the  mother  is  very  deli- 
cate, since  great  harm  may  be  done  to  her,  without  any  corresponding 
benefit  to  the  child.  (5)  Where  experience  on  two  or  three  previous  occa- 
sions under  favourable  conditions  has  shown  her  inability  to  nurse  her 
child.  (6)  When  no  milk  is  secreted.  With  reference  to  the  fourth  and 
fifth  conditions  an  absolute  opinion  can  not  always  be  given  at  the  outset. 
In  cases  of  doubt,  nursing  may  be  allowed  tentatively,  the  effect  upon  both 
mother  and  child  being  carefully  watched.  In  view  of  the  great  value  of 
maternal  nursing  to  the  child,  the  physician  should  encourage  it  and  use 
every  means  in  his  power  to  make  it  easy. 

Care  of  the  Breasts  during  Lactation. — For  the  safety  of  both  mother 
and  child  it  is  essential  that  the  most  scrupulous  attention  be  given  to 
cleanliness.  The  nipples,  and  the  breasts  as  well,  should  always  be  care- 
fully washed  after  each  nursing.  Usually  plain  water  is  sufficient,  or  a 
weak  boric-acid  solution  may  be  employed. 

Nursing  during  the  First  Days  of  Life. — This  is  necessary,  to  accustom 
the  child  and  the  mother  to  the  procedure,  to  promote  uterine  contrac- 
tion, and  to  empty  the  breasts  of  the  colostrum.  All  these  results  can 
be  attained  by  putting  the  child  to  the  breast  on  the  first  day  once  in  six 
hours,  on  the  second  day  once  in  four  hours.  It  is  unnecessary  to  repeat 
the  process  more  frequently.  The  child  gets  from  the  breast  only  from 
four  to  six  ounces  a  day  during  the  first  two  days.  Did  it  require  more 
nourishment  before  the  milk-flow  is  usually  established,  we  may  be  sure 
that  Nature  would  not  have  been  so  late  with  her  supply.  Considering 
how  great  are  the  changes  taking  place  during  these  first  days  in  the  circu- 
latory and  respiratory  systems,  we  are  hardly  surprised  that  two  days  pass 


BREAST-FEEDIXG. 


ICl 


before  the  organs  of  digestion  are  given  much  work  to  do.  The  common 
practice  of  administering  to  an  infant  a  few  hours  old  all  sorts  of  de- 
coctions, with  the  idea  that  because  it  cries  it  is  suffering  from  colic,  can 
not  be  too  strongly  condemned.  A  certain  amount  of  crying  is  proper  and 
necessary.  In  exceptional  circumstances,  when  an  infant  is  unusually 
strong  and  robust  and  screams  excessively,  and  especially  when  the  tem- 
perature is  elevated  (see  page  121),  it  may  be  necessary  to  give  food  before 
the  third  day ;  but  this  is  not  to  be  the  rule.  A  little  warm  water,  or  a 
five-per-cent  solution  of  milk  sugar,  should  first  be  given  ;  from  two  to 
four  teaspoonfuls  at  a  time  are  sufficient.  This  often  satisfies  the  child  ; 
when  it  does  not  do  so,  regular  feeding  should  be  begun  on  the  second 
day.  Should  the  milk  be  delayed  beyond  the  second  day,  feeding  should 
then  be  begun  at  regular  intervals,  as  in  the  cases  which  are  to  have  no 
breast-milk. 

Nursing  Habits. — Good  habits  of  nursing  and  sleep  are  almost  as  easily 
formed  as  bad  ones,  provided  one  begins  at  the  outset.  A  vast  deal  of  the 
wear  and  tear  incident  to  the  nursing  period  may  be  avoided  if  the  child 
is  trained  to  regular  habits.  Attention  to  these  minor  points  often  makes 
all  the  difference  between  successful  and  unsuccessful  nursing.  They 
should  not  be  thought  beneath  the  physician's  notice,  nor  relegated  en- 
tirely to  the  nurse.  The  physician  must  have  a  very  clear  notion  of  how 
often  nursing  is  necessary,  must  give  very  explicit  directions,  and  see  that 
they  are  carried  out.  After  the  third  day,  for  the  first  month,  ten  nurs- 
ings in  the  twenty-four  hours  are  quite  sufficient,  and  no  more  should  be 
allowed.  An  infant  at  this  age  can  usually  be  depended  upon  to  take  at 
least  one  long  nap  of  from  four  to  five  hours  in  the  course  of  the  twenty- 
four.  For  the  rest  of  the  day  the  child  may  be  awakened,  if  necessary, 
at  the  regular  nursing  time,  and  put  to  the  breast ;  this  plan  being  con- 
tinued until  nine  o'clock  at  night.  It  should  then  be  allowed  to  sleep  as 
long  as  it  will,  and  but  two  nursings  given  between  this  hour  and  seven 
in  the  morning.  In  the  course  of  two  or  three  weeks  a  healthy  infant 
can  usually  be  trained  to  nurse  and  sleep  with  almost  perfect  regularity, 
frequently,  when  a  month  old,  going  six  hours  regularly  at  night  without 
feeding.  A  trained  nurse  of  my  acquaintance  states  that  out  of  thirty- 
three  infants  of  which  she  had  the  care  from  birth,  thirty-one  were  trained 
without  difficulty  in  the  manner  described.  In  only  one  case  was  the 
training  a  failure — that  of  a  delicate,  highly  nervous  child.  Of  course, 
success  in  training  must  rest  almost  entirely  with  the  nurse ;  but  the 
physician  should  at  least  appreciate  its  importance  and  lend  it  his  sup- 
port. The  great  gain  to  the  mother  is,  that  she  is  enabled  to  have  a 
quiet,  undisturbed  night.  This  is  of  the  utmost  importance,  and  has  more 
to  do  with  a  good  milk  supply  than  any  other  single  thing  in  connection 
with  the  mother's  habits.  So  far  as  the  child  is  concerned,  regular  habits 
of  feeding  and  sleep,  and  regular  evacuations  from  the  bowels,  which 


162 


NUTRITION. 


nearly  always  go  with  them,  are  important  factors  in  infant  hygiene, 
especially  in  the  prevention  of  gastro-enteric  diseases. 

Schedule  for  Br  east- Feeding. 


First  day 

Second  day  

Third  to  twenty-eighth  day 
Fourth  to  thirteenth  weelv.. 

Third  to  fifth  month 

Fifth  to  twelfth  month 


Number  of  nurs- 
ings in  24  hours. 


4 

6 

10 

8 
7 
6 


Interval  during 
the  day. 


Hours. 
6 
4 
2 

2i 
3 
3 


Night  nursings 

between  9  p.  m. 

and  7  a.  m. 


These  rules  can  be  carried  into  effect  Avith  but  little  difficulty,  and 
with  great  benefit  to  both  mother  and  child.  It  is  to  be  remembered  that 
we  are  here  speaking  only  of  healthy  children.  The  possibility  of  train- 
ing children  to  eat  and  sleep  in  the  manner  described  will  be  doubted  only 
by  one  who  has  not  made  a  careful  trial  of  it.  Eelieving  the  mother  of 
night-nursing  after  the  child  is  five  months  old  is  of  the  greatest  value, 
and  will  often  enable  her  to  go  on  with  lactation,  when  otherwise  it  would 
be  brought  to  an  abrupt  termination.  On  no  account  should  the  child 
be  allowed  to  sleep  upon  the  mother's  breast,  nor  in  the  same  bed  with 
the  mother.  The  temptation  to  frequent  nursing  is  in  this  way  in  great 
measure  removed.  No  mere  sentiment  in  regard  to  these  matters  should 
be  allowed  to  interfere  with  the  plain  dictates  of  reason  and  experience. 

Symptoms  of  Inadequate  Nursing. — So  frequently  does  it  happen  that 
a  mother  is  anxious  to  nurse  her  child,  and  after  two  or  three  months  it  is 
discovered  that  lactation  is  a  failure  and  artificial  feeding  must  be  re- 
sorted to,  that  it  is  important  that  the  question  of  ability  to  nurse  should 
be  settled  as  early  as  possible.  The  lives  of  children  are  often  jeopard- 
ized by  the  vain  efforts  of  a  conscientious  mother  to  do  what  she  is  phys- 
ically unable  to  do.  The  physician  should  be  familiar  with  the  symptoms 
of  inadequate  nursing,  in  order  that  valuable  time  may  not  be  wasted.  If 
artificial  feeding  is  to  be  employed,  the  difficulties  are  much  less  when  it 
is  begun  early  than  after  the  digestion  has  been  deranged  by  several  weeks 
of  very  poor  nursing. 

1.  During  the  first  three  or  four  days  of  life  the  most  important  sign 
of  insufficient  food  is  the  temperature.  As  a  rule,  a  child  who  gets  a 
proper  amount  from  the  breasts  has  a  normal  temperature.  Very  many 
who  get  little  or  nothing  during  this  time  have  a  temperature  of  101°  or 
102°  F.,  and,  in  extreme  cases,  104°  or  even  106°  F.  If  no  obvious  symp- 
toms of  illness  are  present,  such  a  temperature  from  the  second  to  the 
fourth  day  may  be  looked  upon  as  indicating  insufficient  nourishment,  or 
even  starvation.     (See  page  118.) 


BREAST-FEEDIXa.  IGS 

2.  There  is  no  gain  in  iceight.  All  infants,  and  particularly  those 
whose  nutrition  is  the  subject  of  special  difficulty,  should  be  weighed 
twice  a  week  during  the  first  six  months.  Xo  matter  what  other  symp- 
toms are  present,  the  scales  are  an  unerring  guide  by  which  we  are  to 
judge  the  results.  A  child  need  not  gain  rapidly,  but  should  always  gain 
steadily  unless  obvious  signs  of  disease  are  present.  One  should  not  be 
satisfied  unless  the  weekly  gain  is  at  least  four  ounces.  In  the  great  ma- 
jority of  cases  a  failure  to  gain  in  weight  during  the  first  six  months, 
depends  upon  the  nourishment,  and  upon  that  alone. 

3.  The  sleep  is  irregular  and  disturbed.  A  healthy  infant,  after  its 
appetite  has  been  satisfied,  usually  goes  to  sleep  at  once  and  sleeps  quietly 
for  two  or  three  hours  ;  or,  if  awake,  it  lies  in  placid  contentment,  ex- 
hibiting all  the  signs  of  physical  well-being.  If,  after  being  nursed,  a 
child  wakes  habitually  fifteen  or  twenty  minutes  after  being  put  down, 
and  rarely  has  a  long  sleep  except  from  exhaustion,  the  probabilities  are 
great  that  the  food  is  insufficient  in  quantity  or  very  poor  in  quality. 

4.  There  is  frequent  fretfulness  or  crying.  This  may,  of  course,  be 
due  to  many  causes  in  infancy,  but  by  all  odds  the  most  common  one  is 
lack  of  proper  food  or  the  indigestion  which  this  produces. 

5.  Tlie  stools  are  irregular  and  of  an  unheaWiy  appearance.  There 
may  be  constipation  with  dry,  hard  stools,  or  frequent  green  fluid  stools, 
from  four  to  twelve  a  day,  often  containing  undigested  food,  and  after  a 
time  mucus. 

6.  Tlie  child  nurses  a  long  time  before  it  is  satisfied.  Usually  the 
greater  the  milk  supply,  the  shorter  the  time  required  to  satisfy  the  child's 
appetite.  Where  the  milk  is  abundant,  five  or  six  minutes  are  often  suffi- 
cient. If  the  milk  is  very  scanty,  an  infant  will  frequently  nurse  half 
or  three  quarters  of  an  hour  and  then  stop,  more  because  it  is  tired  out 
than  because  it  is  satisfied.  If  this  is  habitual,  it  is  almost  certain  that 
the  milk  is  very  scanty.  Sometimes  a  scanty  supply  is  indicated  by  ex- 
actly the  opposite  symptom,  viz.,  the  child  seizing  the  breast  and  nursing 
vigorously  for  a  few  moments,  then  dropping  the  nipple  in  apparent  dis- 
gust and  refusing  to  make  any  further  efforts.  This  symptom  is  often 
seen  where  the  breasts  are  practically  empty. 

7.  The  symptoms  during  the  later  months  are  stationary  weight  or  a 
gradual  loss,  soft,  flabby  muscles,  inability  to  sit  alone  or  to  stand  at  the 
proper  age,  delayed  closure  of  the  fontanel,  delayed  dentition,  and  fre- 
quently perspiration  about  the  head.  In  addition,  there  are  the  general 
signs  of  malnutrition,  ana?mia,  fretfulness,  and  irregular  bowels,  or  there 
may  be  added  the  symptoms  of  incipient  rickets. 

The  above  symptoms  are  sufficiently  characteristic  to  enable  one  to  be 
quite  sure  of  the  fact  that  the  child  is  not  thriving.  The  proper  course 
now  is  to  examine  the  milk  and  see  in  what  respect  it  is  abnormal  :  whether 
it  is  simply  the  quantity  that  is  at  fault,  or  the  quality,  or  both.     While 


164 


NUTRITION. 


such  an  examination  does  not  always  solve  the  problem,  it  is  of  very  great 
assistance,  and  in  the  majority  of  cases  two  or  three  examinations  of  the 
milk,  in  connection  witli  the  other  symptoms,  will  enable  the  physician 
to  decide  the  question  and  apply  the  appropriate  treatment. 

The  Management  of  Woman's  Milk  where  Nursing  Infants  are  not 
Thriving. — The  milk  examination  usually  discloses  one  of  four  conditions: 
(1)  an  over-rich  milk,  quantity  usually  abundant ;  (2)  milk  poor  in  qual- 
ity and  scanty  ;  (3)  quality  good,  amount  scanty  ;  (4)  quantity  abundant, 
quality  poor. 

Excessively  rich  milk. — This  is  usually  found  under  the  following 
conditions:  The  woman  is  in  good  health,  has  large,  well-developed 
breasts,  which  are  full  and  tense  at  nursing  time.  In  most  cases  she  is 
upon  a  very  abundant  diet,  largely  of  nitrogenous  food,  getting  little  or 
no  exercise,  and  frequently  taking  alcohol  with  the  notion  that  because 
the  child  is  not  thriving  the  milk  is  poor.  Tbis  is  often  seen  in  the 
wet-nurse  after  making  a  change  from  the  simple  life  and  habits  of  home 
to  the  more  luxurious  life  and  diet  of  the  family  to  which  she  goes.  The 
following  analyses  from  Rotch  are  a  good  illustration  of  the  exact  com- 
position of  milk  under  such  circumstances :  Analysis  I  shows  milk  of  a 
healthy  but  under-fed  wet-nurse  two  days  before  change  of  food  ;  II,  the 
milk  of  the  same  nurse  after  one  month  of  rich  food  with  very  little  exer- 
cise ;  III,  milk  of  the  same  nurse,  the  food  and  exercise  being  regulated : 


I. 

II. 

III. 

Fut     

Per  cent. 

0-72 
2-53 
6-75 
0-22 

Per  cent. 

5-44 
4-61 
G-25 
0-20 

Per  cent 

5-50 

2-90 

Sugar 

Salts! 

6-60 
0-14 

The  effect  of  the  diet  and  life  is  seen  to  be,  high  fat  and  high  pro- 
teids.  As  a  result  of  the  exercise,  there  is  seen  a  very  marked  reduction 
in  the  proteids.  The  clinical  examination  shows  the  cream  to  be  from 
eight  to  twelve  per  cent,  and  the  specific  gravity  from  1,033  to  1,033. 
Instead  of  weaning  the  baby,  or  dismissing  the  wet-nurse  because  the 
child  has  indigestion  or  loses  in  weight,  certain  changes  should  be  insti- 
tuted. Alcohol  should  be  entirely  prohibited.  The  diet,  especially  the 
meat,  should  be  reduced,  and  the  nurse  required  to  take  daily  exercise  in 
the  open  air,  particularly  by  walking.  The  improvement  following  such 
a  regimen  is  often  immediate,  the  child's  symptoms  disappearing  in  the 
course  of  a  few  days  and  a  regular  gain  in  weight  beginning. 

Scanty  milk  of  a  poor  quality. — This  is  most  often  seen  in  a  delicate 
or  anaemic  mother — one,  perhaps,  who  has  had  a  difficult  or  complicated 
labour,  who  is  emotional,  anxious,  and  careworn.  In  such  cases  it  is  often 
with  the  greatest  difficulty  that  we  can  secure  the  necessary  half  ounce 


BREAST-FEEDING. 


165 


required  for  examination.  The  milk  is  sometimes  so  poor  that  we  can 
decide  positively  after  two  examinations  that  it  is  useless  to  continue 
lactation.  In  such  cases  we  often  find  the  specific  gravity  from  1,024  to 
1,027,  and  the  cream  only  two  or  three  per  cent.  In  other  cases,  where 
the  variations  from  the  normal  are  not  so  great — i,  e.,  specific  gravity  1,030, 
cream  four  per  cent,  and  the  quantity  fairly  abundant — we  may  be  able  so 
to  improve  the  milk  that  lactation  may  be  easily  and  advantageously  con- 
tinued. In  the  management  of  such  cases  the  first  thing  is  to  secure  to 
the  nurse  undisturbed  rest  at  night.  If  possible,  she  should  be  entirely 
relieved  of  the  care  of  the  infant  at  this  time,  and  if  feeding  is  necessary 
the  bottle  should  be  given.  She  should  have  a  certain  amount  of  fresh 
air  every  day,  driving  if  possible,  or  walking  as  soon  as  she  is  able  to  take 
more  active  exercise.  One  of  the  most  powerful  stimulants  to  the  secre- 
tion of  milk  is  massage  of  the  breasts.  A.  M.  Thomas  (New  York)  places 
it  above  all  others.  It  should  be  done  with  great  care  and  gentleness,  but 
most  of  all  with  every  precaution  against  infection.  The  entire  breast, 
including  the  nipple,  should  be  rendered  aseptic,  as  should  the  hands  of 
the  masseuse.  Some  mild  antiseptic  ointment  may  be  used  with  the 
massage.  It  should  be  done  two  or  three  times  a  day  for  ten  minutes. 
The  diet  should  be  abundant,  with  a  large  allowance  of  milk  and  meat, 
especially  beef.  If  there  is  ansemia,  iron  should  be  given.  Some  of  the 
alcoholic  extracts  of  malt  are  useful.  Every  means  should  be  taken  to 
improve  the  general  nutrition,  for  whatever  benefits  this  improves  the 
milk.  If  the  conditions  present  are  incident  to  the  confinement  or  the 
convalescence,  the  prognosis  is  good  ;  and  in  the  course  of  a  week  or  two 
very  marked  improvement  may  be  evident,  and  lactation  may  be  success- 
fully continued.  If,  however,  the  conditions  depend  upon  constitutional 
debility,  or  if  the  person  has  an  exceedingly  nervous  temperament,  the 
prognosis  is  much  worse.  Temporary  improvement  may  take  place,  but  it 
soon  becomes  evident  that  the  experiment  is  a  failure,  both  as  regards 
mother  and  child. 

Quantity  deficient,  quality  normal. — This  is  often  apparently  the  case, 
but  really  it  is  rarely  so.  If,  in  taking  the  specimen  for  examination,  the 
child  is  first  allowed  to  nurse  for  one  or  two  minutes  as  has  been  suggested, 
there  may  be  left  only  the  final  portion,  or  "  strippings,"  which  part  is 
always  much  riclier  in  fat  than  the  whole  milk.  An  examination  of  such 
a  specimen  often  gives  an  excellent  showing  when  the  milk  is  really  poor. 
In  all  cases  of  scanty  supply,  the  entire  quantity  from  the  breasts  should 
be  secured  for  examination.  If  the  only  object  in  treatment  is  to  increase 
the  quantity,  this  can  usually  be  accomplished  by  largely  increasing  the 
fluids,  especially  milk,  and  by  taking  alcoholic  malt  extracts. 

Quantity  abundant,  quality  very  poor. — This  condition  is  usually  seen 
in  women  who,  to  improve  the  milk,  have  been  taking  large  quantities  of 
fluids,  often  with  alcohol  in  some  form.     In  such  cases,  instead  of  being  a 


166 


NUTRITION. 


formation  from  the  epithelium  of  the  glands,  the  milk  is  chiefly  a  transu- 
dation from  the  blood-vessels.  Where  the  patient  is  very  anasmic  and  the 
general  condition  poor,  the  glands  act  as  little  more  than  a  filter.  In 
such  circumstances  the  breasts  may  be  so  full  as  to  be  painful,  and  the 
milk  may  often  come  away  spontaneously.  An  examination  usually  shows 
low  specific  gravity  and  very  low  fat.  Where  these  conditions  exist  nurs- 
ing should  be  discontinued. 

Summary. — Excessively  rich  milk  is  in  most  cases  easily  modified  by 
a  reduction  in  the  diet  and  increase  in  exercise.  Poor  milk  is  usually  low 
in  fat  and  scanty  in  quantity,  while  the  proteids  may  be  either  high  or 
low.  If  the  variations  from  the  normal  are  only  moderate,  and  the  causes 
are  such  as  can  readily  be  removed,  the  prognosis  is  good.  If  the  opposite 
conditions  exist,  the  prognosis  is  bad,  and  the  chances  of  permanent  im- 
provement are  slight.  On  the  whole,  artificial  feeding  gives  so  much 
better  results  than  poor  or  doubtful  nursing,  that  I  am  inclined,  as  a 
result  of  increased  experience,  to  stop  nursing  and  begin  artificial  feeding 
early,  rather  than  waste  time  in  prolonged  efforts  to  improve  the  breast- 
milk.  Nursing  that  is  continued  only  by  high  pressure,  by  stimulants, 
and  by  deluging  the  mother  with  fluids,  is  rarely  advantageous  either  for 
mother  or  child. 

II.  Wet-Nursing. — In  the  selection  of  a  wet-nurse,  it  is  by  no  means 
so  essential  as  has  generally  been  supposed,  that  her  child  shall  be  of 
about  the  same  age  as  the  child  she  is  to  nurse,  for,  after  the  first 
month,  the  changes  in  the  composition  of  breast  milk  are  insignificant. 
It  is  always  desirable  that  the  wet-nurse  shall  have  nursedjier  own  infant 
long  enough  to  demonstrate  the  fact  that  she  has  an  abundance  of  good 
milk ;  hence,  taking  a  wet-nurse  at  the  end  of  the  first  or  second  week  is 
always  fraught  with  considerable  uncertainty.  For  an  infant  six  weeks 
old,  a  wet-nurse  whose  milk  is  anywhere  between  one  and  five  months  old 
will  usually  answer  perfectly  well.  For  an  infant  only  two  or  three  weeks 
old,  the  milk  should  not  be  more  than  six  weeks  old. 

A  good  nurse  must,  first  of  all,  be  a  healthy  woman,  free  from  syphi- 
litic or  tuberculous  taint,  and  her  throat,  teeth,  skin,  glands,  hair,  and  legs 
should  be  carefully  inspected.  She  must  have  a  good  glandular  develop- 
ment. Not  much  is  to  be  expected  of  small  fiat  breasts.  The  breasts 
must  be  full  and  hard  three  hours  after  nursing.  They  may  be  very 
large  and  yet  supply  very  little  milk,  being  composed  almost  entirely 
of  fat.  On  the  other  hand,  some  smaller  breasts  may  be  almost  all  glan- 
dular tissue.  The  difference  in  the  size  of  a  breast  before  and  after 
nursing,  is  one  of  the  best  guides  to  the  amount  of  milk  it  is  secreting. 
The  nipples  should  be  free  from  erosions  or  fissures,  and  long  enough  for 
the  needs  of  the  child.  The  nurse  should  not  be  anaemic,  since-  it  is  im- 
possible for  a  pale,  anaemic  woman  to  furnish  good  milk.  Preferably  she 
ishould  be  of  a  phlegmatic  temperament,  and  of  a  good  moral  character. 


WEANING.  167 

This  is  desirable  for  personal  reasons,  although  there  is  no  evidence  of 
moral  qualities  being  transmitted  through  the  milk.  It  is  desirable  that 
a  nurse  should  be  between  twenty  and  thirty  years  of  age,  although  much 
more  depends  upon  the  individual  than  ui)on  the  age.  Other  things  being 
equal,  a  primipara  should  be  chosen.  The  best  evidence  to  be  obtained 
of  the  character  of  a  woman's  milk  is  the  condition  of  her  own  child ; 
hence,  if  possible,  it  should  be  examined  before  she  is  accepted.  It  often 
happens  that  a  woman  who  has  had  an  abundant  supply  of  milk  for  her 
own  infant,  has  very  little  for  another  infant  for  the  first  few  days  in  her 
new  surroundings.  This  is  usually  the  result  of  the  nervous  influences 
connected  with  parting  from  her  own  child,  going  to  a  new  place,  being 
carefully  watched,  etc.  In  such  a  case  it  should  not  be  too  readily  de- 
cided that  she  is  incompetent  as  a  nurse,  for,  under  most  circumstances, 
with  proper  treatment  her  normal  flow  of  milk  will  be  re-established. 

III.  Weanixg. — Weaning  should  always  be  done  gradually,  when  pos- 
sible, for  the  sake  of  both  mother  and  child.  Sudden  weaning  is  apt 
to  be  followed  by  an  attack  of  acute  indigestion.  This,  ho\vever,  is  not 
an  invariable  result,  and  usually  depends  upon  the  fact  that  the  child  is 
given  cow's  milk  with  insufficient  dilution.  Weaning  in  hot  weather  is 
usually  to  be  avoided,  but  the  harm  from  this  is  not  nearly  so  great  as 
sometimes  results  where  lactation  is  unduly  prolonged  because  of  a  preju- 
dice against  a  change  of  food  at  this  time.  While  there  are  many 
women  of  the  lower  classes  who  are  able  to  nurse  their  children  to  advan- 
tage for  the  entire  first  year,  the  number  of  such  among  the  better  classes 
is  certainly  very  small.  By  the  latter,  nursing  can  rarely  be  continued 
beyond  the  ninth,  and  often  not  beyond  the  sixth  month,  ^vithout  unduly 
draining  the  vitality  of  the  mother  and  at  the  same  time  harming  the 
child.  The  late  months  of  lactation,  like  the  early  months,  require  close 
watching.  It  is  a  common  mistake  to  continue  both  maternal  and  wet- 
nursing  too  long,  owing  to  a  dislike  of  making  a  change  when  things  are 
going  tolerably.  It  is  a  safe  rule  to  make  the  ninth  month  the  time  to 
supplement  the  breast-feeding  by  other  food.  But  here,  as  in  tlie  early 
mouths,  the  child's  weight  is  the  best  guide.  In  the  absence  of  evident 
signs  of  disease,  a  stationary  weight  for  several  weeks  makes  weaning 
advisable  ;  a  steady  loss  makes  it  imperative. 

The  accompanying  weight-chart  from  a  private  patient  (see  Fig.  30) 
illustrates  this  point.  The  infant  was  nursed  by  the  mother,  and  did  un- 
usually well  until  the  sixth  month.  As  it  did  not  seem  ill,  the  parents 
were  not  disturbed  by  tlie  gradual  loss  in  weight,  and  I  was  not  consulted 
until  the  loss  had  reached  three  pounds.  Feeding  was  at  once  begun,  and 
in  a  week  all  nursing  was  stopped  and  the  child  gradually  regained  its  lost 
weight.  It  was  subsequently  discovered  that  the  mother  was  pregnant  at 
the  time  the  loss  was  going  on. 

When  a  nursing  infant  has  been  accustomed  from  birth  to  take  cither 


1G8 


NUTRITION. 


milk  or  simply  water  from  a  bottle  once  a  day,  as  is  the  practice  of  many 
physicians  to  order,  gradual  weaning  is  generally  an  easy  matter.  Other- 
wise it  is  sometimes  an  impossibility,  the  child  refusing  all  food  except 
the  breast  so  long  as  this  is  given,  and  nothing  but  starvation  inducing 
it  to  take  food  either  from  a  bottle  or  a  spoon.  Infants  will  sometimes 
refuse  food  until  so  weak  as  to  make  their  condition  serious. 

Sudden  weaning  may  be  required  at  any  time  from  the  development 
in  the  mother  of  acute  disease  of  a  serious  nature,  such  as  typhoid  fever 
or  pneumonia,  grave  chronic  disease,  such  as  tuberculosis  or  nephritis, 
from  the  intercurrence  of  pregnancy,  or  from  disease  of  the  mammary 
gland.     On  no  account  should  an  infant  be  suckled  at  a  breast  which  is 


Name 

3- 

__ 

_ 

_ 

_ 

__ 

._ 

._ 

__ 

._ 







_ 



Date 

ofBir 

f/ 

>■ 

_ 

_, 

_. 

.. 

_ 

__ 

__ 

_. 

J8p 

MONTH  OF  AGE.                                                           I 

GUS. 

LB5. 

1          2         3         4          5          6          7          8         9        10        11      121 

9530 
9070 
8C20 
SICO 
7710 
7260 
6S0O 
6350 
5900 
5410 
4990 
4510 
4080 
3C30 
31S0 
2720 
2270 

21 

20 
19 
18 
17 
16 
15 
11 
13 
12 
11 
10 
9 
8 
7 
6 
5 

■x 

Mn 

\v 

^ 

^ 

/ 

/ 

, 

/ 

y^ 

— 

^ 

/ 

\ 

"* 

U--' 

^ 

\ 

-  L^    -1— J 

— ■ 

kC^^'i^ 

-nn 

e 

ri 

^ 

"^ 

/ 

/ 

^ 

^ 

' 

/ 

y 

/" 

/ 

/ 

/\ 

/ 

/ 

/ 

/ 

/ 

- 

^ 

/ 

/ 

y 

/ 

/ 

/ 

I 

\/    '/ 

KV 

1 

\ 

1 

1 

1 

1 

Fig.  30. — Chart  showing  the  effect  of  precfnancy  upon  the  weight  ot  a  nursing  infant.     The 
upper  line  is  tliat  of  the  patient;  the  lower  one  is  the  average  line  for  the  first  year. 


the  seat  of  acute  inflammation.  Through  many  of  the  minor  ills — mild 
attacks  of  bronchitis,  pharyngitis,  indigestion,  and  even  malarial  fever — 
mothers  will  frequently  nurse  their  children  without  any  seeming  detri- 
ment to  them  or  themselves.  In  acute  illness  of  short  duration,  even  if 
severe,  it  is  usually  better,  unless  we  decide  to  wean  altogether,  to  main- 
tain the  flow  of  milk  by  the  use  of  the  breast-pump  rather  than  allow  it 
to  dry  up.     The  breasts  may  be  pumped  three  or  four  times  a  day. 

In  cases  of  sudden  weaning,  the  food  must  in  the  beginning  be  very 
much  weaker  than  for  an  artificially-fed  child  of  the  same  age.  If 
weaned  at  six  months,  the  child  should  be  put  upon  a  food  appropriate 
for  a  healthy  child  of  one  month  ;  if  at  nine  or  ten  months,  upon  a  food 
appropriate  for  one  of  three  or  four  months.     If  this  is  done,  the  change 


MIXED   FEEDING.  109 

can  be  made  without  causing  much  disturbance.  When  the  infant  has 
become  somewhat  accustomed  to  cow's  milk  the  strength  of  the  food 
may  be  gradually  increased. 

MIXED   FEEDING. 

By  mixed  feeding  is  meant  a  combination  of  breast-  and  artificial  feed- 
ing. This  may  be  resorted  to  in  any  case  in  which  the  milk-supply  of  the 
mother  is  insufficient,  or  when  the  drain  upon  her  health  is  unduly  great. 
In  most  cases  it  is  better  than  entire  artificial  feeding,  and  there  is  no 
objection  to  combining  the  two ;  but  before  allowing  a  mother  partly  to 
nurse  and  partly  to  feed  her  infant,  one  must  be  sure  that  the  quality  of 
the  milk  is  good.  This  is  to  be  determined  by  the  principles  given  in  the 
preceding  pages. 

It  is  well  from  the  very  outset  to  accustom  the  infant  to  take  one 
of  its  feedings,  or  at  least  to  take  water,  from  a  bottle  each  day.  In 
maternal  nursing,  the  occasional  feeding  which  is  usually  necessary,  be- 
comes then  an  easy  matter.  If  circumstances  make  it  desirable  to  relieve 
the  mother  of  night-nursing,  or  of  one  or  more  feedings  during  the  day, 
this  also  can  be  accomplished  without  difficulty.  If  the  child  is  beiug 
wet-nursed,  the  same  plan  is  advisable,  for  it  then  becomes  easy  to  put  an 
infant  u2:)ou  the  bottle  entirely  in  the  event  of  the  wet-nurse  leaving  sud- 
denly— a  not  uncommon  occurrence.  If  at  any  time  the  mother's  health 
begins  to  suffer,  she  should  be  relieved  of  two  or  more  nursings  a  day,  and 
the  bottle  substituted.  In  this  way  she  may  be  able  to  continue  lactation 
for  some  time  longer.  When,  however,  the  nursings  have  been  reduced 
to  only  two  or  three  daily,  the  milk  should  be  examined  frequently,  as  it 
is  apt  to  deteriorate  rapidly  in  quality.  Mixed  feeding  is  also  necessary 
in  many  cases  during  the  first  few  weeks,  while  the  mother's  milk  is  insuf- 
ficient in  consequence  of  anything  which  has  retarded  convalescence  after 
parturition.  It  often  happens  that  the  milk  becomes  abundant  and  of 
good  quality  when  the  mother  is  well  enough  to  be  up  and  out  of  doors, 
although  it  was  previously  scanty  and  of  inferior  quality.  Two  or  three 
feedings  a  day  from  the  bottle,  help  to  bridge  over  this  period  and  pre- 
vent the  child's  nutrition  from  suffering.  In  all  cases  of  mixed  feeding, 
the  food  should  be  the  same  as  when  the  child  is  fed  exclusively. 

ARTIFICIAL  FEEDING. 

There  are  several  fundamental  principles  which  must  be  constantly 
borne  in  mind  : 

1.  The  food  must  contain  the  same  constituents  as  woman's  milk,  viz., 
fat,  proteids,  carbohydrates,  inorganic  salts,  and  water. 

2.  These  constituents  must  be  present  in  about  the  same  proportion  as 
in  good  woman's  milk. 


170  NUTRITION. 

3.  As  nearly  as  possible  the  different  constituents  slionld  resemble 
those  of  woman's  milk  both  in  their  chemical  composition  and  in  their 
behaviour  to  the  digestive  fluids. 

4.  The  addition  to  the  food  of  very  young  infants  of  substances  not 
present  in  woman's  milk  (e.  g.,  starch)  is  unnecessary,  contrary  to  the  best 
physiology,  and,  if  used  in  any  considerable  quantity,  may  be  positively 
harmful. 

In  the  artificial  feeding  of  infants,  cow's  milk  is  selected,  as  it  furnishes 
all  the  necessary  elements,  although  not  in  the  proportions  required  by 
young  infants.  In  adapting  cow's  milk  to  infant-feeding,  it  is  necessary, 
first,  to  know  the  differences  in  the  composition  of  cow's  milk  and  woman's 
milk;  and,  secondly,  to  devise  the  simplest  means  of  overcoming  these 
differences,  in  order  to  secure  an  infant-food  which  closely  resembles 
average  woman's  milk  in  its  percentages  of  fat,  sugar,  proteids,  and  salts. 
But  this  is  not  all.  We  can  not  feed  all  infants  exactly  alike,  even  though 
they  are  of  the  same  age  and  weight.  Their  food  must  be  adapted  to  their 
powers  of  digestion.  In  breast-feeding  it  has  long  been  a  matter  of  com- 
mon observation  that  an  infant  might  thrive  perfectly  on  the  milk  of  one 
woman,  and  suffer  immediately  from  indigestion  when  put  npon  that  of 
another,  although  both  were  equally  healthy.  In  the  selection  of  a  wet- 
nurse  it  has  sometimes  been  necessary  to  try  a  dozen  before  one  could  be 
found  whose  milk  agreed  with  the  infant,  or,  in  other  words,  whose  milk 
contained  the  different  ingredients — fat,  sugar,  and  proteids — in  propor- 
tions exactly  suited  to  the  child's  condition.  Hence  it  is  necessary  to  vary 
the  proportions  of  the  different  constituents  in  order  to  meet  exactly  the 
requirements  of  the  individual  infant.  If  cow's  milk  disagrees  with  an 
infant,  the  proper  method  of  procedure  is  to  try  and  discover  which  of 
the  elements  of  cow's  milk  is  causing  the  disturbance,  and  to  change  the 
proportions  until  we  have  a  milk  which  the  child  can  easily  digest.  Re- 
duced to  its  lowest  terms,  the  problem  of  infant-feeding  consists,  first,  in 
obtaining  the  elements  of  the  food  separately ;  and,  secondly,  in  so  com- 
bining them  as  to  meet  the  needs  of  the  case  in  hand.  For  this  simplifica- 
tion of  the  problem  the  world  is  indebted  to  Rotch. 

In  feeding  infants  according  to  this  plan,  it  is  necessary  to  have  a 
method  of  expressing  in  exact  terms  the  composition  of  the  food  used. 
This  can  be  done  only  by  giving  the  percentages  of  the  fat,  sugar,  pro- 
teids, and  salts  which  the  milk  contains.  The  mere  statement  of  the 
amount  of  milk  or  cream  used  conveys  no  definite  idea,  as  these  differ  so 
much  in  their  composition.  Only  by  stating  percentages  can  we  record 
our  own  experience  or  compare  our  results  with  those  of  others.  This 
new  nomenclature,  although  perhaps  a  little  difficult  at  first,  is  easily  mas- 
tered, and  is  absolutely  necessary  in  scientific  infant-feeding. 

The  Modification  of  Cow's  Milk  for  Healthy  Infants  dueing' 
THE  First  Year. — In  modifying  cow's  milk  for  infant-feeding,  our  cal- 


ARTIFICIAL  FEEDING. 


ni 


dilations  are  based  upon  the  composition  of  good  breast-milk,  as  deter- 
mined by  the  latest  analyses  : 


Fat 

Sugar.. . 
Proteids, 
Salts.... 
Water.. . 


Woman's  milk, 
average. 


Per  cent. 

4-00 
7-00 
1-50 
0-20 
87-30 


100-00 


Cow's  milk,  aver- 
age. 


Per  cent. 

8-50 
4-30 
4-00 
0-70 

87-50 


100-00 


We  have,  therefore,  in  cow's  milk,  an  excess  of  proteids  and  salts,  too  little 
sugar,  and  of  fat  aboiit  the  quantity  required.  Other  conditions  which 
must  be  considered  are  the  presence  of  bacteria  in  cow's  milk,  its  acid 
reaction,  and  the  fact  that  its  proteids  are  more  difficult  of  digestion. 
The  same  is  probably  true  of  the  fat  in  the  condition  in  which  we  feed 
it,  but  to  a  much  less  degree. 

Fat. — The  average  amount  of  the  fat  of  cow's  milk  which  a  healthy 
infant  can  digest  varies  from  2  to  4  per  cent.  It  is  rarely  necessary  in 
.health  to  go  either  above  or  below  these  proportions.  Beginning  with  2 
per  cent  in  the  early  days  of  life,  the  amount  may  be  increased  to  3  per 
cent  at  one  month,  and  to  4  per  cent  at  five  or  six  months.  Xo  other 
modification  in  the  fat  is  necessary. 

Sugar. — In  woman's  milk  the  percentage  of  sugar  is  remarkably 
constant  under  all  conditions — between  6  and  7  per  cent.  In  feeding 
cow's  milk  it  is  seldom  required  to  have  the  sugar  less  than  5  and 
never  more  than  7  per  cent.  This  is  the  simplest  part  of  the  modifi- 
cation. As  the  sugar  in  milk  is  simply  lactose  in  solution,  it  is  only 
necessary  to  calculate  the  amount  required  to  be  added  to  bring  this 
up  to  the  6  or  7  per  cent  desired.  The  milk  sugar  should  be  first 
dissolved  in  boiling  water,  and,  when  it  contains  impurities,  filtered 
through  absorbent  cotton.  It  should  be  prepared  at  least  every  second 
day,  and  in  summer  daily.  It  is  more  rational  in  theory,  and  certainly 
better  in  practice,  to  use  milk  sugar  rather  than  cane  sugar,  since  the 
former  supplies  what  exists  in  woman's  milk.  It  should  be  distinctly 
understood  that  the  purpose  of  adding  sugar  to  milk  is  not  to  sweeten 
the  food,  but  to  furnish  the  proper  proportion  of  a  soluble  carbohy- 
drate necessary  for  the  infant's  nutrition.  When,  however,  good  milk 
sugar  can  not  be  obtained,  cane  sugar  may  be  substituted ;  the  amount 
added  must  be  but  little  more  than  half  that  of  milk  sugar  on  account  of 
its  sweeter  taste,  and  greater  liability  to  ferment  in  the  stomach. 

Proteids. — The  modification  of  the  proteids  is  the  most  important 
change  necessary  in  cow's  milk,  for  it  is  the  proteids  which  give  most  of 
the  trouble  to  the  infant  digestion.     In  ordinary  cases  in  health,  a  reduc- 


172 


NUTRITION. 


tion  in  tlie  amount  is  all  that  is  necessary.  But  for  very  young  infants  it 
is  not  enough  to  reduce  the  proteids  to  the  proportion  present  in  average 
woman's  milk — 1-5  per  cent.  In  the  beginning,  and  even  during  the  first 
months,  we  must  go  considerably  below  this  point,  usually  to  1  per  cent, 
and  for  the  first  few  weeks  to  0-75  or  even  0-50  per  cent.  The  secret  of 
success  in  feeding  cow's  milk,  is  to  reduce  the  proteids  at  the  start  to  a 
proportion  which  the  infant  can  easily  digest,  and  then  gradually  increase 
the  amount.     By  the  end  of  the  first  month  the  average  child  can  take 

1  per  cent,  by  the  fourth  month  1-5  per  cent,  and  by  the  sixth  month 

2  per  cent. 

This  reduction  in  the  proteids  is  effected  by  dilution  with  water.  In 
the  following  table  is  shown  the  result  of  various  dilutions  upon  the  pro- 
teids and  inorganic  salts  : 


Cow's  milk. 

Diluted  once. 

Diluted  twice. 

Diluted  three 
times. 

Diluted  four 
times. 

Proteids 

Salts 

Per  cent. 

4-00 
0-70 

Per  cent. 

2-00 
0-85 

Per  cent. 

1-83 
023 

Per  cent. 

1-00 
0-18 

Per  cent. 

0-80 
014 

Inorganic  Salts. — These,  like  the  proteids,  are  excessive  in  cow's  milk, 
and  nearly  to  the  same  degree.  When,  therefore,  milk  is  diluted  as  re- 
quired by  the  proteids,  the  salts  will  be  nearly  in  their  proper  proportion, 
and  they  may  be  dismissed  from  separate  consideration. 

Reaction. — The  acidity  of  cow's  milk  may  be  overcome  by  the  addition 
either  of  lime  water  or  bicarbonate  of  soda.  Of  the  former  there  is  re- 
quired about  one  ounce  to  each  twenty  ounces  of  the  food  ;  of  the  latter, 
about  one  grain  to  each  ounce  of  the  food. 

The  subject  of  heating  milk  for  the  destruction  of  bacteria  has  been 
considered  in  a  previous  chapter  (page  143). 

Milk  Laboratories. — There  have  been  established  in  Boston,  New  York, 
and  other  cities,  laboratories  which  undertake  to  furnish  "  modified 
milk"  of  any  desired  proportions,  upon  the  prescription  of  physicians, 
exactly  as  drugs  are  dispensed  by  an  apothecary.  The  elements  used  by 
these  laboratories  are:  (1)  cream  containing  16  percent  fat;  (2)  separ- 
ated milk  from  which  the  fat  has  been  removed  by  the  centrifugal  ma- 
chine ;  (3)  a  standard  solution  of  milk  sugar,  20  per  cent  strength. 
These  contain  fat,  sugar,  and  proteids  in  the  following  proportions  : 


Cream. 

Separated  milk. 

Sugar  solution. 

Fat 

Per  cent. 

1600 
4-00 
3-60 

Per  cent. 

0-13 
4-40 
4-00 

Per  cent. 

Susrar 

20-00 

Proteids 

ARTIFICIAL   FEEDING.  I73 

By  combining  these  it  is  possible  to  vary  the  percentages  of  fat,  sugar, 
and  proteids  in  the  milk  to  almost  any  degree  desired,  and  to  do  this  with 
very  great  accuracy.  At  the  present  time  a  separate  modification  of  the 
inorganic  salts  is  not  attempted.  The  physician,  in  ordering  the  food, 
simply  writes  for  the  percentages  of  fat,  sugar,  and  proteids  desired,  with 
the  number  of  feedings  for  twenty-four  hours  and  the  quantity  for  each 
feeding.  The  food-supply  for  an  entire  day  is  delivered  each  morning 
in  the  bottles  from  which  it  is  to  be  fed.  The  laboratory  also  under- 
takes to  heat  milk  to  any  temperature  that  may  be  desired.  The  follow- 
ing is  the  form  in  which  prescriptions  are  written  : 

^     Fat .3  per  cent. 

Sugar 6        " 

Prot  eids 1         " 

Alkalinity,  limewater 5  per  cent. 

Number  of  feedings 8 

Amount  for  each  feeding 4  ounces. 

Heat  to  167"  F.,  25  minutes. 

The  establishment  of  the  milk  laboratory,  for  which  the  profession  is 
indebted  to  Rotch,  is  a  great  stride  in  advance  in  infant-feeding,  as  it 
enables  the  physician  to  know  what  his  patient  is  taking,  at  the  same  time 
making  it  possible  to  vary  any  one  of  the  constituents  of  the  food  separ- 
ately, even  to  a  fraction  of  one  per  cent,  until  the  combination  is  reached 
which  is  exactly  suited  to  the  infant's  digestion.  With  the  assistance  of 
the  milk  laboratory,  infant-feeding  can  be  done  with  something  like  sci- 
entific accuracy.  The  laboratory  company  has  the  direct  oversight  of  the 
breeding,  care,  and  food  of  cows  and  the  handling  of  milk,  to  insure  its 
purity,  freshness,  and  cleanliness.  The  practical  workings  of  the  milk 
laboratories  are  so  satisfactory  that  we  shall  doubtless  see  them  established 
in  all  large  cities.     The  only  drawback  is  the  expense. 

After  three  years'  experience  I  have  found  the  laboratory  of  great  value 
in  difficult  cases  of  infant-feeding,  and  it  soon  becomes  almost  as  much 
of  a  necessity  to  the  physician  practising  among  young  children,  as  does 
the  apothecary  shop  to  the  general  practitioner.* 

As  a  general  guide  to  the  modification  of  milk  for  an  average  infant 
the  following  table  is  introduced,  showing  the  changes  required  with  the 
age  of  the  child  : 

*  For  fuller  details  regarding  the  milk  laboratory,  see  Rotch,  Archives  of  Pajdiatrics, 
February,  1893. 


174: 


NUTRITION. 


Schedule  for  feeding  an  average  healthy  infant  from  birth  upon  modi- 
fied cow^s  milk,  showing  percentages  of  fat,  sugar,  and  proteids,  and 
the  daily  quantity. 


No. 


I 

II 
III 
IV 

V 

VI 

VII 

VIII 

IX 

X 
XI 


Fir*;t  and  second  day 

Third  to  fourteenth  day 

Two  to  four  weeks 

One  to  three  months 

Three  to  five  months 

Five  to  six  months 

Six  to  nine  months 

Nine  to  twelve  months 

Twelve  to  fifteen  months  . . . 
Fifteen  to  eighteen  months. . 
Eighteen  months  (whole  milk) 


Sugar. 


Per  cent. 

5-0 
6-0 
6-0 
60 
6-0 
7-0 
7-0 
G-0 
5-0 
5-0 
4-3 


Proteids. 


0-60 
0-80 


1-00 
1-25 
1-50 
200 
2-50 
3-00 
3-50 
4-00 


Daily  quantity. 


Ounces. 

4-  8 
10-15 
20-30 
22-36 
28-38 
32-38 
34-42 
38-45 
40-50 
45-50 
45-50 


Grammes. 

125-   250 

310-   460 

620-   930 

680-1,110 

870-1,180 

990-1,180 

1,050-1,300 

1,180-1.400 

1,240-1.550 

1,400-1,550 

1,400-1,550 


In  ordering  milk  for  an  infant,  not  only  its  age  but  its  weight  must  be 
taken  into  account.  One  that  at  four  months  weighs  as  much  as  the 
average  child  at  eight  months,  will  usually  be  found  able  to  take  the 
quantity  of  food  and  also  the  percentages  advised  for  the  latter  age. 
Again,  there  are  many  cases  where  the  percentages  of  the  milk  must  be 
increased  more  slowly  than  in  the  schedule.  As  a  rule,  it  is  wise  to 
increase  the  strength  of  the  food  just  as  fast  as  the  child's  digestion  will 
permit. 

Modification  of  Milk  at  Home. — Inasmuch  as  milk  laboratories  are  as 
yet  accessible  to  but  very  few  physicians,  the  problem  presented  is  how 
to  secure  similar  results  by  simple  methods  when  milk  is  "modified"  at 
home.  If  directions  are  followed,  resttlts  may  be  obtained  suflficiently 
accurate  for  practical  purposes  in  the  great  majority  of  cases.  However, 
considerable  care  and  intelligence  are  necessary. 

The  elements  with  which  the  formulse  desired  are  most  conveniently 
obtained  are  :  (1)  a  12-per-cent  cream— i.  e.,  one  that  contains  12  per  cent 
fat ;  (2)  an  8-per-cent  cream  ;  (3)  solutions  of  milk  sugar  of  5,  6,  7,  8,  and 
10  per  cent  strength. 

The  12-per- cent  cream  may  be  obtained  in  the  city  by  using  equal 
parts  of  ordinary  (20  per  cent)  centrifugal  cream  and  plain  milk  ;  in  the 
country,  by  using  two  parts  of  ordinary  skimmed  or  gravity  (16  per  cent) 
cream  *  and  one  part  of  plain  milk  ;  or  by  taking  the  upper  fifth  of  the 
niilk  after  standing  five  or  six  hours,  in  the  manner  described  on  page  142. 

The  8-per-cent  cream  may  be  obtained  in  the  city  by  using  one  part  of 
centrifugal  (20  per  cent)  cr^am  and  three  parts  of  plain  milk  ;  in  the 
country,  by  using  one  part  of  gravity  cream  and  two  parts  of  plain  milk  ; 


*  This  is  the  ordinary  cream  twelve  hours  old.     It  should  be  set  at  night  and  used 
in  the  morning. 


ARTIFICIAL  FEEDING.  I75 

or  by  using  the  upper  third  of  the  milk  after  standing  five  or  six  hours,  as 
described  on  page  142. 

The  sugar  solutionis  are  obtained  as  follows  : 

A  5-per-cent  solution:  Dissolve  an  ounce  of  milk  sugar*  in  twenty 
ounces  of  water,  or  one  even  tablespoonf ul  f  in  seven  and  a  half  ounces  of 
water. 

A  6-per-cent  solution  :  Dissolve  one  ounce  of  sugar  in  sixteen  and  a 
half  ounces  of  water,  or  one  even  tablespoonf  ul  in  six  and  a  half  ounces 
of  water. 

A  7-per-cent  solution :  Dissolve  one  ounce  of  sugar  in  fourteen  ounces 
of  water,  or  one  even  tablespoonful  in  five  and  a  half  ounces  of  water. 

An  8-per-cent  solution  :  Dissolve  one  ounce  of  sugar  in  twelve  and  a 
half  ounces  of  water,  or  one  even  tablespoonful  in  four  and  a  half  ounces 
of  water. 

A  10-per-cent  solution:  Twice  the  strength  of  a  five-per-cent  solu- 
tion. 

With  these  ingredients  it  is  a  comparatively  easy  matter  to  make  up 
with  approximate  accuracy  the  various  formulee  required.  Formulae  II  to 
YI  inclusive  may  be  obtained  from  the  12-per-cent  cream  by  simply  dilut- 
ing this  five,  four,  three,  two  and  a  half,  and  two  times  respectively  with 
a  6-  or  7-per-cent  sugar  solution.  This  will  be  plain  from  the  followirg 
table  : 

Formulee  obtained  by  diluting  Ticelve-per-cent  Cream. 

Diluting  5  times  X  with  6^  sugar  solution  =  II :    Fat  2'Ofc 
4      '•  "     G%      "  "        =111:     "    2-5^ 

3       "  "      "!%      "  "        =IV:     "    Z-Ofc 

2J     "  "     7<^      "  "        =V:       "    Z-Qfo 

2      "  "     1%      "  "        =VI:     "   4-0<g 


sugar,  %%;  proteids,  O'GOji. 
"  G^;  "  0-80,^. 
"  H;  "  1-00^. 
"  G$?;  "  1-20^. 
"      H;        "         1-30^. 


In  all  these  formulas  it  will  be  seen  that  the  ratio  of  the  fat  to  the 
proteids  is  three  to  one.  Not  only  these  formulse,  but  any  intermediate 
ones  with  this  ratio,  may  be  derived  by  varying  the  dilution.  The  sugar 
may  be  easily  modified,  if  desired,  by  using  weaker  or  stronger  solutions 
than  those  mentioned.  With  these  formulae  an  average  infant  may  be 
carried  through  the  first  six  months,  the  period  when  accurate  modifica- 
tion is  most  needed. 

Formula  YII  is  obtained  from  an  S-jier-cent  cream  by  diluting  once 
with  a  10-per-cent  sugar  solution  ;  and  in  a  similar  way  are  derived  other 
formula3  in  which  the  fat  and  the  proteids  bear  the  relation  of  two  to  one  : 

*  A  convenient  method  is,  to  obtain  from  a   druggist  a  box  holding  exactly  one 

ounce  of  milk  sugar. 

t  One  even  tablespoonful  may  be  calculated  as  three  drachms. 

X  By  diluting  five  times  is  meant  one  part  of  the  cream  and  five  parts  of  the  sugar 

solution,  etc. 

13 


176  NUTRITION. 

FormuloR  obtained  by  diluting  Eight-per-cent  Cream. 

Diluting  once       with  10^  sugar  solution  =  VII:     Fat,  4%:  sugar,  7^;  proteids,  "2  •  00^. 
li  times  "       Hfc      "  "         =  XII :        "     3%;       "      6^;  "         1-50^. 

3'  times   "       7%      "  "         =  XIII :     "     2%;       "      6%;  "         1-00;^. 

7        "       "       5%      "  "         =XIV:     "     \%;       "      0%;  "        0-50^. 

It  is  in  many  cases  desirable  to  use  a  lower  percentage  of  fat  than  in 
the  foregoing  formulae  without  reducing  the  proteids.  This  may  be  done 
simply  by  diluting  plain  milk  with  a  sugar  solution.  In  these  formulae 
the  fat  and  proteids  are  nearly  in  the  same  proportions,  viz.  : 

FormuloR  obtained  by  diluting  Plain  Milk. 

Diluting  once      with  8^  sugar  solution  =  X  V :      Fat,  1  •  80^  ;  sugar,  i5% ;  proteids,  2  •  00^. 

3  times     "     5%      "  "        =  XVI :      "     0-90/^;       "      b%;         "         1-00^. 

7      "        "     4%      "  "        =XVII:     "     0-455^;       "      Ai;         "         0-50^. 

"       11      "         "     A%      "  "        =  XVIII:  "     0-30<?;       "      A%;         "        0-34^. 

From  the  three  fundamental  formulae — 12-per-cent  cream,  8-per-cent 
cream,  and  plain  milk — we  may  readily  derive  almost  any  desired  formula 
in  which  the  proportion  of  fat  is  to  that  of  the  proteids  as  three  to  one, 
two  to  one,  or  where  they  are  about  equal. 

Following  out  the  directions  given  in  the  preceding  pages,  the  prepa- 
ration of  an  infant's  milk  should  be  somewhat  as  follows  :  The  first  thing 
to  be  decided  is  the  formula  to  be  used,  then  the  size  of  each  feeding  and 
the  number  of  feedings;  as  it  is  always  preferable  to  prepare  at  one  time 
the  entire  amount  of  food  required  for  twenty-four  hours.  Let  us  suppose 
we  wish  to  give  a  milk  containing  fat  3  per  cent,  sugar  6  per  cent,  and 
proteids  1  per  cent  (formula  IV),  and  that  we  require  nine  feedings  of 
four  ounces,  or  thirty-six  ounces  of  food  to  be  prepared.  By  referring  to 
page  175  we  see  that  this  formula  can  readily  be  obtained  by  diluting  a  12- 
per-cent  cream  three  times  with  a  7-per-cent  sugar  solution.  There  will 
thus  be  required,  nine  ounces  of  the  12-per-cent  cream  and  twenty-seven 
ounces  of  the  7-per-cent  sugar  solution.  The  cream  may  be  obtained  by 
taking  four  and  a  half  ounces  of  centrifugal  (20  per  cent)  cream  and 
four  and  a  half  ounces  of  milk,  or  six  ounces  of  skimmed  (16  per  cent) 
cream  and  three  ounces  of  milk.  For  the  sugar  solution  there  will  be 
required  two  ounces,  or  five  and  a  half  even  tablespoonfuls,  of  milk  sugar, 
to  be  dissolved  in  the  twenty-seven  ounces  of  boiling  water ;  or,  if  lime- 
water  is  to  be  added,  one  and  a  half  ounces  of  lime  water  and  twenty-five 
and  a  half  ounces  of  boiling  water.  The  full  directions,  written  out  for 
the  guidance  of  a  nurse,  will  then  be  as  follows  : 

Centrifugal  cream,    4J  ounces,  |        i  skimmed  cream,  6  ounces. 

Plain  milk,  4^      "         f       j  plain  milk,  3       " 

Milk  sugar,  2        •'  or     5|  even  tablespoonfuls. 

Boiling  water,         25^      "        \  ot\  ^°'^i"&  water,  27  ounces. 

Lime  water,  1\  ounce,   )        (  bicarbonate  of  soda,  36  grains. 


ARTIFICIAL   FEEDIXa. 


17 


Dissolve  the  milk  sugar  in  tlie  boiling  water,  filter  through  cotton,  add 
the  milk  and  cream,  and  mix  all  in  a  pitcher  ;  then  add  limewater  or 
soda,  and  divide  in  nine  bottles,  stopping  them  with  cotton. 

If  the  milk  is  to  be  heated  for  purposes  of  sterilization,  directions  for 
this  should  follow ;  if  not,  the  bottles  sliould  be  rapidly  cooled  by  stand- 
ing in  cold  water  for  fifteen  minutes,  during  which  the  water  should  be 
changed  once  or  twice,  or  kept  cold  by  adding  ice.  The  food  should  now 
be  placed  in  an  ice-chest,  where  it  is  kept  until  required.  It  should  be 
warmed  by  placing  the  bottle  in  warm  water,  and  shaken  before  it  is  fed. 

Although  at  first  glance  the  preparation  of  food  in  the  manner  indi- 
cated may  seem  too  complicated  for  general  use,  such  is  really  not  the 
case.  The  labour  involved  is  not  greater  than  when  milk  is  prepared  in  a 
more  irregular  way,  and  any  intelligent  mother  or  nurse  is  fully  compe- 
tent to  carry  out  all  the  directions  given  when  once  they  have  been  fully 
explained. 

To  save  the  physician  the  trouble  of  calculating  the  exact  quantity  of 
each  of  the  ingredients  required  for  the  formulae  most  used — viz.,  II,  IV, 
and  VII — there  are  given  in  the  subjoined  table  the  amounts  needed  for 
the  preparation  of  twenty-foUr,  thirty-two,  forty,  and  forty-eight  ounces 
respectively  of  food  : 


No. 


II. 


IV. 


VII. 


Formula. 


Ingredients. 


Fat,  3-05?  Milk. 

Sugar,      6-0^  Cream  (skimmed,  16^) 

Proteids,  0-G;?|  Water 

Milk  sug.ir,  ounces 

Or  milk  sugar,  even  tablespoonf uls . 


Fat,  3-0:? 

Sugar,      6  ■  0% 
Proteids,  1-0^ 


Fat,  4 

Sugar,      7- 
Proteids,  2' 


Milk 

Cream  (skimmed,  16j?) 

Water 

Milk  sugar,  ounces 

Or  milk  sugar,  even  tablespoonf  uls. 

Milk 

Cream  (skimmed,  16^) 

Water 

Milk  sugar,  ounces 

Or  milk  .-^ugar,  even  tablespoonf  uls. 


QUANTITY  OF  EACH  INGREDIENT 
REQUIRED   TO    PREPARE    THE    FOL- 
LOWING   AMOUNTS   OF   FOOD. 


24  oz. 

32  oz. 

40  oz. 

48  oz. 

l|oz. 

If  OZ. 

2ioz. 

2|oz. 

2i  " 

3+" 

4i  " 

5i  " 

20     " 

2()f  " 

334  " 

40     " 

n  '• 

1^  " 

2     " 

2^  *♦ 

3     " 

4     " 

5i" 

6i  « 

2     " 

2i  " 

3i  " 

4     " 

4     " 

5i  " 

GJ" 

8    " 

18    " 

24     " 

30    " 

36    " 

U" 

1^  " 

3    " 

2^  " 

3     " 

4     " 

5^  '• 

6i" 

8     " 

10^  " 

13*" 

16    " 

4    " 

•H  " 

Of  " 

8    " 

12     " 

Hi     '• 

20     " 

24     " 

H  '• 

1^  " 

2    " 

n  " 

3     " 

4     " 

5i" 

6i" 

If  the  centrifugal  (20  per  cent)  cream  is  used,  equal  parts  of  milk  and 
cream  should  be  taken  for  formula?  Hand  IV  ;  while  for  formula  VII  the 
proportions  should  be  one-fourth  cream  and  three-fourths  milk.  When 
limewater  is  to  be  added,  it  should  replace  the  same  quantity  of  plain 
water.  The  same  is  true  of  barley  water,  if  used  with  formula  VII,  as  is 
sometimes  desirable. 


178 


NUTRITION. 


For  older  infants,  able  to  take  a  stronger  milk  than  formula  VII,  j^ro- 
portions  similar  to  formula  VIII  (p.  174)  may  be  obtained,  thus: 
Milk,  24  oz. ;  cream  (16$^),  7  oz. ;  water,  19  oz. ;  sugar,  2  oz.  =  50  oz. 

Bottles  and  iiipples. — The  best  style  of  bottle  is  that  which  can  be 
most  readily  cleaned.  The  cylindrical  bottles  with  Avide  mouths  are  now 
generally  preferred.  Some  trouble  in  measuring  the  food  is  avoided  if 
graduat-ed  bottles  are  used.  On  no  account  should  bottles  with  any  com- 
plicated apparatus  be  allowed.  The  best  nipples  are  those  of  plain  black 
rubber,  which  slip  over  the  neck  of  the  bottle.  Those  with  a  long  rubber 
tube  going  to  the  bottom  of  the  bottle  should  not  be  used,  as  it  is  prac- 
tically impossible  to  keep  them  clean.  The  hole  in  the  nipple  should  be 
large  enough  for  the  milk  to  drop  rapidly  when  the  bottle  is  inverted, 
but  not  so  large  that  it  will  run  in  a  stream.  When  not  in  use,  nipples 
should  be  kept  in  a  solution  of  borax  or  boric  acid.  The  most  scrupulous 
care  is  necessary  of  both  bottles  and  nipples.  Bottles  should  first  be  rinsed 
with  cold  water,  then  washed  with  hot  soap  suds  and  a  bottle-brush.  AYhen 
not  in  use  they  should  stand  full  of  water.  Before  the  milk  is  put  into 
them  they  should  be  sterilized  by  lying  for  twenty  minutes  in  boiling  water. 

Rules  for  artificial  feeding. — A  bottle  should  not  be  warmed  over  for 
a  second  feeding.  A  child  should  not  be  more  than  twenty  minutes  in 
taking  its  food,  and  should  not  be  allowed  to  sleep  with  the  nipple  of  the 
bottle  in  its  mouth.  It  is  preferable  to  have  the  child  held  in  the  arms 
of  the  nurse  while  taking  its  bottle.  If  this  is  not  done,  the  bottle  should 
at  least  be  held  in  such  a  position  that  the  child  gets  milk,  and  not  air, 
from  the  bottle.  It  is  even  more  necessary  than  in  breast-feeding  that 
rules  as  to  frequency  and  regularity  of  meals  should  be  observed.  The 
following  table  gives  the  size  of  the  meals,  and  the  daily  quantity  of  food, 
as  well  as  the  number  of  meals  and  intervals  of  feeding.  This  is  con- 
structed for  an  average  infant  in  health.  An  infant  much  above  the 
average  in  weight  must  usually  have  its  food  graded  accordingly. 

Schedule  for  Feeding  Healthy  Infants  during  the  First  Year. 


Age. 

No.  of 
feed- 
ings. 24 
hours. 

Inter- 
val be- 
tween 
meals, 
by  day. 

Night 
feed- 
ings (10 
p.  M.  to 

7  A.  M.). 

Quantity  for  one 
feeding. 

Quantity  for  24  hours. 

3d  to  7th  dav 

10 
10 
9 
-    8 
7 
6 
5 

Hours. 

2 
2 
2 

3 
3 

3* 

3 
2 
1 
1 
1 
0 
0 

Ounces. 

1  -n 

1^3 
2^-3i 

3  -4i 

4  -5^ 
5i-7 
7^9 

Grammes. 

30-  45 

45-  90 

75-110 

90-140 

125-170 

170-220 

235-280 

Ounces. 

10-15 
15-30 
22-33 
24-36 
28-38 
83-43 
37-45 

Grammes. 

310-   460 

2d  and  3d  weeks 

4th  and  5th  weeks 

6th  week  to  3d  month . . . 

3d  to  5th  month 

5th  to  9th  month 

9th  to  12th  month 

460-   930 
680-    990 
740-1,110 
870-1,080 
1,020-1,300 
1,150-1,400 

ARTIFICIAL   FEEDING.  179 

Modification  of  Milk  required  by  Particular  Symptoms. — Regarding 
the  exact  indications  according  to  which  the  fat,  sugar,  and  proteids  of 
milk  are  to  be  varied  in  infant-feeding,  much  is  yet  to  be  learned.  The 
following  are  the  points  which  experience  has  thus  far  led  me  to  depend 
upon  : 

If  the  sugar  is  too  low,  the  gain  in  weight  is  apt  to  be  slower  than 
when  it  is  furnished  in  proper  amount.  The  symptoms  most  frequently 
indicating  an  excess  of  sugar  are  colic,  or  thin,  green,  very  acid  stools, 
sometimes  causing  irritation  of  the  buttocks.  In  some  cases,  where  the 
sugar  is  in  excess,  there  is  much  eructation  of  gas  from  the  stomach,  and 
regurgitation  of  small  quantities  of  food. 

An  excess  of  fat  is  indicated  by  vomiting  or  the  regurgitation  of  food 
in  sm:ill  quantities,  usually  one  or  two  hours  after  feeding.  It  is  some- 
times shown  by  frequent  passages  from  the  bowels,  which  are  nearly  nor- 
mal in  appearance.  In  some  cases  the  stools  contain  small  round  lumps 
somewhat  resembling  casein,  but  really  composed  of  masses  of  fat.  In. 
rare  cases  an  excess  of  fat  may  be  the  cause  of  colic.  The  most  constant 
indication  that  too  little  fat  is  given,  is  constipation  with  dry,  hard  stools  ; 
but  it  should  not  be  forgotten  that  such  stools  are  sometimes  seen  when 
the  fat  is  not  too  low.  To  increase  the  fat  above  4  per  cent  in  feeding 
infants  under  six  months  old,  simply  because  of  constipation,  is,  I  think, 
a  mistake.  I  have  rarely  seen  any  advantage  and  often  much  disturbance 
from  higher  fats. 

The  most  reliable  indication  that  the  proteiils  are  in  excess  is  the 
presence  of  curds  in  the  stools.  This  condition  is  also  a  frequent  cause 
of  colic — indeed,  of  most  of  the  colic  of  early  infancy.  Sometimes  there  is 
diarrhoea,  but  more  frequently  there  is  constipation,  especially  when  the 
excess  of  proteids  is  great.  This  condition  may  be  the  cause  of  vomiting 
or  the  regurgitation  of  small  quantities  of  food  from  time  to  time.  Im- 
perfect digestion  of  the  proteids  may  cause  the  same  symptoms  as  when 
they  are  in  excess,  and  the  same  may  be  true  of  the  fat  and  of  the  sugar. 
Often  the  difficulty  may  be,  not  that  the  proportion  of  the  different  ele- 
ments of  the  food  is  actually  in  excess,  but  that  more  is  given  than  the 
infant  can  digest  at  the  time,  and  in  any  event  the  amount  should  be 
reduced. 

It  is  not  practicable,  even  were  it  possible,  to  modify  the  milk  so  as  to 
meet  every  temporary  symptom  of  discomfort  an  infant  may  have.  In 
general  the  most  important  indications  may  be  summarized  as  follows : 
if  not  gaining  in  weight  without  special  signs  of  indigestion,  increase  the 
proportions  of  all  the  ingredients ;  if  habitual  colic,  diminish  the  pro- 
teids; for  frequent  vomiting  soon  after  feeding,  reduce  the  quantity;  for 
the  regurgitation  of  sour  masses  of  food,  reduce  the  fat,  and  sometimes 
also  the  proteids  ;  for  obstinate  constipation,  increase  both  fat  and  pro- 
teids. 


180  NUTRITION. 

The  Use  of  other  Food  than  Milk  during  the  First  Year. — 
In  the  discussion  up  to  this  point,  nothing  but  the  elements  of  milk 
has  been  considered.  Upon  these  alone  the  infant  can  best  be  nour- 
ished during  the  greater  part  of  the  first  year.  The  addition  of  other  food 
should  usually  be  deferred  until  the  eighth  or  ninth  month.  At  this  period 
the  power  of  digesting  starch  is  suflBciently  strong  for  the  infant  to  receive 
some  of  its  carbohydrates  in  this  form,  instead  of  all  of  it  in  the  form  of 
sugar,  as  has  been  previously  the  case.  As  starch  is  added,  the  sugar 
should  be  gradually  reduced.  The  form  of  starch  used  may  be  a  gruel 
made  of  barley,  oatmeal,  or  arrowroot,  or  some  of  the  farinaceous  foods 
(page  156).  If  barley  is  used,  the  proper  proportion  to  begin  with,  is  to 
make  the  food  about  one  third  its  volume  of  barley  water  of  the  strength 
mentioned  on  page  155.  This  will  take  the  place  of  the  same  quantity  of 
boiled  water  in  the  preparation  of  the  food.  It  will  then  be  added  to  each 
one  of  the  feedings.  By  the  eleventh  or  twelfth  month  the  quantity  of 
barley  may  be  further  increased  by  making  the  barley  water  stronger, 
rather  than  by  using  a  larger  quantity.  The  choice  between  the  different 
cereals  will  depend  upon  the  case.  Where  there  is  a  tendency  to  constipa- 
tion, oatmeal  water  is  to  be  preferred ;  at  other  times  barley.  The  only 
other  thing  to  be  advised  during  the  first  year  is  beef-juice  (for  prepara- 
tion, see  page  153),  This  may  be  begun  in  the  tenth  or  eleventh  montfi. 
At  first  only  half  an  ounce  should  be  given  daily,  either  alone  or  added 
to  the  milk.  Later  the  daily  quantity  may  be  increased  to  three  ounces, 
given  with  two  of  the  feedings. 

Feeding  in  Difficult  Cases. — Thus  far  we  have  dwelt  upon  the 
management  of  the  food  for  healthy  infants  of  average  digestion,  or, 
in  other  words,  normal  cases.  There  remain  to  be  considered  the  modi- 
fications required  for  infants  with  feeble  digestion — the  difficult  cases. 
This  group  is  quite  a  large  one.  Some  of  these  are  delicate  children 
with  feeble  digestion  from  birth,  a  class  more  numerous  in  the  city  than 
in  the  country;  but  there  is  a  much  larger  number  with  chi'onic  dis- 
turbances of  digestion  due  to  previous  bad  methods  of  feeding,  or,  what 
may  be  just  as  serious,  improper  nursing.  In  other  cases  the  condition 
of  feeble  digestion  is  the  result  of  unhygienic  surroundings.  In  still 
others  it  is  the  consequence  of  previous  attacks  of  acute  disease  of  the 
■digestive  organs  or  of  some  general  disease,  such  as  influenza,  whoop- 
ing-cough, or  pneumonia.     In  all  the  problem  is  essentially  the  same, — to 

■  adapt  the  food  to  an  infant  whose  powers  of  digestion  and  assimilation 

■  are  very  feeble  and  easily  disturbed.  Time,  patience,  a  careful  study  of 
individual  cases,  and  close  attention  to  details  are  necessary  to  secure  the 
best  results.  The  general  care  required  by  these  children  is  equally  as 
important  as  their  food.  This,  however,  is  considered  in  the  chapter  on 
Malnutrition,  and  only  the  dietetic  treatment  will  be  discussed  in  this 
connection. 


ARTIFICIAL  FEEDING.  151 

The  difficulties  are  always  greatest  in  the  early  months — viz.,  in  giving 
the  infant  a  start.  When  this  has  once  been  done,  future  progress  is  gen- 
erally easy.  A  food  weakened  to  correspond  to  the  child's  power  of  diges- 
tion, may  be  able  to  do  no  more  than  repair  the  waste  of  the  body,  and 
sometimes  not  even  that.  The  most  common  mistake  is  to  use  in  the  be- 
ginning a  food  so  strong  as  to  disturb  the  digestive  organs.  When  once 
this  has  been  done,  all  progress  is  difficult.  These  cases  demand  all  our 
resources,  and  the  difficulties  are  usually  increased  in  proportion  to  the 
duration  of  the  disorder.  It  may  have  existed  so  long  that  no  form  of 
artificial  feeding,  or  even  wet-nursing,  will  succeed.  While  these  cases 
differ  widely  and  each  one  must  be  studied  by  itself,  there  are  certain 
principles  of  general  application. 

1.  The  strength  and  quantity  of  the  food  are  better  gauged  by  the 
weight  than  by  the  age  of  an  infant,  but  best  of  all  by  its  power  of 
digestion.  This  can  only  be  determined  by  careful  experimentation  in 
each  individual  case. 

2.  A  larger  quantity  of  a  dilute  food  is  usually  better  borne  than  a 
smaller  quantity  of  one  more  concentrated. 

3.  Up  to  the  third  month  the  rules  as  to  frequency  of  meals  should  be 
the  same  as  those  for  healthy  infants.  After  this  time  the  intervals 
should  usually  be  shorter. 

Modification  of  Milk  in  Difficult  Cases. — In  the  early  months  the  usual 
symptoms  presented  by  these  cases  are  that  they  do  not  gain  in  weight, 
and  that  they  show  to  a  more  or  less  marked  degree  the  following  signs 
of  indigestion  :  the  stools  contain  undigested  food,  usually  lumps  of 
casein  ;  there  may  be  diarrhoea  or  constipation,  usually  the  latter ;  there  is 
frequently  a  regurgitation  of  small  quantities  of  food,  sometimes  actual 
vomiting;  thfere  are  usually  flatulence  and  colic.  In  consequence  of  the 
foregoing  conditions,  sleep  is  disturbed,  and  the  infants  are  cross  and 
fretful  much  of  the  time. 

No  proper  gain  in  weight  is  to  be  expected  until  the  indigestion  is 
overcome,  and  this  should  be  the  first  purpose  in  the  management  of  such 
cases. 

So  far  as  the  elements  of  milk  are  concerned,  it  should  be  remembered 
that  the  sugar  is  least  likely  to  be  a  cause  of  trouble,  and  it  need  rarely  be 
reduced  below  5  per  cent,  and  never  below  3  per  cent.  It  is  the  proteids 
which  give  the  most  trouble,  the  fat  coming  next.  For  young  infants 
with  feeble  digestion  the  proteids  should  always  be  reduced  to  1  per  cent, 
and  usually  to  0*5  per  cent;  it  may  even  be  necessary  to  reduce  to  0-25 
per  cent  for  a  short  time.  The  fat  can  usually  be  taken  in  the  propor- 
tion of  1  or  2  per  cent,  rarely  more  than  the  latter.  For  a  short  time  it 
may  be  necessary  to  reduce  the  fat  below  1  per  cent.  The  proportions 
to  be  used  under  these  conditions  may  be  those  of  formula  II,  page 
175:    fat,  2   per  cent;    sugar,  6  per  cent;    proteids,  0-6   per  cent;   or, 


132  NUTRITION. 

if  the  12-per-cent  cream  (page  174)  is  diluted  with  eleven  parts  of  a  5-per- 
cent sugar  solution,  we  obtain  : 

iFat 1  •  00  per  cent. 
Sugar 500       " 
Proteids 0-30 

If  we  desire  a  relatively  lower  j)roportion  of  fat,  we  may  use  formula 
XIV  (page  176):  fat,  1  per  cent;  sugar,  5  per  cent;  proteids,  0-50  per 
cent;  or,  diluting  the  8-per-ceut  cream  (page  174)  with  fifteen  parts  of 
a  4-per-cent  sugar  solution  (one  ounce  to  twenty-five  ounces),  we  obtain : 

f  Fat 0  •  50  per  cent. 

Formula  XX  ]  Sugar 4-00 

(Proteids 0-25 

Usually,  then,  we  should  begin  with  one  of  the  formulte  having  the  low 
percentages  mentioned,  and  with  improvement  in  the  symptoms  gradually 
increase  the  fat  and  proteids  by  making  the  dilution  less;  if  we  began 
with  formula  XIX,  instead  of  eleven  parts  of  the  sugar  solution,  using 
ten,  nine,  seven,  five,  etc. ;  or,  in  a  similar  way,  varying  formula  XX.  The 
rapidity  with  which  these  changes  can  be  made  will  of  course  vary  with 
the  progress  of  the  case. 

For  infants  from  four  to  ten  months  old  presenting  similar  symptoms, 
a  somewhat  different  modification  must  be  made,  particularly  in  cases  of 
the  marasmus  type  with  long-standing  trouble.  As  much  difficulty  may 
be  experienced  by  them  with  the  fat  as  with  the  proteids,  and  in  some 
cases  even  more.  But  by  most  of  these,  as  well  as  by  the  younger  infants, 
sugar  is  well  tolerated.  We  may  begin  with  formula  XVIII  (page  176) : 
fat,  0-30  per  cent ;  sugar,  4  per  cent ;  proteids,  034  per  cent ;  after  a 
time  the  strength  of  the  food  being  gradually  increased  to  formula  XVII, 
XVI,  and  XV  by  diminishing  the  dilution  of  the  milk.  Sometimes,  how- 
ever, we  may  succeed  better  by  beginning  exactly  as  with  younger  infants, 
making  the  increase  in  strength  usually  with  somewhat  greater  rapidity. 

The  Use  of  Peptonized  Milk. — Another  plan  which  may  be  followed 
with  infants  who  have  great  trouble  in  digesting  the  proteids  of  cow's 
milk  is  that  of  peptonizing  the  milk.  For  a  description  of  the  process, 
see  page  148.  It  is  important  that  a  proper  formula  should  likewise  be 
used  in  these  cases.  For  young  infants  such  proportions  as  those  of  for- 
mula XIII,  page  176,  are  appropriate — fat,  2  per  cent;  sugar,  6  per  cent; 
proteids,  1  per  cent.  In  the  beginning,  the  process  may  be  continued  for 
an  hour;  later,  with  improvement  in  the  symptom.s,  reducing  the  time  to 
half  an  hour,  and  then  to  fifteen  and  even  ten  minutes.  It  is  preferable 
that  the  bottles  of  milk  should  be  peptonized  separately  just  before  each 
feeding.  The  amount  of  the  powder  required  is  one  grain  of  the  ex- 
tractum  pancreatis  and  three  grains  of  bicarbonate  of  soda  to  each  three 
ounces  of  the  milk.     The  partial  digestion  of  the  milk  may  be  continued 


ARITFICIAL  FEEDING.  183 

for  several  weeks,  or  until  tlie  stomach  has  in  a  measure  regained  its  di- 
gestive jiower.  There  is  a  serious  objection  to  its  use  for  as  long  a  period 
as  four  or  five  months,  for  in  sucli  a  case  the  stomach  gradually  becomes 
less  and  less  able  to  do  its  proper  work.  Which  of  the  two  methods  of 
procedure — greatly  reducing  the  amount  of  proteids  or  iDredigesting  them 
— is  the  better  one,  will  de{)end  u})on  the  individual  case. 

The  Addition  of  other  Substances  to  Milk. — The  opinion  has  long  pre- 
vailed that  the  addition  to  milk  of  some  mucilaginous  substance,  such  as 
a  gruel  made  from  barley,  oatmeal,  or  arrowroot,  or  gelatine  and  water, 
facilitates  the  digestion  of  the  proteids  of  cow's  milk  by  preventing  in  the 
stomach  the  coagulatioH  of  the  casein  in  large  solid  masses  which  are  dis- 
solved with  such  difficulty.  The  method  of  preparation  has  been  to  use 
these  substances  in  the  place  of  water,  simply  as  diluents  for  milk,  or  more 
frequently  to  cook  the  milk  with  them  for  a  short  time — two  to  fifteen 
minutes — in  order  to  obtain  a  more  intimate  combination  with  the  casein. 
The  substance  most  commonly  employed  has  been  a  thin  barley  gruel. 
(For  preparation,  see  page  155.)  This  may  take  the  place  of  some  of  the 
plain  boiled  water  in  any  of  the  formula  previously  given,  the  usual 
proportion  being  to  make  the  food  from  one  fourth  to  one  half  its  volume 
of  the  gruel. 

The  recent  experiments  of  Rotch  and  others  throw  a  good  deal  of 
doubt  upon  the  traditional  belief  in  regard  to  the  effect  upon  the  casein 
of  this  treatment,  and  it  is  really  questionable  whether  anything  more  is 
accomplished  than  by  diluting  with  water.  This  method  of  preparing 
milk  is  certainly  of  much  less  value  than  the  careful  modification  of  the 
milk  constituents  which  has  been  previously  considered.  Still,  it  is  a 
method  which  is  useful  in  certain  cases,  whether  the  explanation  which 
has  been  offered  be  the  correct  one  or  not.  It  should,  however,  be  remem- 
bered that  the  starchy  substance,- whatever  it  may  be,  plays  but  a  very 
small  part  in  the  nutrition  of  the  infant ;  first,  because  the  amount  of 
starch  used  is  considerably  below  one  per  cent  of  the  food,  the  other  ele- 
ments of  the  gruel  being  in  such  small  proportions  that  they  may  be 
almost  ignored  ;  and,  secondly,  because  of  the  very  feeble  power  of  trans- 
forming starch  into  sugar  which  exists  in  the  young  infant. 

The  Use  of  other  Sugars  than  Milk  Sugar, — It  has  been  already  stated 
that  it  is  rare  that  there  is  difficulty  in  the  digestion  of  sugar;  but  such  is 
sometimes  the  case.  It  is  also  true  that  there  are  exceptional  instances 
in  which  milk  sugar  is  not  well  borne,  where  cane  sugar  or  even  maltose 
(as  in  some  of  the  malted  foods)  may  be  taken.  Both  of  these  are  so 
sweet  they  must  be  used  in  jDroportions  considerably  smaller  than  those  of 
milk  sugar,  and  generally  as  temporary  substitutes  only. 

The  addition  of  Beef  Juice  (page  153)  to  the  milk  where  the  digestion 
is  so  feeble  as  to  require  a  great  reduction  in  the  proteids,  is  at  times 
advantageous.     From  one  half  to  two  tablespoonfuls  may  be  added   to 


Ig4  NUTRITION. 

each  feeding.  Instead  of  beef  juice,  some  of  the  beef  peptonoids  men- 
tioned on  page  154  may  be  used. 

The  number  of  cases  which  can  not  be  managed  by  simply  varying  the 
different  elements  of  cow's  milk,  is  small.  In  private  practice,  if  the  child 
can  be  taken  in  hand  at  the  outset,  the  number  is  very  small,  the  excep- 
tions being  premature  and  delicate  infants,  which  are  reared  under  any 
circumstances  only  with  the  greatest  difficulty.  The  difficulties  are  much 
increased  where  the  disordered  digestion  has  already  lasted  several  weeks 
or  months.  They  are  greatest  in  institutions  where  many  infants  are 
brought  together.  As  the  weight  is  our  most  important  guide  to  the  suc- 
cess of  any  method  of  feeding,  we  must  have  accurate  scales  and  weigh 
the  infants  twice  a  week,  in  order  to  determine  as  soon  as  possible  what 
progress  is  made,  so  that  a  useless  experiment  may  not  be  unduly  pro- 
longed. For  the  first  week  or  two  no  more  than  an  arrest  of  the  pre- 
vious loss  in  weight  is  to  be  expected.  There  can  be  no  material  gain 
until  the  symptoms  of  indigestion,  colic,  bad  stools,  restlessness,  and  vom- 
iting are  greatly  lessened  or  entirely  gone.  Until  this  is  the  case  the  food 
can  not  be  increased  in  strength.  The  gain  is  almost  always  slow  at  first, 
amounting  perhaps  only  to  two  or  three  ounces  a  week ;  but  it  should  be 
steady.  Later,  under  favourable  conditions,  it  should  increase  to  six  or 
eight  ounces,  or  even  more. 

For  those  children  who  do  not  thrive  with  an  intelligent  modifica- 
tion of  cow's  milk  according  to  the  plan  above  outlined,  the  thing  most 
likely  to  succeed  is  the  employment  of  a  wet-nurse,  although  if  the  condi- 
tion of  malnutrition  has  become  firmly  established  even  this  often  fails. 
Sometimes  condensed  milk  succeeds,  although  its  composition  after  dilu- 
tion (page  149)  is  similar  to  that  which  we  have  been  employing  (for- 
mula XVII  or  XVIII,  page  176),  the  chief  difference  being  the  substitu- 
tion of  cane  sugar  for  the  milk  sugar.  In  rare  cases  infants  seem  unable 
to  digest  raw  milk,  but  improve  when  put  upon  milk  that  has  been  steril- 
ized. Sometimes  there  is  an  advantage  in  withholding  for  a  short  time 
all  milk  constituents,  and  giving  one  of  the  malted  foods  with  water,  or 
animal  broths.  In  apparently  hopeless  cases  the  most  unpromising  food 
or  combination  may  occasionally  succeed.  I  have  lately  seen  an  infant 
thrive  upon  plain  milk  undiluted,  where  all  scientific  modifications  and 
additions  had  failed  utterly.  In  every  instance  the  general  principle  must 
be  to  begin  with  something  which  the  child  can  digest  and  assimilate, 
and  return  to  the  usual  proportions  of  the  milk  ingredients  gradualh^  but 
just  as  soon  as  possible.  We  must  often  begin  by  doing  what  we  can,  not 
what  we  would  like  to  do.  We  must  avoid  the  danger  of  keeping  an 
infant  for  a  long  time  upon  completely  peptonized  milk,  also  upon  milk 
containing  very  low  percentages  of  fat  and  proteids,  like  some  of  those 
referred  to,  and  the  continuance  of  food  composed  almost  entirely  of  car- 
bohydrates where  all  milk  has  been  withdrawn. 


FEEDING  DURING  THE  SECOND   YEAR.  185 

CHAPTER   IV. 
FEEDING  AFTER   THE  FIRST  TEAR. 

HEALTHY  INFANTS  DURING  THE   SECOND   YEAR. 

The  physician  should  not  relax  his  vigilance  in  the  feeding  of  a  child 
after  the  first  year  has  passed.  The  ideas  of  the  laity  in  regard  to  what  a 
child  can  digest  after  it  has  outgrown  an  exclusive  milk  diet,  are  very 
erroneous.  The  majority  of  infants  are  given  solid  food  too  early  and  in 
too  large  quantities.  Most  of  the  attacks  of  indigestion  during  the  second 
year  are  directly  traceable  to  such  gross  dietetic  errors.  The  diet  of  a 
healthy  child  during  the  second  year  should  consist  of  milk,  some  farina- 
ceous food,  bread,  a  small  amount  of  animal  food,  such  as  beef  or  mutton, 
beef  juice,  eggs,  and  fruit. 

Milk  should  be  the  basis  of  the  diet.  There  are  a  few  infants  for 
whom  no  modification  of  the  milk  is  necessary,  as  they  are  able  to  digest 
without  difficulty  that  containing  4  j^er  cent  proteids.  The  great  ma- 
jority of  infants  do  better  if  the  proteids  are  kept  at  3  or  3.5  per  cent 
during  the  first  half  of  the  second  year.  If  the  fat  is  4  per  cent,  chronic 
constipation,  usually  so  troublesome  at  this  time,  may  often  be  avoided. 
Since  the  child  is  now  able  to  take  a  considerable  proportion  of  its  carbo- 
hydrates in  the  form  of  starch,  it  is  not  necessary  to  continue  the  large 
quantity  of  milk  sugar  given  during  the  first  year,  and  in  many  cases 
the  sugar  may  be  omitted  altogether.  However,  where  starch-digestion  is 
so  feeble  that  only  a  small  quantity  of  farinaceous  food  can  be  allowed,  it 
may  be  necessary  to  continue  the  milk-sugar  during  the  entire  second 
year.     The  formulae  most  generally  useful  during  this  period  are : 

IX.  At  12  months:  Fat,  4-0^;  sugar,  5-0^:  proteids,  30^. 
X.     "    15        "  '•     4-0$r;       "       50^;         "         3-5^. 

XI.    "   18        "  "    3-5^;      "       4-3^;        "         4 •  0;*  (i.  e.,  plain  milk). 

We  may  obtain  approximately  these  formula?  by  using  the  following 
proportions  for  one  feeding  of  ten  ounces  : 

Formula  IX.    Milk,  6  oz. :  cream  (16^),  1  oz. ;  water.  3    oz. ;  sugar,  2  even  teaspoonfuls. 
X.       "      8  •'  "  "      i  "  *'       li  ■'  "       1     '■      teaspoonful. 

Instead  of  plain  water  in  these  formula,  we  may  use  the  same  quantity 
of  barley  or  oatmeal  gruel  or  jelly. 

Farinaceous  food  :  The  easiest  plan  is  to  add  this  in  the  form  of  a  gruel 
made  of  one  of  the  cereals  or  farinaceous  foods  (page  156) ;  the  latter 
being  partlv  dextrinized,  require  but  ten  to  fifteen  minutes'  cooking.  If 
these  prepared  flours  are  used,  one  even  tablespoonful  should  be  added  to 
one  pint  of  water,  to  make  a  gruel  of  about  the  proper  strength.    We  may 


186  NUTRITION. 

use  with  equally  good  results  a  gruel  or  jelly  made  from  oats,  wheat,  or 
barley-  If  the  grains  themselves  are  used,  they  should  first  be  soaked  for 
six  hours  or  over  uight  in  water  which  is  thrown  away,  and  then  cooked 
for  from  four  to  six  hours  and  strained  through  muslin.  Two  table- 
spoonfuls  of  the  grains  to  one  quart  of  water,  cooked  down  to  one  pint, 
gives  a  jelly  of  about  the  desired  consistency.  Salt  should  always  be 
added  to  make  it  palatable. 

During  the  first  half  of  the  second  year  children  require  from  forty  to 
fifty  ounces  (1,240  to  1,550  grammes)  of  fluid  food  daily  ;  during  the 
second  half  of  the  year  from  forty-five  to  fifty-five  ounces.  This  quantity 
should  be  given  in  five  feedings ;  four  of  these  being  of  equal  size,  one — 
usually  the  midday  feeding,  which  is  given  in  connection  with  the  meat 
or  meat  juice — being  smaller. 

Beef  juice  may  be  given  as  directed  for  the  feeding  during  the  latter 
part  of  the  first  year,  the  amount  allowed  being  from  one  to  three  ounces 
daily.  After  the  eighteenth  month,  if  most  of  the  teeth  are  present,  rare 
scraped  beef  or  mutton  may  be  given  at  times  in  jilace  of  the  beef  juice. 
Not  more  than  a  tablespoonful  should  be  allowed  daily.  After  the  eigh- 
teenth month,  a  soft-boiled  fresh  egg  may  also  be  given  in  place  of  the 
meat  or  meat  juice,  once  or  twice  a  week. 

A  small  piece  of  stale  bread  dried  in  the  oven,  or  a  piece  of  zwieback 
may  be  given,  usually  with  the  midday  meal,  after  the  child  has  most  of 
its  teeth. 

Fruit  is  a  part  of  the  diet  too  often  omitted.  Orange  juice  may  be 
begun  as  eai'ly  as  the  fifteenth  month  ;  from  half  an  ounce  to  two  ounces 
may  be  given  daily.  A  little  later  one  or  two  tablespoonfuls  of  baked 
apple  or  two  or  three  stewed  prunes  may  be  added.  Both  should  be 
cooked  until  they  are  very  soft.  The  baked  apple  should  be  given  with- 
out sugar,  and  the  prunes  should  be  put  through  a  sieve  to  remove  the 
skins.  The  best  time  for  giving  fruit  is  about  an  hour  before  one  of  the 
milk  feedings. 

The  daily  diet  for  a  child  of  eighteen  months  should  be  arranged 
somewhat  as  follows  :  The  first,  second,  fourth,  and  fifth  meals  should 
each  consist  of  ten  or  twelve  ounces  of  milk  prepared  with  gruel,  as  above 
described,  the  fruit  being  given  an  hour  before  the  second  feeding.  The 
third  meal  should  consist  of  six  or  seven  ounces  of  the  milk  and  gruel, 
with  beef  juice,  scraped  beef,  or  egg,  and  dried  bread.  The  form  of 
farinaceous  food  may  be  varied  from  day  to  day,  according  to  the  child's 
taste.  All  other  food  may  be  advantageously  omitted.  Water  only  is  to 
be  allowed  between  the  feedings. 

The  milk  for  the  twenty-four  hours  is  best  prepared  at  one  time.  The 
quantity  needed  for  the  different  feedings  should  be  put  in  separate  bot- 
tles, as  during  the  first  year.  What  was  said  regarding  the  heating  of 
milk  during  the  first  year  for  sterilization,  applies  also  to  the  second  year. 


FEEDING   DURING   THE  SECOND   YEAR.  187 

Children  can  usually  be  taught  to  drink  from  a  cup  at  from  twelve  to 
fifteen  months. 

DIFFICULT  CASES  DURING  THE  SECOND  YEAR. 

The  number  of  children  whose  nutrition  is  a  matter  of  difficulty  dur- 
ing the  second  year  is  much  smaller  than  during  the  first  year  ;  yet  there 
are  cases  in  which  the  difficulties  are  just  as  great.  Some  of  these  are 
infants  that  have  been  very  delicate  from  birth,  and  carried  through  the 
first  year  only  by  the  greatest  effort.  Others  are  healthy  at  birth,  but 
their  digestion  has  been  badly  deranged  in  consequence  of  improper  feed- 
ing during  the  first  year.  Some  are  infants  who  did  well  until  they  were 
weaned,  but  from  that  time  began  to  suffer  from  constant  indigestion  and 
malnutrition  because  they  were  jiut  upon  improper  food,  often  undiluted 
cow's  milk.  In  some  the  symptoms  are  the  result  of  a  severe  attack  of 
acute  disease  of  the  stomach  or  intestines  during  the  first  year.  Many  of 
them  are  rachitic. '  A  frequent  cause  of  trouble  is  that  children  have  been 
put  to(f  early  upon  solid  food,  the  mother  often  thinking  that  a  child  who 
is  delicate  is  only  to  be  built  up  by  giving  "  strong  food."  Very  often  the 
difficulty  is  that  the  food  has  been  excessive  in  starch,  especially  in  the 
form  of  potato  or  oatmeal. 

Whatever  may  be  the  cause  of  the  symptoms,  all  cases  of  feeble 
digestion  or  chronic,  indigestion  of  the  second  year  are  to  be  managed 
very  much  in  the  same  general  way.  Usually  the  first  thing  to  be  done 
is  to  stop  all  solid  food  except  the  rare  scraped  meat.  Starches  must 
be  reduced  to  the  minimum  or  prohibited  altogether.  In  most  cases 
milk,  meat,  and  a  little  suitable  fruit  must  constitute  the  diet.  While 
it  is  undoubtedly  true  that  the  use  of  plain  cow's  milk  often  fails  en- 
tirely, it  is  certain  that  nothing  is  more  likely  to  succeed  than  cow's 
milk  when  properly  modified.  This  must  be  continued  as  the  principal 
diet,  sometimes  as  the  sole  diet,  for  the  greater  part  of  the  second  year. 
The  milk  must  be  modified  as  for  healthy  infants  who  are  from  eight 
to  twelve  months  younger  than  the  patient  under  treatment.  Thus  a 
child  of  twelve  or  fourteen  months,  should  be  given  milk  prepared  as  for 
a  healthy  child  of  four  or  five  months  (formula  VI,  })ago  175);  one  of 
twenty  to  twenty-four  months,  as  for  a  healthy  child  of  from  ten  to 
twelve  months  (formula  VIII,  page  178).  Milk  containing  a  larger 
quantity  of  casein  than  in  these  formula^  is  rarely  digested  unless  partly 
peptonized,  and  this  may  be  required  even  with  the  lower  i^ercentages. 
The  daily  quantity  should  geueraWy  be  somewhat  larger  than  for  a 
young,  healthy  infant  taking  food  of  the  same  strength.  The  regular  in- 
tervals of  feeding  should  never  be  shorter  than  three  hours,  and  in  many 
cases  four  hours  is  to  be  preferred.  The  number  of  meals  usually  re- 
quired in  the  twenty-four  hours  is  five. 

From  few  things  is  more  striking  improvement  seen  in  these  patients 


188  NUTRITION. 

than  from  the  administration  of  rare  meat-pnlp,  especially  to  those  jvho  are 
over  eigliteen  months  old.  From  one  to  two  ounces  may  be  given  daily. 
Generally  tlie  proteids  in  the  food  have  been  previously  deficient.  Many  of 
these  children  digest  meat  when  given  in  this  way  better  than  they  do  the 
casein  of  the  milk.  Kaw  beef  juice  may  be  used  with  the  meat,  or  from 
time  to  time  may  take  its  place. 

The  same  fruits  should  be  allowed  as  for  healthy  infants,  the  quantity 
being:  smaller.  Inasmuch  as  it  is  with  the  starches  that  the  greatest  diffi- 
culty  is  usually  experienced,  the  carbohydrates  must  be  administered  either 
in  the  form  of  milk-sugar  or  some  of  the  malted  foods.  When  starch  is 
first  allowed  it  should  be  given  with  some  reliable  preparation  of  malt. 

When  the  child  is  once  well  started  and  gaining  steadily,  the  food 
may  be  gradually  modified,  until  the  diet  recommended  for  healthy  in- 
fants is  reached.  AH  changes  must,  however,  be  made  very  gradually,  and 
it  should  never  be  forgotten  that  there  is  a  constant  disposition  on  the 
part  of  all  mothers  and  nurses  greatly  to  over-feed  these  children. 

FEEDING   FROM   THE   THIRD   TO    THE   SIXTH    YEAR. 

Articles  allowed. — From  the  following  list  the  diet  of  a  healthy  child 
may  be  arranged  : 

Milk. — This  should  be  the  basis  of  the  diet ;  most  children  require 
about  one  quart  daily.  This  usually  needs  no  modification,  but  if  some- 
what difficult  of  digestion,  it  should  be  prepared  as  for  the  second  year — 
six  ounces  of  milk,  one  ounce  of  cream,  and  three  ounces  of  water.  The 
milk  should  usually  be  given  warm. 

Cream. — This  is  of  great  value,  especially  Avhen  there  is  a  tendency  to 
constipation.  From  two  to  eight  ounces  may  be  given  daily.  It  may  be 
used  upon  cereals,  upon  potato,  in  broths,  and  mixed  with  milk.  In  many 
eases  it  is  advisable  to  withhold  milk  and  give  only  cream. 

Efjg.9. — These  are  a  valuable  form  of  proteid.  They  should  be  fresh, 
soft-boiled  or  poached,  but  never  fried.  Usually  eggs  should  not  be 
given  oftener  than  every  other  day,  as  children  readily  tire  of  them. 

Meats. — Some  form  of  meat  should  be  given  once  a  day.  The  best 
forms  are  beefsteak,  mutton  chop,  and  roast  beef  or  lamb  ;  next  to  these 
the  white  meat  of  chicken,  or  fresh  fish,  which  should  be  boiled  or  broiled. 
Beef  and  mutton  should  be  given  rare. 

Vegetables. — Potato  may  be  given  once  a  day,  preferably  baked,  with 
the  addition  of  cream  or  beef  juice  rather  than  butter.  Of  the  green 
vegetables  the  best  are  asparagus  tops,  sjainach,  stewed  celery,  string 
beans,  and  fresh  peas.  One  of  these  vegetables  should  be  given  daily — 
always  well  cooked  and  mashed. 

Cereals. — Nearly  all  these  may  be  used — oatmeal,  wheaten  grits,  homi- 
ny, rice,  farina,  and  arrowroot.  The  most  important  part  of  the  prep- 
aration is  thorough  cooking.     If  the  grains  are  used,  cereals  should  be 


FEEDING   FROM   THE  THIRD  TO   TUE   SIXTH   YEAR.  139 

cooked  at  least  three  hours,  after  having  been  previously  soaked  several 
hours.  They  should  always  be  well  salted,  and  given  with  milk  or  cream, 
but  with  little  or  no  sugar. 

Broths  and  soups. — The  meat  broths  are  jireferable  to  the  vegetable 
broths.  Nearly  all  varieties  may  be  given.  Plain  broths  are  not  very 
nutritious,  but  when  thickened  with  arrowroot  or  cornstarch,  and  when 
cream  or  milk  is  added,  they  are  very  palatable,  and  at  the  same  time  a 
valuable  addition  to  the  diet.  Beef  juice  may  be  used  as  directed  for 
the  second  year. 

Bread  and  biscuits  [crackers). — In  some  form  these  may  be  given 
with  nearly  every  meal,  better  witliout  butter  until  the  fourth  year,  as 
for  youug  children  cream  is  a  better  form  of  fat.  xVll  varieties  of  bi'ead 
may  be  allowed  when  stale ;  also  dried  bread,  zwieback,  and  oatmeal, 
Graham,  or  gluten  biscuits. 

Desserts. — The  only  ones  that  should  be  allowed  up  to  the  sixth  year 
are  Junket  (page  153),  plain  custard,  rice  pudding  without  raisins,  and,  not 
oftener  than  once  a  week,  ice-cream.  Of  the  last  three,  the  quantity 
given  should  be  very  moderate. 

Fruits. — An  effort  should  be  made  to  give  fruit  in  some  form  every 
day.  Oranges,  baked  apple,  and  stewed  prunes  are  the  most  to  be  de- 
pended upon.  Raw  apples  in  most  cases  should  not  be  given.  Peaches, 
pears,  and  grapes  (with  seeds  removed)  may  be  given  when  thoroughly 
ripe  and  fresh,  but  only  in  moderate  quantity.  Special  care  should  be 
exercised  in  the  use  of  fruits  in  very  hot  weather,  and  in  cities  where  they 
may  not  always  be  fresh.  Berries  are  best  deferred  until  children  are  six 
or  seven  years  old,  and  even  then  should  be  given  very  sparingly. 

Articles  forbidden. — The  following  articles  should  not  be  allowed  to 
children  under  four  years  of  age,  and  with  few  exceptions  they  may  be 
withheld  with  advantage  up  to  the  seventh  year  : 

Meats. — Ham,  sausage,  pork  in  all  forms,  salt  fish,  corned  beef,  dried 
beef,  goose,  duck,  game,  kidney,  liver  and  bacon,  meat  stews,  and  dress- 
ings from  roasted  meats. 

Vegetahles. — Fried  vegetables  of  all  varieties,  cabbage,  carrots,  potatoes 
(except  when  boiled  or  roasted),  raw,  or  fried  onions,  raw  celery,  radishes, 
lettuce,  cucumbers,  tomatoes  (raw  or  cooked),  beets,  egg-plant,  and  green 
corn. 

Bread  and  cake. — All  hot  bread  and  rolls ;  buckwheat  and  all  other 
griddle  cakes ;  all  sweet  cakes,  particularly  those  containing  dried  fruits 
and  those  heavily  frosted. 

Desserts. — All  nuts,  candies,  pies,  tarts,  and  pastry  of  every  descrip- 
tion ;  also  all  salads,  jellies,  syrups,  and  preserves. 

Drinks. — Tea,  coffee,  cocoa,  wine,  beer,  and  cider. 

Fruits. — All  dried,  canned,  and  preserved  fruits  ;  bananas  ;  all  fruits 
out  of  season  and  stale  fruits,  particularly  in  summer. 


190  NUTRITION. 

From  the  third  to  the  sixth  years  four  meals  should  usually  be  given 
daily  and  at  regular  intervals — e.  g.,  7  and  10.30  a.  m.  ;  1.30  and  6  p.  m. 
The  second  meal  should,  in  most  cases,  be  smaller  than  the  others. 

The  following  is  a  sample  diet  for  a  child  of  four  years : 

First  meal. — Half  an  orange,  two  tablespoonfuls  of  some  cereal  well 
salted  with  two  or  three  tablespoonfuls  of  cream,  a  glass  of  milk,  one 
piece  of  bread  with  a  little  butter. 

Second  meal. — A  glass  of  milk  or  cup  of  broth  with  bread  or  two  or 
three  biscuits  (crackers). 

Third  meal. — Two  tablespoonfuls  of  finely  divided  steak  or  chop,  one 
tablespoonful  of  baked  potato,  one  tables^DOonful  of  spinach,  bread  and 
butter,  a  cup  of  junket,  water  to  drink. 

Fourtli  meal. — Milk  with  bread,  or  milk,  toast. 

From  the  list  of  articles  given  above,  a  sufficient  variety  in  the  diet  can 
be  secured.  The  only  way  for  the  physician  to  be  sure  that  proper  food 
is  given  to  young  children,  is  to  write  out  for  the  guidance  of  the  mother 
or  nurse  two  lists  somewhat  similar  to  the  above,  of  articles  forbidden  and 
articles  allowed.  This  plan  I  have  followed  for  several  years  with  the. 
happiest  results.  It  is  rarely  safe  to  trust  anything  to  the  judgment  of 
the  mother. 

There  are  a  few  simple  rules  in  feeding  which  should  always  be  fol- 
lowed : 

A  child  must  be  taught  to  eat  slowly  and  thoroughly  masticate  his 
food.  The  food  must  always  be  very  finely  divided,  for,  as  a  rule,  mas- 
tication is  very  imperfect  even  up  to  the  sixth  or  seventh  year.  If  the 
child  is  fed  by  the  nurse,  plenty  of  time  should  be  taken  for  the  meal. 
It  is  almost  always  the  case  that  the  food  is  given  too  rapidly.  It  is  un- 
W'ise  continually  to  urge  children  to  eat  when  they  are  disinclined  to  do 
so  at  the  regular  hours  of  meals,  or  when  the  appetite  is  habitually  poor, 
and  under  no  circumstances  should  children  be  forced  to  eat.  Indigesti- 
ble articles  of  food  should  not  be  given  to  tempt  the  appetite  when  ordi- 
nary simple  food  is  refused,  nor  should  these  be  allowed  because  of  the 
notion  that  "  the  child  must  eat  something."  Food  should  not  be  allowed 
between  meals  when  it  is  habitually  declined  at  meal-time.  If  a  child  re- 
fuses to  eat,  and  examination  reveals  no  fault  with  the  food  prepared,  it 
should  seldom  be  offered  again  until  the  next  feeding  time.  In  all  cases 
of  temporary  indisposition,  no  matter  of  what  nature,  and  during  periods 
of  excessive  heat  in  summer,  the  amount  of  solid  food  should  be  reduced 
and  more  water  given.     If  milk  is  the  food,  it  should  be  diluted. 

FEEDING  DURING   ACUTE   ILLNESS. 

Infants. — This  is  an  important  part  of  the  treatment  of  every  acute 
disease  in  childhood,  but  especially  so  in  infancy.  Whether  the  illness 
be  one  of  the  eruptive  fevers,  diphtheria,  pneumonia,  or  influenza,  all 


FEEDING   DURING  ACUTE  ILLNESS.  191 

cases  must  be  fed  in  about  the  same  way.  It  is  much  easier  by  proper 
feeding  to  prevent  disturbances  of  digestion  in  acute  disease,  than  to  allay 
them  when  they  have  been  excited.  In  infancy  this  complication  often 
turns  the  scale  against  the  patient.  One  of  the  most  important  conditions 
which  must  be  taken  into  consideration  is,  that  in  every  severe  acute 
illness,  especially  if  it  is  of  a  febrile  character,  the  power  of  digestion 
is  much  diminished.  One  evidence  of  this  is  the  onset  with  vomiting; 
another  is  the  anorexia  which  accompanies  the  early  stage  of  nearly  all 
acute  diseases,  the  child  often  refusing  everything  in  the  way  of  nourish- 
ment. We  should  respect  this  inclination  and  make  it  our  guide  in  the 
treatment.  On  the  other  hand,  there  is  great  thirst  from  existing  fever, 
and  water  is  needed ;  withholding  this  will  often  cause  the  temperature  to 
rise  even  higher  than  before. 

In  all  acute  febrile  diseases  the  fundamental  principle  is,  less  food  and 
more  water.  The  total  amount  of  food  given  in  tlie  twenty-four  hours 
should  be  considerably  less  than  in  health.  For  infants  the  character  of 
the  food  may  generally  be  the  same  as  in  health,  but  should  be  given  in 
very  much  greater  dilution.  For  nursing  infants  this  may  be  accomplished 
by  making  the  nursing  time  shorter — four  or  five  minutes,  instead  of  the 
customary  eight  or  ten — or  a  single  breast,  instead  of  both,  may  be  given. 
Nursing  children  should  be  given  water  freely  from  a  spoon  or  bottle. 
For  those  who  are  artificially  fed,  the  amount  of  the  ordinary  food  should 
be  reduced  by  one  third,  or  even  one  half,  and  this  made  up  by  addino- 
water,  at  the  same  time  allowing  water  freely  between  the  feedings.  In 
many  cases  the  food  must  be  not  only  diluted,  but  partly  digested. 

The  food  should  be  given  at  regular  intervals,  never  less  than  two 
hours,  even  if  the  amount  taken  at  a  single  time  is  small ;  otherwise  the 
interval  should  be  three  hours.  Regularity  should  always  be  adhered  to. 
If  food  is  given  oftener  than  every  two  hours,  vomiting  and  indigestion 
almost  invariably  result.  The  water  allowed  between  the  feedings  should 
be  boiled,  given  frequently,  and  in  liberal  quantity.  When  stimulants  are 
required,  they  may  be  mixed  with  the  water  given.  The  foregoing  rules 
apply  to  the  early  stage  of  most  of  the  acute  diseases  of  infancy,  and  in 
many  cases  this  plan  may  be  followed  throughout. 

Forced  feeding — gavage. — Not  a  few  cases,  however,  are  seen  in  which, 
after  a  child  has  been  several  days  sick,  in  consequence  of  delirium,  stupor, 
sepsis,  or  some  other  serious  condition,  it  may  refuse  all  food  or  take  so 
little  that  it  is  in  danger  of  death  from  inanition.  At  this  juncture  forced 
feeding  or  gavage  (see  page  G2)  serves  a  most  excellent  purpose.  Both 
food  and  stimulants  can  thus  be  introduced  at  regular  intervals  with  slight 
disturbance,  and  lives  saved  which  would  otherwise  be  lost.  If  gavage  is 
employed,  the  stomach  should  be  first  washed.  The  intervals  of  feeding 
should  be  made  at  least  one  hour  longer  than  is  customary  in  health,  and 
usually  predigested  foods  given. 
14 


192  NUTRITION. 

In  Older  Children. — The  same  or  similar  conditions  exist  with  reference 
to  digestion  in  acute  disease.  These  patients,  however,  are  not  so  easily 
disturbed,  and  the  disturbance  of  digestion  is  not  so  likely  to  be  serious  as 
in  the  case  of  infants.  Even  here  the  physician  should  direct  the  food  to 
be  given  at  regular  intervals,  usually  not  oftener  than  every  three  hours, 
but  should  never — as  is  so  often  done — order  milk  to  be  given  to  the  child 
every  time  it  asks  for  a  drink.  In  most  cases,  for  children  under  five 
years  old,  milk  should  be  somewhat  diluted,  usually  with  limewater,  and 
partly  peptonized  if  the  child's  digestion  is  feeble.  Children  who  do  not 
take  milk  readily  may  be  given  beef  tea,  broth,  gruel,  or  kumyss,  but  rarely 
ice-cream  or  jellies  so  frequently  prescribed,  as  these,  if  given  in  any  con- 
siderable quantity  or  very  often,  are  likely  to  disturb  the  stomach  and  take 
away  what  little  desire  for  food  the  child  may  have.  Kaw  eggs  are  pala- 
table when  beaten  up  with  sherry,  a  little  sugar,  and  cracked  ice.  Fruits, 
particularly  oranges,  grapes,  and  grape  fruit,  may  be  allowed  in  almost 
every  febrile  disease,  but  never  given  within  two  hours  of  a  milk  feeding. 

The  water  given  may  be  plain  boiled  water,  but  better,  in  most  cases, 
are  some  of  the  carbonated  waters,  Vichy,  Seltzer,  or  Apollinaris,  these 
being  less  likely  to  disturb  the  stomach. 

It  is  certainly  a  mistake  to  force  food  upon  older  children*  in  any  dis- 
ease in  which  their  condition  is  not  dangerous.  But  when  there  is  sepsis, 
delirium,  or  coma  associated  with  other  dangerous  symptoms,  gavage  may 
be  resorted  to  with  but  little  more  difficulty,  and  with  no  less  satisfactory 
results,  than  in  infants. 


CHAPTER  V. 

TUE  DERANGEMENTS  OF  NUTRITION. 

The  derangements  of  nutrition  form  a  distinct  and  a  very  large  class 
in  the  ailments  of  infancy,  particularly  during  the  first  year.  The  symp- 
toms are  sufficiently  definite  and  characteristic  for  them  to  be  regarded 
as  separate  diseases,  and  to  be  discussed  as  such.  In  adults  such  symp- 
toms are  seldom  seen  except  in  connection  with  organic  disease.  These 
cases  are  often  very  puzzling,  and  in  a  large  number  of  them  a  diag- 
nosis of  some  constitutional  disease,  such  as  hereditary  syphilis,  or  tuber- 
culosis, or  organic  disease  of  the  stomach  or  intestines,  is  erroneously 
made.  At  other  times  the  symptoms  resemble  those  of  acute  toxaemia. 
The  essential  condition  in  all  these  cases  is  the  inability  of  the  infant  to 
get  from  its  food  what  its  system  needs.  It  can  not  digest  or  assimilate 
enough  to  support  life.  It  is  unable  to  replace  from  its  food  the  daily 
waste  of  its  tissues.     The  constructive  metabolism  is  not  equal  to  the 


ACUTE   INAXITIOX.  I93 

destructive  metabolism  of  tlie  body ;  the  process  is,  therefore,  essentially 
starvation,  which  may  be  rapid  or  slow,  according  to  circumstances. 

The  fault  in  these  cases  is  partly  with  the  digestion,  but  principally 
with  the  food.  The  problem  is,  to  adapt  the  food  to  the  digestion  of  the 
particular  child  under  consideration.  The  solution  is  often  very  easy  at 
first,  but  the  difficulties  multiply  rapidly  the  longer  the  condition  has 
lasted.  It  is  tlierefore  essential  that  the  true  explanation  of  the  symp- 
toms should  be  recognised  at  the  earliest  possible  moment.  Changes 
occur  so  rapidly  in  very  young  infants  that  a  mistake  in  diagnosis  and  a 
consequent  delay  of  a  few  days,  may  be  sufficient  to  determine  a  fatal  re- 
sult. The  outcome  in  cases  ot  imperfect  nutrition  depends  almost  en- 
tirely upon  their  management.  The  condition  is  not  one  which  tends  to 
right  itself.  Spontaneous  improvement  or  recovery  rarely  takes  place. 
In  order  to  recognise  the  condition  and  anticipate  the  result,  nothing  is 
so  important  as  a  close  observation  of  the  body-weight.  A  child  whose 
nutrition  is  a  matter  of  difficulty  should  be  weighed  regularly,  in  the  early 
months  twice  a  week,  and  once  a  week  throughout  the  first  year.  If 
this  is  done,  the  first  symptoms  of  failing  nutrition  are  unerringly  de- 
tected. If  a  child  does  not  gain  in  weight  something  is  wrong,  and  a 
steady  loss  in  weight  in  an  infant  is  a  warning  which  should  never  be 
unheeded ;  for,  unless  the  conditions  are  changed,  it  is  practically  certain 
to  continue,  and  generally  with  increasing  rapidity,  until  the  infant's 
vitality  has  been  reduced  to  such  a  point  that  no  means  of  treatment  can 
restore  it.  The  younger  the  child,  the  more  rapid  the  loss,  and  the  longer 
it  has  continued,  the  greater  is  the  danger. 

For  convenience  of  description  these  derangements  of  nutrition  have 
been  divided  into  three  groups,  differing,  however,  rather  in  degree  than 
in  kind. 

1.  Cases  of  acute  inanition,  which  are  quite  rapid,  generally  lasting 
from  a  few  days  to  a  few  weeks.  They  are  rare  except  in  young  infants, 
being  most  frequently  seen  in  the  first  three  months. 

2.  Cases  of  malnutrition,  in  which  the  symptoms  are  much  less  severe 
than  in  the  other  groups,  although  they  may  be  of  long  duration.  While  it 
is  most  common  in  the  first  two  years,  malnutrition  may  be  seen  at  any  age. 

3.  Cases  of  marasmus.  This  is  similar  to  inanition,  but  a  much  slower 
process,  lasting  usually  for  several  months.  It  may  be  seen  in  infants  of 
any  age. 

ACUTE   INANITION. 

Inanition,  or  starvation,  is  a  condition  depending  upon  lack  of  assimi- 
lation. It  is  common  in  early  infancy,  when  it  often  simulates  sei'ious 
organic  disease.  In  older  children  it  is  not  so  frequent,  and  not  usually 
so  obscure.  In  all  the  acute  diseases  of  the  digestive  tract  many  of  the 
symptoms  are  due  to   inanition.     The  cases  considered  in  the  present 


194  •  NUTRITION. 

chapter,  however,  are  those  in  which  there  is  no  such  association,  or  where 
the  digestive  symptoms,  strictly  speaking,  are  not  prominent. 

Etiology. — The  essential  cause  of  inanition  is  that  the  child  does  not 
get  sufficient  food,  or  that  the  food  taken  is  not  assimilated.  It  usually 
develops  under  one  of  the  following  conditions :  (1)  When  a  child  refuses 
all  food,  whether  from  the  breast  or  the  bottle,  or  can  be  made  to  take 
only  so  small  an  amount  that  it  is  not  enough  to  support  life.  The 
cause  of  this  it  is  often  impossible  to  discover.  I  have  seen  it  in  a  variety 
of  circumstances — once  recently  in  an  infant  five  months  old,  previously 
healthy,  who  was  suffering  from  whooping-cough.  This  infant  utterly 
refused  the  breast,  and  from  the  spoon  would  take  less  than  two  ounces  a 
day.  This  continued  for  four  days,  at  the  end  of  which  time  its  symp- 
toms were  quite  alarming.  Gavage  was  then  begun,  and  its  life,  I  think, 
saved  by  this  procedure.  (2)  When  the  food  given  is  entirely  inadequate, 
as  when  an  infant  is  nursing  upon  a  dry  breast,  or  one  in  which  the  milk 
supply  is  so  scanty  that  the  child  gets  practically  nothing.  This  is  most 
frequent  during  the  first  two  weeks  of  life.  (See  page  118.)  I  have  occa- 
sionally seen  it  later,  when  an  infant  was  put  upon  the  breast  of  a  wet- 
nurse  whose  milk,  for  some  unexplained  reason,  had  suddenly  failed.  (3) 
Where  the  character  of  the  food  is  improper.  Breast-milk  may  be  not  only 
scanty,  but  of  very  poor  quality.  On  account  of  extreme  poverty,  the  in- 
fant may  be  getting  only  tea,  as  I  have  known  to  be  true  in  several  cases 
before  admission  to  the  hospital.  In  some  cases  a  very  young  infant  may 
be  fed  entirely  on  starchy  food.  (4)  Where  the  infant  at  birth  has  such 
feeble  powers  of  digestion,  because  premature  or  delicate,  that  it  is  unable 
to  digest  enough  of  the  food  given  to  maintain  life.  Sometimes  this  food 
is  breast-milk,  which,  though  abundant,  is  of  inferior  quality  and  can  not 
be  assimilated.  Very  often  it  is  some  proprietary  food.  (5)  When  a  sud- 
den change  of  food  is  made  to  one  so  difficult  of  digestion  that  the  child 
is  unable  to  assimilate  it.  This  may  happen  after  sudden  weaning.  In 
such  cases  the  symptoms  of  inanition  are  mingled  with  those  of  acute  in- 
digestion, but  the  former  usually  predominate. 

In  children  over  one  year  old,  and  sometimes  in  younger  ones  also,  the 
symptoms  of  inanition  follow  those  of  some  acute  disease,  such  as  influ- 
enza, malaria,  pneumonia,  or  even  otitis.  Although  they  may  recover 
from  the  acute  process,  the  general  vitality  is  so  much  lowered  that  as- 
similatioii  is  not  sufficient  to  replace  the  waste  of  the  body. 

Symptoms. — The  mode  of  development  depends  upon  the  antecedent 
condition.  In  young  infants  inanition  often  follows  malnutrition  where 
perhaps  there  has  been  nothing  noticeable  except  a  gradual  loss  in 
weight ;  and  if  the  weight  has  not  been  watched,  it  may  be  observed  only 
that  the  infant  has  not  been  doing  well.  Severe  symptoms  may  come  on 
quite  suddenly,  and  if  the  nature  and  the  gravity  of  the  condition  are  not 
appreciated  the  case  may  terminate  fatally  in  two  or  three  days.     The 


ACUTE  INANITION.  I95 

loss  in  weight  is  now  rapid,  amounting  often  to  three  or  four  ounces  a 
day.  The  temperature  is  variable :  in  the  newly-born  it  is  often  high,  but 
it  may  be  subnormal,  or  it  may  be  normal.  The  pulse  is  always  weak 
and  rapid.  The  extremities  are  usually  cold  and  the  peripheral  circula- 
tion poor.  There  is  marked  general  prostration.  The  skin  may  be  dry, 
or  it  may  be  covered  with  a  clammy  perspiration.  There  is  extreme 
pallor,  and  in  the  most  severe  form  there  is  cyanosis.  This  may  be 
marked  and  may  last  for  two  or  three  days,  gradually  deepening  until 
death  occurs,  or  it  may  disappear  entirely  and  recovery  follow.  Cyanosis 
may  be  present  in  children  who  have  previously  cried  well  and  in  whom 
there  is  no  suspicion  of  atelectasis.  The  respirations  are  rapid  and  may 
be  irregular.  There  may  be  constant  worrying  and  fretfulness,  or  a  con- 
dition of  semi-stupor,  in  which  the  child  makes  no  sign  of  wanting  food. 
The  fontanel  is  sunken  and  the  pupils  are  often  contracted.  The  stools 
contain  undigested  food,  or  if  predigested  foods  are  given  they  seem  to 
pass  through  the  intestines  unchanged.  The  bowels  usually  move  fre- 
quently, although  in  rare  cases  there  may  be  constipation.  When  all  food 
is  refused  for  two  or  three  days  the  stools  may  resemble  meconfuni,  as  I 
once  saw  in  a  child  six  months  old.  While  no  desire  for  food  is  mani- 
fested, infants  will  sometimes  swallow  food  when  it  is  offered,  retaining 
everything  given  for  several  feedings,  when  the  whole  quantity  is  vomited. 

The  course  of  the  disease  depends  much  upon  the  age  of  the  infants. 
Those  under  one  month  succumb  most  quickly.  In  them  the  symptoms 
sometimes  last  but  two  or  three  days,  seldom  more  than  a  week  or  ten 
days,  the  children  simply  drooping  steadily  until  death  occurs.  With 
proper  treatment  complete  recovery  may  take  place  in  a  week.  In 
older  infants  the  progress,  whether  upward  or  downward,  is  usually  less 
rapid. 

Prognosis. — The  outcome  of  these  cases  is  always  uncertain.  In  few 
conditions  is  it  more  so.  It  is  hard  for  one  who  is  not  familiar  with  the 
condition  to  appreciate  the  great  and  even  the  immediate  danger  in  which 
a  young  infant  may  be  from  inanition,  especially  in  the  absence  of  both 
vomiting  and  diarrhoea.  It  is  difficult  to  estimate  the  gravity  of  an  indi- 
vidual case  except  after  twenty-four  hours'  observation.  The  best  of  all 
guides  is  perhaps  the  weight.  Where  the  loss  is  several  ounces  each  day  the 
chances  of  recovery  are  small.  The  presence  also  of  frequent  vomiting 
or  of  diarrhoea  makes  the  outlook  very  bad.  A  high  temperature,  very 
marked  relaxation,  copious  perspiration,  cold  extremities,  and  cyanosis 
are  all  bad  symptoms. 

Diagnosis. — Inanition  is  distinguished  from  malnutrition  by  its  greater 
severity,  and  from  marasmus  by  its  more  acute  character.  The  usual  mis- 
take is  that  of  confounding  inanition  with  some  local  or  constitutional 
disease.  It  may  be  mistaken  for  acute  indigestion,  meningitis,  gastro- 
enteritis, pneumonia,  and  for  some  of  the  fevers.     The  temperature  when 


196  NUTKITION. 

elevated  is  especially  likely  to  mislead.  This  is  not  often  seen  except 
where  little  or  no  food  is  taken  or  retained. 

Treatment. — The  existence  of  inanition  in  young  infants  presupposes 
only  the  feeblest  powers  of  digestion  and  assimilation.  If  possible,  a  good 
wet-nurse  should  be  secured,  for  in  most  of  the  cases  the  time  for  action 
is  so  short  that  there  is  no  opportunity  to  experiment  with  artificial  feed- 
ing. This  is  one  of  the  few  conditions  in  which  wet-nursing  is  almost 
indispensable.  If  a  wet-nurse  can  not  be  obtained,  a  diluted  milk  like 
formula  XIV  (page  176)  may  be  given  after  being  peptonized  for  two 
hours.  If  food  is  not  readily  taken,  it  should  be  given  by  gavage.  This 
is  frequently  necessary,  as  very  many  of  these  infants  will  not  take  food 
at  all,  or  only  in  such  small  quantities  as  to  be  insufficient  for  nourish- 
ment. If  there  is  vomiting,  even  greater  dilution  may  be  required.  If 
food  so  prepared  is  not  retained,  kumyss,  whey,  animal  broths,  and  malted 
foods  may  be  tried  in  succession.  Wherever  the  symptoms  have  come  on 
very  rapidly,  temporary  improvement  sometimes  results  from  the  hypo- 
dermic use  of  a  one-per-cent  saline  solution,  two  ounces  every  five  or 
six  hours.  The  amount  of  food  actually  taken  in  the  twenty-four  hours 
should  be  noted,  as  it  is  often  found  to  be  only  one  fourth  that  which 
is  actually  needed  for  the  child's  nutrition. 

The  general  treatment  includes  stimulants  and  the  careful  regulation 
of  the  body  temperature.  If  there  is  fever,  sponging  with  tepid  water, 
cold  to  the  head  and  heat  to  the  extremities  may  be  employed.  If  the 
temperature  is  subnormal,  the  child  should  be  rolled  in  cotton  and  sur- 
rounded by  hot-water  bottles,  or  put  into  an  incubator.  Stimulants  are 
required  in  most  cases,  the  best  form  being  some  of  the  beef  peptonoids 
with  wine,  given  in  frequent,  small  doses.  As  soon  as  the  child  begins  to 
improve,  one  must  be  careful  about  increasing  the  food  too  rapidly,  for 
renewed  vomiting  with  an  aggravation  of  all  the  other  symptoms,  is  almost 
certain  to  follow  such  a  mistake. 

In  older  infants  the  symptoms  of  inanition  may  develop  when  a  child 
who  is  suddenly  taken  from  the  breast  absolutely  refuses  all  other  forms 
of  nourishment.  This  may  continue  for  three  or  four  days  until  the 
symptoms  are  quite  alarming.  For  such  cases  gavage  may  be  employed, 
and  formula  XII  or  XIII  (page  176)  given,  peptonized  two  hours. 

When  inanition  develops  in  children  over  a  year  old  it  is  usually  after 
an  attack  of  some  acute  disease.  They  lie  in  a  dull,  apathetic  condition, 
sometimes  with  subnormal  temperature,  showing  no  desire  for  food.  The 
circulation  is  poor,  the  skin  dry ;  there  may  be  small  petechise  upon  the 
abdomen ;  bedsores  form  with  great  rapidity  over  the  heels,  sacrum,  or 
occiput.  There  may  be  no  vomiting,  and  the  stools  may  appear  quite 
good.  Something  seems  to  be  needed  here  to  arouse  the  slumbering  cells 
to  activity,  and  massage,  external  heat,  hot  baths,  together  with  careful 
feeding,  temporarily  upon  predigested  foods,  are  means  by  which  a  few 


MALNUTRITION.  I97 

of  these  cases  can  be  saved ;  but  the  majority  sink  gradually  and  die  of 
exhaustion,  the  autopsy  showing  no  sufficient  explanation  of  the  symp- 
toms. 

MALNUTRITION. 

Cases  of  malnutrition  are  exceedingly  common,  and  occupy  a  large 
part  of  the  time  and  attention  of  one  engaged  in  practice  among  chil- 
dren. Although  these  children  can  not  be  said  to  be  actually  ill,  they 
are  very  far  from  well,  and  their  condition  is  often  the  cause  of  the  great- 
est solicitude  on  the  part  of  anxious  parents,  not  only  from  the  existing 
state  of  health,  but  from  the  apprehension  of  the  development  of  some 
serious  organic  or  constitutional  disease,  especially  tuberculosis. 

Etiology. — Malnutrition  may  depend  upon  inherited  conditions.  Cer- 
tain children  are  delicate  from  birth,  possessing  only  feeble  physical 
vitality,  but  without  giving  evidence  of  any  actual  disease.  They  are 
often  the  offspring  of  parents  of  delicate  constitution,  or  of  those  with 
inherited  tuberculosis,  gout,  syphilis,  or  alcoholism.  Very  many  city  chil- 
dren are  included  in  this  group.  They  are  a  product  of  modern  life,  in 
whom  is  seen  a  too  highly  developed  nervous  organization  with  a  corre- 
sponding amount  of  physical  deterioration.  In  another  group  of  cases  the 
children  are  premature  or  very  small  at  birth,  weighing  perhaps  only  three 
or  four  pounds.  Many  cases  are  traceable  to  improper  feeding  or  equally 
poor  nursing  during  the  first  few  months.  These  children  get  a  bad  start 
in  life,  and  on  that  account  are  handicapped  throughout  infancy.  In 
many  cases  malnutrition  develops  as  a  result  of  the  patient's  surroundings. 
While  this  is  common  among  the  poor,  it  is  not  rare  among  the  better 
classes.  One  of  the  most  frequent  causes  is  the  pernicious  custom  of 
keeping  infants  in  close  apartments  where  the  thermometer  ranges  from 
72°  to  78°  F.,  and  where  the  greatest  anxiety  is  constantly  felt  lest  the 
children  take  cold.  Such  infants  may  lose  in  weight,  become  anasmic, 
and  exhibit  all  the  signs  of  malnutrition  where  nothing  else  is  wrong  ex- 
cept the  conditions  mentioned.  In  infants,  malnutrition  often  depends 
upon  some  previous  acute  disease,  especially  of  the  stomach  and  intes- 
tines, and  sometimes  of  the  lungs. 

In  children  who  are  over  two  years  old  the  condition  of  malnutrition 
may  be  due  to  any  of  the  factors  above  mentioned — inherited  feebleness 
of  constitution,  bad  feeding  and  its  resulting  indigestion,  too  little  fresh 
air,  and  close  confinement  indoors.  It  is,  however,  at  this  period  much 
more  frequently  than  in  infancy,  dependent  upon  some  previous  acute 
disease.  This  may  have  been  acute  broncho-pneumonia,  acute  ileo-colitis, 
influenza,  malaria,  or  any  of  the  eruptive  fevers.  As  a  result,  an  im- 
pression is  left  upon  the  child's  constitution  which  lasts  for  months, 
often  for  years,  and  which  manifests  itself  not  by  any  special  local  symp- 
toms, but  by  a  general  condition  of  debility  or  malnutrition.  Sometimes 
such  diseases,  instead  of  being  directly  the  cause  of  the  symptoms,  are 


198  NUTRITION. 

the  occasion  which  brings  out  some  latent  inherited  taint  or  constitu- 
tional weakness  in  children  who  up  to  this  time,  perhaps,  have  appeared 
exceptionally  healthy.  In  other  cases  malnutrition  depends  upon  faulty 
methods  in  education,  especially  upon  overpressure  in  schools.^ 

Symptoms. — In  mfants. — In  weight  these  children  are  much  below 
the  average,  and  the  weight  is  stationary  or  the  gain  very  slow,  often  only 
five  or  six  ounces  a  month  at  a  period  when  it  should  be  from  one  to  two 
pounds.  In  a  case  recently  under  treatment,  a  child  at  fourteen  months 
weighed  but  eight  and  a  half  pounds.  This  infant  at  birth  weighed  three 
and  a  half  pounds,  but  in  the  course  of  a  few  weeks  the  weight  dropped  to 
two  pounds.  Not  only  is  the  weight  low  in  these  cases,  but  the  growth 
of  the  body  in  every  respect  is  delayed.  At  one  year,  the  length  is  often 
only  four  or  five  inches  more  than  at  birth.  Dentition  is  usually  but  not 
invariably  delayed.  I  have  repeatedly  seen  children  suffering  from  a  very 
marked  degree  of  malnutrition  in  whom  dentition  was  normal.  In  mus- 
cular development  such  children  are  always  very  backward,  often  not 
sitting  alone  until  they  are  a  year  old,  making  no  attempt  to  stand  until 
the  middle  of  the  second  year,  and  not  walking  alone  until  the  end  of  the 
second  or  the  middle  of  the  third  year.  The  muscles  are  soft  and  flabby 
and  the  ligaments  weak. 

Anaemia  is  invariably  present,  and  varies  much  in  degree,  being  rarely 
extreme.  The  circulation  is  commonly  poor,  the  hands  and  feet  are  fre- 
quently cold.  In  many  children  the  skin  is  unnaturally  dry  ;  in  others 
there  is  a  disposition  to  excessive  perspiration,  particularly  about  the  head. 
Nervous  symptoms  are  usually  present.  These  children  are  restless,  fret- 
ful, and  irritable  ;  they  sleep  badly  during  the  day,  and  often  worse  at 
night.  Enlargement  of  the  lymph  glands  is  common,  especially  in  the 
neck.  The  cervical  adenitis  may  have  started  from  a  slight  catarrhal 
cold,  but  the  glands  continue  to  swell  after  this  has  subsided  and  may 
remain  enlarged  for  months. 

One  of  the  most  characteristic  things  about  these  infants  is  their  feeble 
powers  of  digestion  and  assimilation.  Unremitting  care  and  constant 
watchfulness  are  required  to  keep  them  up  even  to  a  moderate  standard 
of  health.  The, most  trivial  changes  in  food  may  upset  them.  At- 
tacks of  acute  indigestion  are  usually  brought  on  by  overfeeding — the 
mistake  which  is  almost  invariably  made  by  mothers  who  are  discouraged 
with  the  slow  progress  made,  and  are  anxious  to  make  their  children  grow 
fat  and  strong.  The  balance  is  so  delicately  adjusted  that  the  slightest 
deviation  from  proper  rules  of  feeding,  either  as  to  the  quality  of  the 
food  or  quantity  given,  is  immediately  followed  by  an  attack  of  acute 
indigestion,  often  by  severe  diarrhoea.  As  a  result,  the  child  may  lose  as 
much  in  two  or  three  days  as  it  has  gained  in  a  month  or  more.  These 
acute  attacks  in  summer  not  infrequently  prove  fatal.  Not  only  do  these 
patients  have  but  little  resistance  to  acute  disturbances  of  the  stomach 


MALNUTRITION.  I99 

and  intestines,  but  any  acute  disease  is  serious — measles,  whooping-cough, 
and  pneumonia  being  especially  fatal. 

Among  the  poor  or  in  institutions,  cases  of  malnutrition  like  those 
described,  if  they  are  under  nine  months  old,  are  almost  certain  to  go 
on  from  bad  to  worse  until  they  have  reached  the  condition  described 
as  marasmus.  Between  this  and  malnutrition  no  sharp  line  can  be 
drawn  ;  they  are  rather  different  degrees  of  the  same  general  process. 
In  private  practice,  where  it  is  possible  to  have  the  best  care  and  sur- 
roundings, with  the  co-operation  of  an  intelligent  mother  or  nurse,  a 
very  large  number  of  these  infants  can  be  reared.  After  the  second  year 
has  passed  the  problem  becomes  a  much  simpler  one,  and  if  infectious 
diseases  and  other  forms  of  acute  illness  can  be  avoided,  the  probabili- 
ties are  in  favour  of  the  child's  growing  to  maturity  and  becoming 
stronger  each  year. 

In  older  children. — In  general  appearance  these  children  are  thin, 
spare,  and  very  often  undersized,  particularly  if  the  condition  is  constitu- 
tional or  hereditary.  In  other  cases  they  are  taller  than  the  average  for 
their  age,  and  their  symptoms  are  often  attributed  to  too  rapid  growth. 
One  of  the  most  striking  things  about  children  suffering  from  malnutri- 
tion is  their  vulnerability.  They  "  take  "  everything.  Catarrhal  processes 
in  the  nose,  pharynx,  and  bronchi  are  readily  excited,  and,  once  begun,  tend 
to  run  a  protracted  course.  There  is  but  little  resistance  to  any  acute  in- 
fectious disease  which  the  child  may  contract.  One  illness  often  follows 
another,  so  that  these  children  are  frequently  sick  for  almost  an  entire 
season.  Their  muscular  development  is  poor,  they  tire  readily,  are  able  to 
take  but  little  exercise,  and  their  circulation  is  sluggish.  Xervous  symp- 
toms are  usually  present.  Many  of  these  would  be  called  nervous  children. 
They  are  cross,  fretful,  and  any  unusual  excitement  produces  an  effect 
which  lasts  for  some  time  ;  for  example,  after  a  children's  party  or  a 
Christmas  tree  they  may  lie  awake  half  the  succeeding  night,  and  may 
be  really  ill  for  two  or  three  days.  Their  sleep  is  usually  disturbed  and 
restless;  they  waken  frequently,  and  occasionally  suffer  from  night-ter- 
rors. At  a  later  age  they  are  favourable  subjects  for  chorea,  neuralgia,  and 
all  functional  nervous  disorders. 

Digestive  symptoms,  if  not  constant,  are  very  easily  excited.  In  fact, 
they  do  not  suffer  so  much  from  chronic  indigestion  as  from  a  delicate  or 
feeble  digestion,  which  is  easily  upset  by  the  slightest  deviation  from 
the  regular  routine.  Children  of  five  or  six  years  have  to  be  fed  as  care- 
fully as  infants  of  eighteen  months  or  two  years.  The  appetite  is  usually 
poor,  and  mothers  are  distressed  because  their  children  eat  so  little,  yet, 
when  food  is  urged  upon  them,  attacks  of  indigestion  follow  with  singular 
uniformity.  The  tongue  is  slightly  coated  the  greater  part  of  the  time. 
The  bowels  are  apt  to  be  constipated,  apparently  more  from  lack  of  mus- 
cular tone  than  from  anything  else.      From  time  to  time,  from  slight 


200  NUTRITION. 

causes,  such  as  exposure  to  cold,  or  even  fatigue,  there  may  be  large  quan- 
tities of  mucus  in  the  stools  for  two  or  three  days  at  a  time,  although  this 
is  not  a  prominent  feature  of  most  of  these  cases.  When  they  are  not  fed 
with  the  greatest  care  these  children  suffer  constantly  from  indigestion. 
A  moderate  amount  of  anjemia  is  always  present,  and  in  some  cases  this  is 
one  of  the  most  striking  features  of  the  disease.  In  very  many  children 
with  a  marked  disturbance  of  nutrition,  there  is  an  excessive  elimination 
of  uric  acid. 

The  duration  of  these  cases  depends  very  much  upon  the  cause.  If 
the  cause  is  constitutional  or  inherited,  the  condition  may  last  throughout 
childhood.  Where  it  follows  some  acute  illness  it  commonly  lasts  for  a 
few  months  only  ;  but  the  effect  of  an  acute  attack  of  broncho-pneumonia 
or  of  ileo-colitis  may  last  for  years.  If  the  malnutrition  is  the  result  only 
of  the  child's  surroundings,  like  the  confinement  incident  to  city  life,  very 
rapid  improvement  and  prompt  recovery  may  follow  a  removal  to  the 
country. 

Diagnosis. — The  physician  should  not  be  too  ready  to  make  a  diagnosis 
of  simple  malnutrition.  Before  accepting  such  a  diagnosis,  he  should 
examine  the  child  with  the  greatest  care,  to  exclude  the  common  organic 
and  constitutional  diseases  of  children.  Much  regarding  inherited  con- 
stitutional tendencies  can  be  learned  from  the  family  history  and  from  the 
condition  of  the  other  children.  In  the  first  place,  tuberculosis,  syphilis, 
and  rickets  should  be  excluded ;  then  chronic  malaria  and  the  diseases  of 
the  blood ;  and,  finally,  organic  diseases  of  the  lungs,  heart,  stomach,  in- 
testines, liver,  and  kidneys.  Even  malignant  disease,  though  rare,  should 
not  be  overlooked.  It  may  take  careful  observation  for  several  days,  and 
sometimes  for  weeks,  with  repeated  physical  examinations,  before  all  these 
conditions  can  positively  be  excluded. 

The  next  step  in  the  diagnosis  is  to  discover  upon  which  one  of  the 
many  possible  causes,  malnutrition  depends.  In  my  own  experience  in 
private  practice  the  proportion  in  infancy  has  been  about  as  follows : 
sixty  per  cent  due  to  improper  feeding  or  nursing ;  twenty  per  cent  to 
improper  surroundings,  particularly  to  hot  rooms  and  want  of  fresh  air ; 
and  twenty  per  cent  to  inherited  constitutional  conditions.  In  other 
words,  most  of  these  children  are  born  healthy,  but  become  ill  or  delicate 
in  consequence  of  improper  management. 

In  older  children,  after  excluding  constitutional  and  local  diseases, 
the  whole  life  of  the  child  must  be  investigated  to  discover  the  funda- 
mental condition  which  is  at  fault.  It  is  often  difficult,  and  sometimes 
impossible,  to  get  at  this  primary  factor,  for  in  cases  of  long  standing 
there  may  be  symptoms  connected  with  almost  every  function  of  the 
body.  One  should  scrutinize  closely  the  quality  and  quantity  of  food 
given,  the  amount  of  sleep,  the  hours  of  study  and  recreation,  the 
amount  of  exercise  in  the  open  air,  and  the  psychical  conditions  sur- 


MALNUTRITION.  201 

rounding  the  child.  Usually  we  can  decide  which  is  the  most  important 
factor  in  the  case. 

Prognosis. — An  accurate  diagnosis  carries  with  it  the  data  for  prog- 
nosis. If  the  cause  can  be  discovered,  and  if  it  is  one  which  can  be 
removed,  the  prospects  are  good  for  improvement,  and  usually  for  com- 
plete recovery.  The  longer  the  cause  has  been  operative,  the  more  pro- 
found will  be  the  general  disturbance  of  nutrition,  and  the  longer  the  time 
required  for  improvement.  Cases  due  to  improper  feeding  or  surroundings 
usually  improve  immediately  when  a  jjroper  regime  is  instituted,  and  the 
worse  the  previous  management  of  the  case  has  been  the  more  marked 
is  the  improvement  to  be  expected.  In  these  cases  everything  depends 
upon  the  fidelity  with  which  the  directions  given  in  regard  to  diet  and 
surroundings  can  be  carried  out.  The  cases  which  offer  the  greatest 
difficulties  are  those  in  which  the  condition  of  malnutrition  depends  upon 
an  inherited  delicate  constitution  ;  although  these  may  improve,  they 
require  the  closest  attention  throughout  childhood.  Without  the  co- 
operation of  an  intelligent  and  devoted  mother,  or  an  experienced  nurse, 
very  little  progress  can  be  made. 

Treatment. — This  is  a  problem  of  nutrition  to  be  solved  by  diet  and 
general  management,  drugs  occupying  a  very  small  place. 

hi  infants. — In  very  young  infants  treatment  is  chiefly  a  question  of 
feeding.  If  possible  a  wet-nurse  should  be  secured.  If  this  is  impossible, 
artificial  feeding  should  be  carried  on  according  to  the  rules  given  in 
the  chapter  upon  the  feeding  of  delicate  children  and  those  with  feeble 
digestion.  (See  page  180.)  These  children  often  do  fairly  well  during 
the  first  year,  but  after  this  time  has  passed  mistakes  are  most  frequently 
made,  on  account  of  the  failure  to  appreciate  the  fact  that,  although 
over  twelve  months  old,  these  children  in  point  of  development  resemble 
healthy  infants  of  four  or  five  months,  and  are  to  be  managed  as  such.  If 
possible,  weaning  should  be  deferred  until  the  sixteenth  or  eighteenth 
month,  or  at  least  partial  nursing  should  be  continued  until  that  time. 
When  cow's  milk  is  begun  it  should  always  be  very  largely  diluted,  usually 
modified  as  for  a  healthy  infant  a  month  old.  (See  formula  IV,  pages  174, 
175.)  It  is  surprising  to  see  with  what  uniformity  the  giving  of  cow's 
milk,  pure  or  slightly  diluted,  will  produce  attacks  of  indigestion  in  these 
infants.  I  have  seen  a  single  feeding  in  which  one  ounce  of  milk  was 
given,  and  that  diluted  three  times,  produce  a  violent  attack  of  acute  indi- 
gestion which  proved  well-nigh  fatal.  Feeding  during  the  entire  second 
year  should  be  carried  on  very  much  as  in  ordinary  healthy  children  from 
the  sixth  to  the  twelfth  month.  A  deviation  from  this  rule  almost  inva- 
riably results  disastrously.  One  must  be  guided  in  the  amount  and  char- 
acter of  the  food  not  so  much  by  the  child's  age  as  by  its  digestive  capacity, 
and  in  most  cases  this  is  much  feebler  than  the  mother  or  even  the  physi- 
cian supposes.     In  many  of  these  cases,  cow's  milk — for  them  the  most 


202  NUTRITION. 

valuable  of  all  foods — has  been  excluded  from  the  diet,  when  the  only 
trouble  is  that  it  has  not  been  given  in  sufficient  dilution.  For  some 
children  it  must  be  partially  peptonized  during  periods  when  digestion 
is  especially  feeble. 

Next  in  importance  to  diet  is  the  question  of  fresh  air.  Oxygen  is  the 
best  of  all  tonics  for  these  children.  Often  they  will  not  improve  with 
any  variation  in  diet  until  fresh  air  is  allowed.  Then  increased  digestive 
power  is  seen  in  the  course  of  a  few  weeks,  sometimes  in  a  few  days. 
The  natural  tendency  of  a  mother  who  has  a  delicate  infant,  or  one  suffer- 
ing from  malnutrition,  is  to  house  it  closely  and  never  allow  it  a  breath 
of  fresh  air.  Even  in  winter  this  may  be  obtained  by  changing  apart- 
ments, or  by  airing  in  the  room  with  the  windows  open.  In  the  beginning 
this  should  be  done  for  a  few  minutes  only,  the  time  being  gradually  in- 
creased to  two  or  three  hours  each  day.  The  child  should  be  clothed  as 
for  the  street,  and,  if  necessary,  hot  bottles  should  be  placed  at  the  feet. 
Experiments  which  I  have  lately  made  in  the  hospital  with  these  delicate 
infants,  have  proved  conclusively  the  value  and  safety  of  this  plan. 

Cold  sponging  is  another  valuable  tonic.  After  the  morning  bath  is 
given,  at  90°  P.,  the  entire  body  should  be  sponged  for  a  moment  with 
water  at  a  temperature  of  60°,  or  even  55°  F.  This  produces  a  certain 
amount  of  shock  and  causes  loud  crying,  which  is  of  itself  beneficial. 
How  frequently  this  should  be  used  will  depend  upon  the  reaction  follow- 
ing it.  If  the  child  remains  blue  and  cold  for  some  time  afterward,  the 
cold  sponging  should  not  be  repeated.  If  there  is  a  good  reaction  and 
improved  colour,  it  may  be  used  daily. 

Friction  and  massage  are  useful  in  many  cases.  The  child  should  be 
laid  upon  the  lap  of  the  nurse,  if  possible  before  an  open  fire,  and  should 
always  be  covered  with  a  blanket.  The  entire  body  may  now  be  rubbed 
for  ten  or  twenty  minutes  with  the  bare  hand,  or,  better,  with  cocoa  butter. 
Simple  rubbing  may  be  used,  or  the  usual  movements  of  massage  em- 
ployed. If  the  latter,  they  should  be  very  gentle  at  first,  and  only  for  a 
short  time.  Professional  operators  are  inclined  to  be  too  energetic  for 
little  children.  There  is  no  advantage  in  rubbing  with  cod-liver  oil  in- 
stead of  cocoa  butter,  while  the  odour  makes  it  decidedly  objectionable. 

The  only  tonics  I  have  found  of  much  value  are  alcohol,  nux  vomica, 
and  cod-liver  oil.  Alcohol  may  be  given  in  the  form  of  port  or  sherry 
wine.  Xux  vomica  may  be  given  alone  or  with  the  wine.  Cod-liver  oil 
is  too  much  used  in  these  cases,  and  in  too  large  doses.  Many  of  these 
infants  can  not  take  it  atall.  It  should  rarely  be  given  when  the  tongue 
is  coated  and  the  appetite  very  poor.  The  dose  should  always  be  small — 
e.  g.,  ten  drops  of  tiie  pure  oil  three  times  a  day,  or  twice  as  much  of  an 
emulsion.  In  these  doses  it  may  be  given  for  a  long  time  without  dis- 
turbance. 

The  secret  of  success  in  treating  cases  of  malnutrition  is,  to  hold  the 


MALNUTRITION.  203 

patient  to  a  regular  routine  in  feeding,  sleep,  and  in  everything  relating 
to  his  life.  Experiments  are  nearly  always  unfortunate.  The  physician 
should  lay  down  in  writing  for  the  guidance  of  the  mother,  specific  rules 
with  regard  to  the  amount  of  food,  the  time  at  which  it  is  to  be  given,  the 
hours  of  bathing,  sleep,  and  airing,  and  should  insist  upon  their  rigid 
enforcement.  Good  results  are  obtained  only  by  constant  watchfulness, 
and  although  they  may  not  be  seen  at  once,  they  are  in  most  cases  sure  to 
come  if  the  mother  will  co-operate.  In  .my  own  experience  no  class  of 
patients  have  given  me  so  piuch  satisfaction  as  cases  of  malnutrition  in 
infancy. 

In  older  children. — The  same  general  principles  are  to  be  applied  to 
them  as  to  infants.  •  The  diet  is  of  the  first  importance.  Only  the  sim- 
plest, plainest,  and  most  easily  digested  articles  of  food  should  be  given. 
Milk,  beef,  eggs,  bread,  and  fruit  should  form  the  staple  diet.  All  sweets, 
pastry,  highly  seasoned  food,  candy,  nuts,  tea,  and  coffee  should  be  abso- 
lutely prohibited,  and,  in  fact,  none  of  the  articles  mentioned  as  "  forbid- 
den "  on  page  189  should  under  any  circumstances  be  permitted.  When 
the  appetite  is  poor  and  simple  food  not  well  taken,  the  child  should  not 
be  allowed  to  take  indigestible  articles  for  the  sake  of  eating  something. 
Nothing  should  be  given  between  meals,  and  regular  hours  of  feeding  must 
be  followed.  Usually  I  have  found  three  meals  a  day,  for  children  over 
three  years  old,  better  than  the  practice  of  giving  more  frequent  feedings. 
But  this  is  not  always  the  case.  Under  no  circumstances  should  children 
be  coaxed,  urged,  or  hired  to  eat ;  much  less  should  they  be  forced  to  do  so. 
There  is  a  popular  misapprehension  in  regard  to  the  variety  in  diet  which 
children  need.  Most  cases  do  better  when  a  very  simple  and  fairly  uni- 
form diet  is  continued. 

The  general  habits  of  children  should  be  directed  ;  there  should  be 
regular  and  early  hours  for  retiring,  freedom  from  undue  excitement, 
and  interest  should  be  awakened  in  out-of-door  amusements.  Children 
should  be  kept  as  much  as  possible  in  the  open  air ;  usually  they  do  much 
better  if  they  can  be  in  the  country  during  the  entire  year.  Only  a  limited 
amount  of  reading  and  study  should  be  allowed  ;  and  if  children  are  at 
school,  care  should  be  taken  that  overpressure  is  not  the  cause  of  the 
symptoms,  particularly  in  an  ambitious  child.  The  cold  sponging  given 
in  the  morning,  as  described  on  page  55,  is  extremely  beneficial  to  chil- 
dren w'ho  are  prone  to  take  cold  readily.  Massage  is  useful  for  the  benefit 
which  it  affords  to  the  chronic  constipation  which  is  so  frequently  a  symp- 
tom of  malnutrition. 

Of  the  tonics,  iron,  arsenic,  and  cod-liver  oil  are  required  in  most  cases, 
and  the  amount  and  combination  may  be  varied  from  time  to  time,  with 
the  season  of  the  year  and  the  condition  of  the  child's  digestion. 


204:  NUTRITION. 

MARASMUS. 
Synonyms  :  Athrepsia,  infantile  atrophy,  simple  wasting. 

Wasting  is  a  symptom  of  many  conditions  in  infancy.  It  occurs  in 
tuberculosis,  in  infantile  syphilis,  and  also  as  a  result  of  acute  or  chronic 
disease  of  the  stomach  and  intestines.  Cases  of  wasting  dependent  upon 
such  causes  are  not  included  in  this  chapter. 

Marasmus  is  the  extreme  form  of  malnutrition  seen  in  infancy,  occur- 
ring, so  far  as  is  now  known,  without  constitutional  or  local  organic  dis- 
ease.    It  is  a  vice  of  nutrition  only. 

Etiology. — Marasmus  is  not  often  seen  in  the  country  or  in  private 
practice.  It  is  frequent  in  dispensary  practice  in  all  large  cities,  and  is 
especially  common  in  institutions  for  young  infants.  In  my  own  experi- 
ence in  four  hospitals  for  infants,  more  than  one  half  the  deaths  were 
directly  or  indirectly  from  this  cause.  Marasmus  is  a  very  large  factor  in 
the  immense  infant  mortality  of  large  cities  in  summer.  Although  the 
cause  of  death  is  usually  reported  under  some  other  name,  the  determining 
factor  in  the  fatal  result  is  the  previous  marantic  condition  of  the  patient. 
The  primary  cause  may  be  an  inherent  weakness  of  constitution  which 
may  depend  upon  heredity.  It  is  often  seen  in  premature  children  and 
in  the  illegitimate  offspring  of  girls  of  sixteen  or  eighteen.  In  the  vast 
majority  of  cases,  however,  it  depends  upon  two  factors — the  food  and  the 
surroundings.  Among  the  poor  who  live  in  tenements,  infants  who  are 
artificially  fed  almost  invariably  do  badly.  This  is  due  to  ignorance  in 
regard  to  the  proper  methods  of  infant-feeding  and  inability  to  procure 
what  the  child  requires,  especially  pure  cow's  milk.  A  country  infant 
may  be  neglected  in  many  respects,  and  is  often  badly  fed ;  but  it  has 
plenty  of  pure  air,  and  usually  thrives.  In  the  city,  as  long  as  an  infant 
has  a  plentiful  supply  of  good  breast-milk  it  continues  to  do  well  in  most 
instances,  in  spite  of  the  fact  that  its  surroundings  are  bad.  When  there 
are  not  only  bad  feeding  and  unhealthful  surroundings,  but  also  an  in- 
herited constitutional  vice,  we  have  all  the  factors  required  to  produce 
marasmus  in  its  most  marked  form.  The  odds  are  so  against  the  infant 
that  its  feeble  spark  of  vitality  flickers  for  a  few  months  only  and  gradu- 
ally goes  out. 

Another  prominent  factor  in  the  production  of  marasmus  is  the  over- 
crowding of  infants  in  institutions.  Even  though  artificially  fed  after  tlie 
most  approved  methods,  I  have  seen  scores  of  infants  who  were  plump 
and  healthy  on  admission  lose  little  by  little,  until  at  the  end  of  three  or 
four  months  they  had  become  wasted  to  skeletons — hopeless  cases  of 
marasmus,  dying  of  some  mild  acute  illness,  such  as  an  attack  of  indiges- 
tion or  bronchitis,  the  essential  cause,  however,  being  marasmus.  The 
common  mistake  is  that  of  placing  too  many  children  in  one  ward,  with 


MARASMUS.  205 

no  chance  of  obtaining  a  proper  amount  of  fresh  air.  No  house-plant  is 
more  delicate  or  sensitive  to  its  surroundings  than  an  infant  during  the 
first  few  months  of  life. 

Lesions. — The  post-mortem  findings  in  cases  of  marasmus  are  exceed- 
ingly unsatisfactory,  and  throw  little  if  any  light  upon  the  disease.  Every 
now  and  then  general  tuberculosis  is  discovered  in  patients  dying  appar- 
ently of  marasmus,  the  existence  of  which  was  not  previously  suspected. 
In  perhaps  one  third  of  the  marked  cases  there  is  found  a  fatty  liver.  The 
organ  is  enlarged,  often  sufficiently  so  to  be  made  out  during  life  ;  its 
weight  may  exceed  the  normal  by  one  half,  or  it  may  be  doubled  in  size. 
Both  to  the  naked  eye  and  under  the  microscope,  it  presents  the  usual 
changes  of  fatty  degeneration,  often  to  an  extreme  degree.  The  signifi- 
cance of  this  lesion  I  do  not  knoAv.  It  is  to  be  compared  with  the  similar 
condition  seen  in  tuberculosis  and  other  chronic  wasting  diseases.  It  may 
be  looked  upon  either  as  a  cause  or  a  result  of  the  pathological  process. 

With  these  exceptions  the  autopsies  show  nothing  of  importance,  and 
I  have  had  opportunity  to  make  at  least  two  hundred  of  them.  Tlie 
lesions  usually  found  are  the  following :  The  brain  is  commonly  ansemic, 
wdth  dark  fiuid  blood  in  the  sinuses,  marantic  thrombi  being  rare.  A  strip 
of  hypostatic  pneumonia,  from  one  to  two  inches  wide,  is  seen  along  the 
posterior  border  of  both  lungs,  involving  the  lung  to  the  depth  of  half 
an  inch,  or  less.  In  the  younger  infants  there  are  frequently  areas  of 
atelectasis  in  the  lower  lobes.  The  pleura  is  almost  invariably  normal. 
The  heart  is  pale,  with  perhaps  a  sliglit  increase  in  the  pericardial  fluid. 
The  spleen  and  kidneys  are  pale,  but  otherwise  normal.  The  stomach 
may  be  dilated  ;  the  mucous  membrane  is  usually  pale,  often  coated  with 
tenacious  mucus.  The  intestines  contain  undigested  food,  sometimes 
mucus.  The  solitary  follicles  of  the  colon  and  small  intestine,  and  some- 
times Peyer's  patches,  are  slightly  enlarged,  the  mucous  membrane  in 
other  respects  being  normal.  The  mesenteric  glands  are  often  slightly 
enlarjred.  In  addition  to  the  above,  there  mav  be  evidence  of  some  re- 
cent  disease  from  which  the  patient  has  died — acute  bronchitis,  broucho- 
pneumoTiia,  or  a  slight  intestinal  catarrh. 

The  above  lesions  represent  what  has  been  found  in  the  great  majority 
of  the  cases,  and  very  disappointing  they  are  to  one  who  sees  them  for  the 
first  time.  Xor  does  the  microscopical  examination  of  the  organs  throw 
any  light  upon  these  cases.  I  have  personally  examined  with  care  the 
stomach  and  intestines  of  more  than  a  dozen  cases,  several  of  them  in 
which  autopsies  were  made  only  two  or  three  hours  after  death,  without 
finding  anything  of  pathological  importance.  The  theory  advanced  by 
certain  German  writers,  that  atrophy  of  the  intestinal  tubules  is  the  ex- 
planation of  marasmus,  has  found  no  support  in  my  observations. 

The  true  pathology  of  marasmus  seems  to  me  to  be  a  failure  of  assimi- 
lation from  imperfect  digestion,  due  to  improper  food,  unhygienic  sur- 


206 


NUTRITION. 


roundings,  or  feeble  constitution.  As  a  result,  there  is  a  progressive  loss 
in  weight,  feeble  circulation,  imperfect  lung  expansion,  imperfect  oxida- 
tion of  tlie  blood,  lowered  body  temperature,  and,  finally,  a  deterioration 
of  the  blood  itself.  Each  of  these  effects  becomes  in  turn  a  cause  aggra- 
vating all  the  others,  continuing  until  a  condition  is  reached  which  is 


Fig.  31.-   M. 


• ;  a  patient  in  the  Babies'  Hospital,  ten  months  old,  weight  si.\  pounds. 
Weight  at  birth  reported  to  have  been  nine  pounds. 


incompatible  with  life,  for  resistance  becomes  so  feeble  that  the  slightest 
functional  disturbance  proves  fatal. 

Symptoms. — The  general  history  of  these  cases  is  strikingly  uniform. 
The  following  is  the  story  most  frequently  told  at  the  hospital :  "  At  birth 
the  baby  was  plump  and  well  nourished,  and  continued  to  thrive  for  a 
month  or  six  weeks  while  the  mother  was  nursing  it ;  at  the  end  of  that 
period,  circumstances  made  weaning  necessary.     From  that  time  the  child 


MARASMUS.  207 

ceased  to  thrive.  It  began  to  lose  weight  and  strengtli,  at  first  slowly, 
then  rapidly,  in  spite  of  the  fact  that  every  known  form  of  infant-food 
has  been  tried."  As  a  last  resort  the  child,  wasted  to  a  skeleton,  is 
brought  to  the  hospital. 

The  most  constant  symptom  is  a  steady  loss  in  weight.  The  general 
appearance  of  these  patients  is  characteristic.  They  have  an  old  look ; 
the  skin  is  wrinkled,  has  lost  its  tone,  and  hangs  in  folds  upon  the  ex- 
tremities (Fig.  31).  The  legs  are  like  drumsticks;  the  abdomen  is  promi- 
nent ;  the  temples  are  hollow  ;  the  eyes  large  ;  the  features  sharp  ;  and 
the  hands  resemble  bird-claws.  Often  the  children  are  reduced  literally 
to  skin  and  bone.  Anaemia  is  a  very  marked  and  almost  a  constant  symp- 
tom, the  amount  of  heemoglobin  being  frequently  reduced  to  30  per  cent., 
and  in  one  case  of  mine  to  18  per  cent.  Anemic  heart-murmurs  are  fre- 
quently heard.  The  body  temperature  is  usually  subnormal,  unless  arti- 
ficial heat  is  used.  A  rectal  temperature  of  9G°  or  97°  F.  is  very  common, 
and  one  of  94°  or  95°  F.  is  occasionally  seen.  In  addition  to  the  pallor 
of  the  face,  there  may  be  a  leaden  hue  due  to  congenital  or  acquired  ate- 
lectasis. An  occasional  symptom  is  general  oedema,  depending  upon  the 
condition  of  the  blood  or  blood-vessels.  The  first  thing  which  calls  at- 
tention to  this  is  often  an  unexpected  gain  in  weight.  The  adema  may 
increase  until  the  cellular  tissue  of  the  whole  body  is  affected.  I  have 
never,  however,  seen  effusions  into  the  large  cavities.  CEdema  is  usually 
associated  with  marked  anaemia,  and  is  generally  a  very  bad  symptom. 
The  stools  are  sometimes  normal,  but  usually  contain  undigested  food, 
and  are  large  in  proportion  to  the  amount  of  food  taken.  Xo  matter  how 
carefully  fed,  these  patients  are  easily  upset.  Xow  and  then  mucus  is 
seen  in  the  discharges,  but  this  is  not  a  constant  or  a  marked  feature. 
Vomiting  is  excited  from  the  slightest  cause,  and  often  food  is  regurgi- 
tated almost  as  soon  as  swallowed.  The  appetite,  in  a  severe  case,  is  almost 
entirely  lost ;  children  refuse  to  take  food  from  the  bottle  or  spoon,  and 
unless  fed  by  gavage  they  die  of  inanition.  In  the  earlier  cases  there  may 
be  an  unnatural  hunger,  so  that  the  children  cry  much  of  the  time,  and 
are  relieved  only  when  the  bottle  is  given. 

The  complications  are  thrush,  erythema  of  the  buttocks,  and  bed- 
sores, sometimes  over  the  sacrum  and  heels,  but  most  frequently  upon  the 
occiput.  Occasionally  there  is  seen  a  reflex  spasm  of  the  muscles  of  the 
neck,  producing  a  marked  opisthotonus,  which  may  last  for  several  days 
or  weeks. 

The  course  of  the  disease  in  most  cases  is  steadily  downward.  It  may 
be  cut  short  at  any  time  by  acute  disease.  Frequently  these  infants  die 
suddenly  when  they  have  apparently  been  as  well  as  for  several  weeks.  In 
many  instances  the  autopsy  reveals  no  explanation  of  this  sudden  death; 
but  in  other  cases  it  is  due  to  the  regurgitation  of  food,  and  its  aspiration 
into  the  larynx,  the  patient  being  too  weak  to  cough.  Rarely,  death  occurs 
35 


208  NUTRITION. 

from  convulsions.  In  summer,  these  children  wilt  with  the  first  days  of 
very  hot  weather,  and  die  often  in  a  few  hours  from  a  slight  functional 
derangement  of  the  stomach  and  bowels. 

Diagnosis. — No  sharp  line  caii  be  diawn  between  marasmus  and  mal- 
nutrition. In  the  wasting  which  follows  chronic  disease  of  the  stomach 
and  intestines  there  is  usually  a  history  of  an  antecedent  acute  attack. 
The  chief  difficulty  in  the  diagnosis  of  marasmus  is  to  exclude  tubercu- 
losis. In  some  cases  a  differential  diagnosis  is  impossible  during  life.  Not 
infrequently  tuberculosis  is  found  at  autopsy,  even  in  infants  of  a  few 
months,  in  whom  there  have  been  no  symptoms  except  those  of  maras- 
mus. Even  when  the  signs  in  the  lungs  are  present,  if  situated  posteriorly, 
they  may  be  due  either  to  tuberculosis  or  to  the  hypostatic  pneumonia 
which  is  present.  Signs  in  front  are  more  significant ;  and  consolidation 
anteriorly  makes  tuberculosis  almost  certain.  In  simple  wasting  there  is 
often  a  history  that  the  child  was  in  splendid  condition  at  birth,  and  con- 
tinued so  until  it  was  weaned,  from  which  date  it  has  gone  down  steadily. 
In  tuberculosis  no  such  definite  cause  may  be  present ;  the  children  are 
often  very  delicate  from  birth.  Simple  wasting  is  so  much  more  com- 
mon that  the  chances  are  always  in  its  favour. 

Prognosis. — This  dej^ends  on  the  age  of  the  infant  and  the  extent 
and  duration  of  the  disease.  If  the  child  is  over  eight  months  old,  the 
chances  of  recovery  are  much  better  than  in  one  under  four  months,  for 
the  fact  that  it  has  lived  so  long  is  generally  evidence  of  pretty  strong 
vitality.  Very  young  infants  are  always  difficult  subjects  to  deal  with. 
They  go  down  more  rapidly,  and  build  up  more  slowly  than  those  who 
are  older.  In  most  other  circumstances  the  prognosis  is  much  worse 
in  cases  of  long  duration.  In  a  given  case  much  depends  upon  whether 
everything  possible  can  be  done  for  the  child — whether  a  wet-nurse  can 
be  secured  or  artificial  feeding  done  in  the  best  manner,  and  whether  the 
patient  can  have  the  benefit  of  the  best  surroundings,  in  the  country  in 
summer  and  a  warm  climate  in  winter  where  it  can  be  kept  out  of  doors 
the  greater  part  of  the  time.  In  institutions  cases  under  four  months  old 
are  usually  hopeless.  Of  those  over  eight  months  quite  a  proportion  can 
be  saved  by  proper  treatment,  even  though  the  body-weight  is  reduced  to 
eight  or  nine  pounds.  When  recovery  occurs  it  may  be  complete,  and 
the  child  at  three  years  may  be  as  vigorous  as  any  child  of  its  age.  All 
these  statements  refer  only  to  cases  of  simple  marasmus.  The  presence 
of  organic  disease  puts  the  case  in  another  category. 

Treatment. — The  most  important  is  that  which  relates  to  prophylaxis. 
This,  for  large  cities,  may  be  summed  up  in  a  single  sentence  :  giving  the 
poor  the  opportunity  to  obtain  pure  cow's  milk  and  teaching  them  how 
to  feed  it  to  young  infants,  and  at  the  same  time  giving  ample  opportuni- 
ties for  obtaining  fresh  air.  In  institutions  the  most  important  thing  is 
to  give  adequate  air-space  for  each  child.    Often  only  four  or  five  hundred 


SCORBUTUS.  209 

cubic  feet  are  allowed,  when  at  least  eight  hundred  are  necessary,  even 
with  the  best  ventilation.  Children  should  be  changed  from  one  apart- 
ment to  another  and  opportunities  given  for  thorougli  airing,  and  there 
should  be  perfect  ventilation,  not  only  in  the  daytime  but  at  night. 

As  far  as  possible,  wet-nurses  should  be  obtained  if  the  infants  are 
under  four  months  old.  For  these  very  young  patients  success  by  artifi- 
cial feeding  is  not  often  possible.  With  those  of  six  months  and  over, 
good  artificial  feeding  is  very  frequently  successful.  In  modifying  cow's 
milk  for  these  cases  the  formulge  most  likely  to  agree  are  those  with  low 
fat,  low  proteids — partly  peptonized  in  many  cases — and  relatively  high 
sugar.  Such  are  obtained  by  formula?  XV,  XVI,  and  XVII,  page  176. 
Starting  with  the  lower  percentages,  they  may  be  gradually  increased  to 
the  highest;  then  the  fat  may  be  increased  to  that  in  formula  XIII. 
Further  suggestions  will  be  found  in  the  chapter  on  Feeding  in  Difficult 
Cases  (page  180).  In  institutions  we  are  not  likely  to  succeed  very  often 
without  wet-nurses. 

For  very  young  infants,  with  a  temperature  which  is  habitually  sub- 
normal, the  incubator  should  be  used.  If  this  is  impossible,  children 
should  be  rubbed  with  oil,  rolled  in  cotton,  and  surrounded  with  hot- 
water  bags  or  bottles.  The  general  management  should  be  much  the  same 
as  described  in  the  chapter  on  Malnutrition.  At  least  once  every  day — by 
means  of  spanking,  mild  flagellation,  or,  better,  by  the  alternate  use  of  the 
hot  and  cold  baths — children  should  be  made  to  cry  vigorously,  in  order 
to  keep  the  lungs  expanded.  They  require  no  drugs,  but  a  great  deal  of 
careful  nursing. 


CHAPTER   VI. 

DISEASES  DUE   TO  FAULTY  NUTRITION. 

The  diseases  due  to  faulty  nutrition  are  really  numerous.  There  are, 
however,  two  which  have  been  so  clearly  shown  to  originate  in  this  way 
that  they  may  be  singled  out  and  put  in  a  class  by  themselves.  These 
are  scorbutus  and  rickets.  The  prevailing  opinion  of  the  medical  pro- 
fession is  that  both  of  these  are  essentially  "  food-diseases."  The  purpose 
of  considering  them  in  connection  with  the  disturbances  of  nutrition  is 
to  emphasize  this  relationship. 

SCORBUTUS  (SCURVY). 

Scorbutus  is  a  constitutional  disease,  due  to  some  prolonged  error  in 
diet.  It  is  characterized  by  spongy,  bleeding  gums,  swellings  and  ecchy- 
moses  about  the  joints,  especially  the  knee  and  ankle,  hajmorrhages  from 
the  nose,  and  occasionallv  from  other  mucous  membranes,  extreme  hyper- 


210 


NUTRITION. 


sesthesia,  and  often  pseudo-paralysis  of  the  lower  extremities.  Added  to 
these  local  symptoms  there  is  usually  a  general  cachexia  with  marked 
anjfimia.  While  scorbutus  and  rickets  are  very  frequently  associated,  they 
are  not  necessarily  connected,  and  can  hardly  be  considered  as  different 
forms  of  the  same  disease;  although  cases  of  scorbutus  have  been  described 
in  older  writings  under  the  title  of  Acute  Rickets.  The  course  of  the 
disease  is  somewhat  chronic,  lasting  for  weeks  or  months;  and  while  it 
usually  yields  immediately  to  proper  treatment,  if  unrecognised  and  if  the 
original  error  in  diet  is  continued,  it  not  infrequently  proves  fatal.  It  is 
only  within  the  last  twelve  or  fourteen  years  that  infantile  scurvy  has 
found  a  distinct  place  in  medical  literature.  For  oar  present  understand- 
ing of  the  disease,  the  profession  is  indebted  chiefly  to  the  work  of  the 
English  physicians  Cheadle,  Gee,  and  Barlow,  especially  the  last  named, 
who  in  1883  made  a  full  report  upon  thirty-one  cases  of  scorbutus  in  in- 
fants and  young  children,  in  which  publication  the  etiological  factors  and 
clinical  history  were  worked  out  so  fully  that  but  little  has  since  been 
added  to  the  subject.  In  Germany  it  still  passes  to-day  under  the  title  of 
Barlow's  Disease.  To  ISTorthrup  is  due  the  credit  of  bringing  the  subject 
prominently  before  the  minds  of  the  profession  of  this  country.* 

Etiology. — Scorbutus  is  not  uncommon  in  infancy,  but  it  is  frequently 
unrecognised.  During  the  past  two  years  twelve  cases  have  come  under 
my  own  observation.  All  of  these  were  under  two  years  of  age,  as  were 
also  all  of  Cheadle's  twenty  cases  and  twenty-five  of  Barlow's  original 
thirtv-one.  The  great  majority  of  cases  occur  between  the  eighth  and 
twentieth  months.  There  is  no  preference  for  sex  or  season.  Since  the 
essential  cause  of  scorbutus  is  dietetic,  it  may  be  found  in  all  surround- 
ings. Of  the  reported  cases,  the  majority  have  occurred  in  private  prac- 
tice and  among  the  better  classes  of  society,  in  the  country  quite  as  often 
as  in  the  cit}'.  The  previous  diet  of  most  of  the  patients  who  develop 
scurvy  has  been  either  some  of  the  proprietary  foods  or  condensed  milk, 
or  a  combination  of  the  two.  Scurvy  may  be  induced  by  the  giving  of 
proprietary  foods,  even  when  a  small  amount  of  cow's  milk  has  been 
added.  In  one  reported  case  (Delafield's),  scurvy  was  produced  in  a  child 
three  years  old  by  an  exclusive  diet  of  rare  meat,  continued  for  three 
months. 

Since  the  introduction  of  the  practice  of  heating  milk  used  in  infant- 
feeding,  the  question  has  been  raised  in  many  quarters  whether  this  may 
not  be  a  cause  of  scurvy.  I  have  carefully  investigated  this  question  in 
the  records  of  three  institutions  in  which  for  five  years  "  sterilized  "  milk 
was  the  standard  food  for  all  artificially-fed  infants.  The  number  of 
children  under  eighteen    months  who  have  had  this  diet  is   nearly  one 

*  See  paper  by  Northrup  and  Crandall,  New  York  Medical  Journal,  May  26,  1894, 

in  which  will  be  found  thirtv-six  tabulated  cases. 


SCORBUTUS.  211 

thousand.  During  this  period  but  two  cases  of  scurvy  were  observed, 
and  in  neither  case  had  the  child  been  upon  a  diet  of  "  sterilized  "  milk. 
However,  I  have  recently  seen  in  private  practice  two  cases  of  scurvy  in 
which  the  cause  seemed  to  be  prolonged  sterilization  at  a  high  temperature 
— i.  e.,  212°  F.  for  over  an  hour.  In  some  of  the  cases  in  which  the  "ster- 
ilized" milk  is  supposed  to  have  been  the  cause  of  scurvy,  it  is  undoubt- 
edly the  milk-formula  employed  which  was  at  fault,  and  not  the  process 
of  heating.  In  two  patients  under  personal  observation,  who  developed 
scurvy  while  taking  "  sterilized  "  milk  and  a  proprietary  food,  the  food 
was  discontinued  and  the  patient  recovered,  although  heating  the  milk 
was  continued.  In  four  cases  observed  by  Winters  no  other  treatment 
was  employed  than  the  substitution  of  "  sterilized  "  milk  for  the  previous 
diet,  whicli  in  tliree  instances  had  been  proprietary  foods.  All  the  patients 
jiromptly  recovered.     In  these  cases  the  milk  was  heated  to  212°  F. 

Scurvy  in  nursing  infants  is  very  rare.  In  one  of  Xorthrup's  cases,  a 
fatal  one,  the  foundling  was  wet-nursed  by  a  woman  whose  own  child 
thrived.  The  presumption  here  was  that  the  scurvy  was  induced  by  in- 
sufficient food.  Southgate  *  has  reported  a  fairly  typical  case  of  scurvy  in 
an  infant  of  fifteen  months,  who  had  been  nursed  exclusively  up  to  that 
time.  The  child  was  rachitic  and  quite  markedly  cachectic,  but  recovered 
immediately  when  weaned  and  placed  upon  a  diet  of  cow's  milk,  orange- 
juice,  potato,  etc.  The  probabilities  are  that  in  this  case  the  scurvy  was 
due  to  the  poor  quality  of  the  breast-milk,  coupled  with  the  bad  surround- 
ings of  the  child. 

From  all  the  above  evidence  it  would  appear  that  scurvy  may  be  in- 
duced by  the  continued  use  of  any  food  which  either  lacks  some  elements 
needed  for  the  child's  nutrition,  or  which  furnishes  them  in  such  a  form 
that  the  child  can  not  assimilate  them.  Clinical  experience  is  overwhelm- 
ing in  support  of  the  view  that  it  is  the  proprietary  infant-foods  which 
are  most  certain  to  produce  scurvy,  especially  when  they  form  the  exclu- 
sive diet. 

Symptoms. — The  following  cases  illustrate  the  chief  clinical  types  of 
the  disease  : 

The  most  serious  form  with  fatal  tei'mination. — A  case  of  extreme 
marasmus  came  under  observation  in  the  Babies'  Hospital,  in  1892,  in  an 
infant  who  for  two  months  had  been  upon  an  exclusive  diet  of  a  well- 
known  proprietary  food.  At  the  end  of  that  time  there  was  observed  a 
swelling  about  the  left  knee,  which  slowly  increased  in  size,  and  was  ac- 
companied by  an  extreme  degree  of  tenderness  about  the  joint.  The 
swelling  was  ditfuse,  spindle-shaped,  and  accompanied  by  a  purplish  dis- 
coloration of  the  skin.  A  little  later  the  gums  became  spongy  and  bled 
easily  at  the  margin  of  the  teeth.     In  places  where  the  next  teeth  were 

*  Arcliives  of  Pirdiatric?.  vol.  xi.  p.  005. 


212  NUTRITION. 

expected,  the  gum  was  purple  and  swollen,  evidently  from  submucous 
ecchymoses.  There  were  very  marked  cachexia  and  anaemia.  The  swell- 
ing extended  up  to  the  middle  of  the  thigh,  and  gradually  increased  in 
size  until  the  limb  was  fully  four  inches  in  diameter.  An  aspirating 
needle  was  introduced,  but  only  blood  was  found.  The  child  wasted 
steadily,  and  died  of  exhaustion  two  months  after  the  appearance  of  the 
first  symptoms.     During  the  last  few  weeks  slight  fever  was  present. 

The  autopsy  in  this  case  showed  the  typical  lesions  of  scorbutus.  The 
periosteum  of  the  femur  was  stripped  from  the  bone  throughout  the  lower 
two  thirds  of  its  extent  by  subperiosteal  haBmorrhage.  There  were  also 
extravasations  of  blood  between  the  muscles  and  into  the  subcutaneous 
tissue,  and  to  these  haemorrhages  the  swelling  was  mainly  due.  There 
was  complete  separation  of  the  lower  epiphysis  from  the  shaft.  No  other 
bones  were  affected. 

In  most  of  the  cases,  however,  that  have  come  to  autopsy  other  bones 
also  have  been  involved  with  lesions  of  a  similar  character ;  the  other  long 
bones  most  frequently  affected  are  the  tibia  and  humerus;  of  the  flat 
bones,  the  scapulse  and  cranium.  Epiphyseal  separation  may  take  place 
near  any  of  the  large  joints,  haemorrhages  may  be  found  between  the 
muscles,  in  the  subcutaneous  tissue,  and  occasionally  in  the  lungs,  spleen, 
and  kidney.     The  lesion  in  the  mouth  is  a  hEemorrhagic  gingivitis. 

A  typiccd  case  of  the  severe  form,  ending  in  recovery. — The  patient 
was  a  boy  fourteen  months  old,  of  healthy  parents  and  good  surroundings, 
living  in  a  country  town  near  New  York.  At  birth  it  was  said  he  weighed 
fourteen  pounds.  The  mother  being  unable  to  nurse  him,  he  had  been  fed 
exclusively  upon  condensed  milk  and  proprietary  foods.  He  had  never 
thriven,  but  the  symptoms  of  malnutrition  and  anemia  had  been  the  only 
ones  present  until  four  months  before  coming  under  observation.  The 
evolution  of  the  symptoms  in  this  case  is  interesting  because  it  is  so  typ- 
ical. There  was  first  noticed  tenderness  about  the  ankles,  then  about  the 
knees,  this  being  so  acute  that  the  child  screamed  whenever  the  legs  were 
handled,  but  at  other  times  he  gave  no  evidence  of  pain.  A  little  later, 
boggy  swellings  were  discovered  about  one  knee  and  both  ankles.  Soon 
after  this  the  gums  were  noticed  to  bleed  frequently,  and  at  times  they 
were  so  much  swollen  as  to  conceal  the  teeth.  All  these  symptoms  had 
continued  up  to  the  time  the  child  was  brought  for  treatment.  He  had 
been  growing  gradually  worse,  each  day  becoming  more  anaemic  and  ca- 
chectic. Several  attacks  of  epistaxis  had  occurred,  and  once  there  had 
been  haemorrhage  from  the  ear.  In  one  of  the  best  general  hospitals  of 
New  York  the  diagnosis  of  ostitis  of  the  knee  had  been  made,  and  a 
plaster-of- Paris  splint  applied. 

On  examination,  the  child  presented  the  signs  of  rickets  of  moderate 
severity.  There  were  irregular  swellings  about  the  left  knee  and  ankle, 
but  no  discoloration  of  the  skin.     Slight  swelling  was  seen  also  upon  the 


SCORBUTUS.  213 

lower  part  of  the  right  leg.  The  limbs  were  exquisitely  tender,  the  slightest 
movement  causing  the  child  to  scream  with  pain.  It  was  several  months 
since  voluntary  movement  had  been  seen,  and  the  legs  now  lay  absolutely 
motionless,  apparently  owing  to  the  pain  which  any  attempt  at  motion 
excited.  The  gums  were  like  those  in  the  jireceding  case,  but  the  condi- 
tion was  more  marked,  and  ulceration  was  seen  along  the  incisor  teeth. 

Under  treatment  exclusively  dietetic,  the  symptoms,  which  had  been 
unchanged  for  three  months,  were  wonderfully  improved  in  three  days; 
and  at  the  end  of  two  weeks  the  child  was  kickiug  his  legs  about,  the 
swelling  and  tenderness  were  gone,  the  gums  entirely  well,  and  the  gen- 
eral condition  greatly  improved.  The  case  went  on  to  a  rapid  and  com- 
plete recovery. 

The  mildest  type  seen  without  either  sioellings  or  mouth-sympto7ns. — 
These  cases  are  not  often  recognised  as  scurvy,  but  they  are  probably  the 
most  common  form.  This  cliild  was  seen  in  the  country,  in  jirivate  prac- 
tice. It  was  an  exceedingly  healthy  infant  in  appearance,  nine  months 
old ;  the  diet  from  birth  had  been  milk  "  sterilized  "  at  170°,  with  the 
addition  of  a  well-known  infant-food.  At  the  time  of  his  attack  he  was 
apparently  in  the  best  of  health,  with  bright  red  cheeks.  He  was  first 
noticed  to  cry  out  sharply  as  if  in  pain  when  lifted  in  a  certain  way.  It 
soon  became  evident  that  the  trouble  was  located  about  the  left  knee. 
Nothing  could  be  discovered  upon  examination  except  a  very  great  amount 
of  tenderness.  This  symptom  continued  for  six  weeks ;  on  some  days  the 
tenderness  was  extremely  acute,  and  on  others  scarcely  noticeable.  After 
three  weeks  a  slight  ecchymosis  was  discovered  over  the  head  of  the  tibia 
of  the  affected  limb.  About  this  time  tenderness  and  a  disinclination  to 
move  the  right  shoulder  were  noticed,  and  soon  an  ecchymosis  like  a  small 
bruise  w^as  seen  in  front  of  the  shoulder  joint.  The  diet  at  this  time  was 
a  liberal  amount  of  milk,  a  small  quantity  of  the  infant-food  daily,  with 
beef  juice.  The  ecchymoses  about  the  knee  and  shoulder,  with  tender- 
ness, pain,  and  disability,  sufficed  for  a  diagnosis  of  scurvy,  in  spite  of  the 
fact  that  the  gums  were  normal,  although  two  teeth  were  through,  and 
that  no  swelling  existed  about  the  joints.  The  proprietary  food  was  now 
discontinued,  the  amount  of  beef  juice  increased,  and  in  three  days  the 
symptoms  entirely  disappeared.    No  change  in  heating  the  milk  was  made. 

I  have  seen  several  other  cases  presenting  symptoms  in  all  respects 
identical  with  the  above,  but  lacking  even  the  ecchymoses  about  the  joints, 
which  were  immediately  relieved  by  dietetic  treatment  after  having  lasted 
from  two  to  six  weeks.  In  none  of  these  cases  were  the  gums  affected, 
but  in  one  there  was  quite  a  marked  cachexia.  There  is  no  doubt  in  my 
mind  that  all  these  were  cases  of  genuine  scurvy  of  a  mild  type,  and  if 
allowed  to  go  on  would  iuive  developed  the  other  usual  symjitoms. 

In  older  children,  scurvy  is  occasionally  seen  with  causes  and  symp- 
toms more  like  the  adult  type  of  the  disease.     The  symptoms  referred  to 


214  NUTRITIOX. 

the  lower  extremities  are  not  so  marked.  There  are  swelling  and  spongi- 
ness  of  the  gums  with  frequent  ha?morrluiges ;  the  teeth  may  loosen  and 
fall  out;  there  may  even  be  some  sloughing  of  the  gums;  the  breath  is 
intensely  fetid ;  and  haemorrhages  may  take  place  from  the  kidneys,  the 
bladder,  or  the  stomach.  There  is  a  very  marked  general  cachexia,  ex- 
treme languor,  and  often  syncopal  attacks.  These  cases  are  usually  due 
to  a  diet  deficient  in  fresh  vegetables,  and  are  most  frequent  among  the 
very  poor. 

Diagnosis. — The  diagnosis  of  scorbutus  is  usually  an  easy  one,  as  the 
great  majority  of  cases  are  fairly  typical.  The  symptoms  to  be  relied 
upon  for  diagnosis  are : 

1.  Hyperesthesia,  especially  about  the  knees  and  legs,  which  is  often 
very  acute.  It  may  be  the  first  symptom  noticed.  The  pain  is  increased 
by  any  motion  or  pressure,  but  otherwise  does  not  seem  to  be  present. 

2.  There  is  disability  or  disinclination  to  move  the  limbs — usually  the 
legs — which  may  be  so  great  as  to  lead  to  the  suspicion  of  paralysis.  This 
disability  is  usually  due  to  pain,  sometimes  to  epiphyseal  separation.  It- 
is  similar  to  the  pseudo-paralysis  of  hereditary  syphilis  depending  upon 
osteo-chondritis. 

3.  The  mouth  is  the  seat  of  ha?morrhagic  gingivitis.  The  gums  are 
swollen,  bleed  easily,  and  at  times  cover  the  teeth.  There  is  ulceration 
about  the  teeth  which  have  appeared,  and  partial  discoloration  of  the 
mucous  membrane  over  the  teeth  soon  to  appear. 

4.  There  are  swelling  and  ecchymoses  about  the  large  joints,  especially 
about  the  knee  and  ankle.  The  ecchymoses  may  be  seen  in  any  part  of 
the  body. 

5.  There  may  be  haemorrhages  from  the  mouth,  nose,  stomach,  bowels,, 
and  occasionally  from  the  kidneys.  In  rare  instances  haemorrhage  has 
occurred  into  the  orbit,  producing  exophthalmus. 

6.  There  are  a  general  cachexia  and  marked  antemia  with  flabby  mus- 
cles, and  often  the  signs  of  rickets. 

7.  There  is  a  history  of  bad  feeding,  nsually  of  the  continued  use  of 
some  proprietary  food. 

8.  The  symptoms  are  immediately  improved  and  in  most  instances 
rapidly  cured,  by  antiscorbutic  diet  without  other  treatment.  This  is 
perhaps  the  most  diagnostic  of  all  the  symptoms. 

Scorbutus  in  infancy  is  usually  mistaken  for  rheumatism  or  paralysis; 
less  frequently  for  rickets,  ostitis,  and  purpura.  By  close  attention  to  the 
symptoms  above  mentioned  it  is  almost  impossible  to  make  a  mistake  in 
diagnosis. 

Prognosis. — This  is  invariably  good  if  the  disease  is  recognised  early. 
Scarcely  any  other  cases  improve  with  such  marvellous  rapidity  as  do 
these  when  the  proper  dietetic  changes  are  made.  Complete  recovery  can 
usually  be  predicted  in  two  or  three  weeks.     Death  is  not  an  uncommon 


RICKETS. 


215 


termination  in  cases  which  have  been  unrecognised.  Of  Barlow's  thirtv- 
one  cases  seven  were  fatal.     I  have  seen  but  one  fatal  case. 

Treatment. — This  is  remarkably  simple  :  to  discontinue  all  propri- 
etary foods  and  condensed  milk,  and  give  an  abundance  of  fresh  cow's 
milk,  beef  juice,  orange  juice  or  other  fresh  fruit,  and,  in  cases  that  are 
over  a  year  old,  potato.  In  addition,  iron  and  cod-liver  oil  may  be  re- 
quired later,  but  the  essential  thing  is  the  change  in  diet. 

The  tenderness  requires  that  the  child  shall  be  kept  as  quiet  as  pos- 
sible, and  its  cachexia  that  it  be  protected  against  cold  and  exposure. 

RICKETS  (RACHITIS). 

Eickets  is  a  chronic  disease  of  nutrition.  While  the  only  important 
anatomical  changes  are  found  in  the  bones,  it  is  not  to  be  regarded  as  a 
bone  disease  ;  but  as  a  very  complex  pathological  process  which  affects  the 
bones,  muscles,  ligaments,  mucous  membranes,  and  nearly  all  the  organs 
of  the  body,  particularly  those  of  the  nervous  system.  It  occurs  especially 
between  the  ages  of  six  months  and  two  years.  It  is  not  common  in  the 
country,  but  is  exceedingly  frequent  in  most  large  cities.  While  not  a 
fatal  disease  ^jer  se,  rickets  adds  very  greatly  to  the  danger  from  all  acute 
diseases  in  infancy,  and  even  to  some  degree  also  to  those  of  later  life. 
Under  proper  conditions  of  diet  and  hygiene  it  tends  to  spontaneous 
recovery. 

Etiology. — The  essential  cause  of  rickets  is  dietetic,  although  hygienic 
influences  play  a  very  important  role  in  its  production.  While  it  seems 
to  be  demonstrated  that  diet  alone  may  produce  rickets,  nevertheless  this 
condition  is  much  more  easily  produced  when  there  are  also  unfavourable 
hygienic  surroundings.  Rickets  is  not  common  in  nursing  children  un- 
less lactation  be  unduly  prolonged,*  as,  for  example,  where  nursing  is 
continued  for  fifteen  to  eighteen  months  without  other  food.  Arti- 
ficially-fed children  are  much  more  prone  to  the  disease,  esiJecially  those 
who  are  l)adly  fed.  The  diet  in  these  cases  is  usually  very  deficient  in  fat, 
and  often  at  the  same  time  in  proteids,  while  it  contains  an  excess  of  car- 
bohydrates. It  is  somewhat  difficult  to  separate  the  effects  which  these 
different  conditions  produce.  It  appears,  however,  that  the  most  impor- 
tant factor  is  a  great  deficiency  in  fat.  Rickets  is  exceedingly  common  in 
children  reared  upon  the  proprietary  foods,  nearly  all  of  which  are  very 
low  in  fat  and  contain  an  excess  of  carbohydrates.  It  is  also  common  in 
children  who  are  reared  upon  sweetened  condensed  milk,  and  for  precisely 
the  same  reason.  When  both  fat  and  proteids  are  low,  rickets  is  more 
liable  to  result  than  when  only  the  fat  is  deficient. 

*  An  exception  to  this  statement  must  be  made  in  the  case  of  Italian  children.  In 
this  class  as  observed  in  New  York  it  is  very  common  to  see  marked  rickets  in  those 
getting  nothing  but  the  breast. 


216  NUTRITION. 

Hygienic  surroundings  are  next  in  importance  to  diet.  Although,  as 
previously  stated,  rickets  is  essentially  a  disease  of  cities,  being  princi- 
pally seen  in  children  living  in  crowded  tenements  where  the  effects  of 
improper  food  are  most  strikingly  shown,  yet  even  here  the  disease  is  rare 
in  those  who  get  a  plentiful  supply  of  good  breast  milk. 

Animal  experiments.— BldiU^-^niton  experimented,  in  the  Zoological 
Gardens,  London,  upon  lion  whelps.  Those  which  were  weaned  early  and 
fed  solely  upon  raw  meat  invariably  became  extremely  rachitic.  Two 
young  cubs,  fed  upon  rice,  biscuits,  and  raw  meat,  died  from  rickets. 
Two  young  monkeys,  upon  an  exclusively  vegetable  diet,  became  rachitic. 
To  the  young  lions  who  had  developed  rickets,  milk,  cod-liver  oil,  and 
pounded  bones  were  given  in  addition  to  the  meat,  and  in  three  months, 
although  the  hygienic  condition  of  the  animals  remained  unchanged,  all 
signs  of  rickets  had  disappeared.  Guerin  produced  typical  rickets  in 
puppies  which  were  kept  upon  a  meat  diet  for  four  or  five  months,  while 
others  of  the  same  litter,  which  were  suckled,  remained  in  good  health. 
Other  animal  experiments  by  various  observers  with  different  articles  of 
food  have  given  results  that  were  not  uniform.  It  seems,  however,  to  be 
pretty  positively  established,  that  withholding  milk  from  young  animals 
and  putting  them  upon  a  diet  of  meat,  vegetables,  or  starches  is  sufficient 
to  produce  rickets,  and  that  the  earlier  this  is  done  the  more  certain  is 
the  result.  This  may  occur  apart  from  any  change  in  the  hygienic  sur- 
roundings. These  animal  experiments  strengthen  the  opinion  above 
given,  that  the  essential  cause  of  rickets  is  improper  food,  and  that  the 
element  most  uniformly  lacking  is  fat. 

Distribution  of  riclrts. — According  to  Palm,  the  disease  is  almost  un- 
known in  the  extreme  north — Greenland,  Iceland,  Norway,  and  Den- 
mark. It  is  also  very  rare  in  China,  Japan,  Greece,  Turkey,  and  the 
southern  portions  of  Italy  and  Spain.  Its  greatest  frequency  is  in  the 
temperate  zone.  The  general  immunity  of  children  in  southern  climates 
appears  to  be  due  to  the  out-of-door  life,  and  the  almost  universal  custom 
of  maternal  nursing.  In  the  cities  of  America  no  race  is  exempt  from 
the  disease.  In  New  York  the  greatest  susceptibility  is  among  the  Negroes 
and  the  Italians.  Extreme  cases  of  rickets  are  almost  invariably  in  one 
of  these  nationalities.  It  is  exceptional  to  see  in  a  dispensary  or  hospital 
a  child  of  either  of  these  races  who  does  not  show,  to  a  greater  or  less 
degree,  the  signs  of  rickets.  These  two  southern  races  seem  to  bear  very 
badly  the  climate  and  the  confined  life  of  the  northern  cities.  So  far  as 
my  observations  are  concerned,  there  is  no  peculiarity  in  the  food  of  these 
people  which  explains  the  prevalence  of  rickets  among  them,  and  this 
must  be  attributed  to  a  race  peculiarity.  In  the  country,  the  immunity 
from  rickets  is  due  partly  to  the  more  prevalent  custom  of  maternal  nurs- 
ing, and  partly  to  the  better  surroundings ;  the  increased  resistance  of  the 
children  rendering  them  much  less  susceptible  to  the  infiuences  of  bad 


RICKETS.  217 

feeding  than  those  of  the  cities.  Iti  New  York  among  dispensary  and 
hospital  patients,  rickets  is  exceedingly  common,  and  is  seen  in  all  nation- 
alities, although  chiefly  in  the  foreign  elements  of  the  population. 

Heredity. — There  is  no  evidence  that  rickets  is  a  hereditary  disease. 
Any  cachexia  in  the  parents,  such  as  syphilis,  tuberculosis,  or  alcoholism, 
may,  however,  by  diminishing  the  child's  resistance,  be  a  predisposing 
cause  of  rickets.  The  later  children  in  a  family  are  more  likely  to  be 
affected  than  the  earlier  ones,  especially  when  the  intervals  between  the 
pregnancies  has  been  short,  or  where  anything  else  has  caused  a  deterio- 
ration in  the  general  health  of  the  mother. 

Previous  disease. — Rickets  not  infrequently  develops  in  syphilitic 
children ;  the  connection,  hqwever,  seems  to  be  no  closer  than  to  any 
other  cachexia.  The  relation  of  rickets  to  other  diseases,  particularly 
with  those  of  the  digestive  tract,  is  very  much  less  intimate  than  one 
would  expect.  Acute  diseases  of  the  stomach  and  intestines  are  very 
frequently  followed  by  marasmus,  but  only  exceptionally  by  marked 
rickets.  There  is  no  sufficient  ground  for  believing  that  rickets  exerts 
any  protective  influence  against  tuberculosis,  as  has  been  asserted.  In 
fact  the  thoracic  deformity  of  rickets  may  be  a  predisposing  cause  to 
tuberculosis. 

Rickets  affects  both  sexes  with  equal  frequency.  The  symptoms  usu- 
ally manifest  themselves  between  the  sixth  and  fifteenth  months.  Con- 
genital and  late  rickets  will  be  considered  separately. 

Rickets  is  therefore  a  complex  disease  of  nutrition,  whose  exact 
pathology  has  not  yet  been  definitely  settled.  It  is  more  difficult  to 
believe  that  the  general  nutritive  disturbances  are  the  result  of  the  bone 
changes,  than  to  regard  both  as  having  a  common  origin.  Kassowitz 
regards  the  bone  changes  as  inflammatory,  excited  by  the  presence  of 
some  irritant.  The  irritant  has  been  believed  by  many  to  be  lactic  acid, 
originating  in  the  digestive  tract ;  but  the  evidence  in  support  of  this 
theory  is  not  conclusive.  It  is  very  doubtful  whether  the  process  is  as 
simple  as  the  formation  of  lactic  acid  in  the  intestine  and  its  circulation  in 
the  blood.  It  is,  however,  clear  that  it  is  something  which  interferes  with 
the  assimilation  of  the  lime  salts.  At  the  present  time,  the  disposition  is  to 
regard  rickets  as  a  disease  of  nutrition,  which  may  be  produced  in  animals 
by  certain  dietetic  changes.  In  infants,  it  seems  to  be  settled  that  it  may 
be  produced  by  similar  changes  in  diet,  aided  very  greatly,  however,  by 
unhygienic  surroundings.  The  effect  of  these  abnormal  conditions  is 
shown  upon  the  whole  organism,  but  the  only  constant  and  regular  ana- 
tomical changes  are  in  the  bones.  These  osseous  lesions  resemble  those 
of  chronic  inflammation.  Precisely  how  the  dietetic  and  other  causes 
produce  the  bone  changes  is  still  a  matter  of  speculation.  The  constancy 
of  bone  changes  in  rickets  give  it  a  place  as  an  essential  disease,  and  not 
merely  a  form  of  malnutrition. 


218  NUTRITION. 

Lesions. — The  only  constant  and  characteristic  lesions  of  rickets  are 
found  in  tlie  bones.  It  is  still  a  matter  of  dispute  whether  these  bony 
changes  are  to  be  considered  as  inflammatory,  or  simply  as  the  result  of 
disordered  nutrition.  Perverted  nutrition  and  chronic  inflammation  are 
closely  allied,  and  it  really  makes  but  little  difference  which  view  is  taken. 
Occurring  at  a  time  when  the  growth  of  bone  is  so  rapid,  the  effects  of 
rickets  are  very  striking  and  very  serious. 

In  order  to  appreciate  how  bones  are  affected  by  rickets,  it  must  be  re- 
membered that  the  long  bones  grow  in  length  by  the  production  of  bone 
in  the  cartilage  between  the  epiphysis  and  the  shaft ;  that  the  shaft  grows 
in  thickness  by  the  production  of  bone  beneath  the  inner  layer  of  the 
periosteum  ;  and  that  the  medullary  canal  is  continually  increasing  in 
size  by  the  absorption  of  the  inner  layers  of  the  bone.  In  rickets  there  is 
an  exaggerated  production  of  cartilage  at  the  epiphysis,  and  excessive  cell- 
growth  beneath  the  periosteum,  while  the  process  of  ossification  in  these 
tissues  goes  forward  slowly  and  imperfectly,  or  is  entirely  arrested.  At 
the  same  time  the  absorption  of  the  medullary  layers  may  be  even  more 
rapid  than  normal.  In  health  the  growth  of  bone  in  length  is  much 
more  rapid  than  its  increase  in  diameter,  owing  to  the  greater  activity  of 
the  changes  taking  place  at  the  epiphysis ;  so,  in  rickets,  it  is  at  the 
extremities  of  the  long  bones  that  the  most  marked  changes  are  seen. 

One  of  the  most  striking  features  of  rachitic  bones  is  their  unnatural 
flexibility.  This  is  due  to  deficient  ossification  in  the  superficial  layers  of 
the  shaft  of  the  long  bones,  and  also  at  their  extremities.  Normally, 
bone  contains  about  one  third  organic  and  two  thirds  inorganic  matter. 
In  marked  rickets  the  proportions  are  reversed,  the  bones  often  containing 
twice  as  much  organic  as  inorganic  matter.  Changes  are  seen  in  all  the 
long  bones,  but  all  are' not  affected  to  the  same  degree.  Sometimes  those 
most  affected  will  be  the  bones  of  the  leg,  sometimes  those  of  the  forearm,, 
and  sometimes  the  ribs.    The  extent  varies  with  the  severity  of  the  process. 

There  are  characteristic  changes  in  form.  The  most  constant  is  en- 
largement of  the  epiphyses  of  all  the  long  bones.  This  is  most  strikingly 
seen  in  the  lower  extremities  of  the  radius  and  tibia.  The  enlargement 
may  be  so  marked  that  the  width  of  the  epiphysis  is  increased  by  one  half 
its  diameter.  All  the  sharp  angles,  borders,  and  prominences  of  the  bones 
are  rounded  off.  The  curvatures  of  rachitic  bones  are  more  fully  de- 
scribed under  the  symptoms.  They  may  be  due  to  a  variety  of  causes. 
Some  are  simply  an  exaggeration  of  the  normal  curves,  much  increased 
by  the  swelling  of  the  epiphyses  ;  others  are  due  to  muscular  action,  to 
atmospheric  pressure,  to  some  unnatural  posture,  such  as  the  cross-legged 
position,  to  the  weight  of  the  limbs,  or  to  the  weight  of  the  body.  The 
principal  change  in  the  form  of  the  flat  bones  consists  in  the  production 
of  large  bosses  or  prominences  due  to  thickening  of  the  bone,  usually 
about  the  centre  of  ossification.    These  bosses  are  soft  and  spongy.     Frac- 


PLATE  IV. 


Bone  in  Rickets. 

Longitudinal  section  of  a  rib  at  the  junction  of  the  costal  cartilage,  in  a  severe 
case  of  rickets  (slightly  magnified).  C  =  costal  cartilage.  B  =  bone,  A  =  proliferating 
cartilage-zone,  which  is  much  widened.  Between  the  hypertrophied  cartilage  cell- 
columns  (a)  making  up  this  proliferating  zone,  are  seen  medullary  spaces  (b)  contain- 
ing blood-vessels.  In  this  zone  lie  masses  of  bone  (c)  not  calcified.  The  calcification 
zone  is  almost  wanting,  only  scattered  islands  (d)  of  calcified  cartilage-cells  being  seen. 

Beyond  this  proliferating  zone  (A)  is  a  layer  of  bony  tissue  (B)  made  up  of  small 
bands"  of  which  only  a  few  have  a  nucleus  containing  lime  (e).  These  nuclei  appear 
black.  The  bony  bands  differ  both  in  form  and  arrangement  from  those  of  normal 
ossification.  Between  the  bony  masses  are  medullary  spaces  which  appear  light  in  the 
illustration.  At  (g)  the  beginning  of  cartilage  proliferation  is  seen.  Above  this  zone 
the  cartilage  is  normal.  (From  Karg  and  Schmorl.) 


RICKETS.  219 

tures  are  not  uncommon.  Tlie  bones  most  frequently  broken  are  the 
radius  and  ulna  ;  next,  the  clavicle  or  the  ribs.  The  fractures  are  usually 
of  the  green-stick  variety.  There  is  a  bending  of  the  outer  and  a  frac- 
ture of  the  inner  layers  of  the  shaft  of  a  long  bone.  This  results  in  more 
or  less  impaction,  and  is  usually  followed  by  the  production  of  consider- 
able callus.  The  epiphyseal  changes  result  in  arrested  growth  in  length, 
rachitic  bones  being  usually  much  shorter  than  normal.  Increased  vascu- 
larity is  seen  in  the  bosses  upon  the  flat  bones,  at  the  extremities  of  the 
long  bones  and  upon  stripj^ing  the  periosteum  from  the  shaft. 

In  a  longitudinal  section  of  one  of  the  long  bones,  the  principal  change 
seen  at  the  extremity  is  that  the  cartilaginous  layer  which  unites  the  epi- 
physis and  the  shaft  is  very  much  enlarged,  both  in  width  and  thickness, 
the  latter  being  sometimes  four  or  five  times  the  normal.  This  cartilagi- 
nous area  is  of  a  bluish  colour,  rather  softer  than  normal  cartilage.  On  one 
side  it  blends  with  the  cartilage  of  the  epiphysis,  on  the  other  it  presents 
an  irregular  dentated  border,  and  in  it  the  calcified  areas  are  irregular  and 
scattered.  The  epiphyseal  centres  of  ossification  are  enlarged,  softer,  and 
more  vascular  than  normal,  thus  increasing  the  size  of  the  extremity  of 
the  bone.  In  the  shaft,  the  outer  layers  of  bone  are  thickened  and  soft, 
like  decalcified  bone,  the  deeper  parts  being  firmer,  w'hile  the  deepest 
layers  may  be  completely  ossified.  The  medullary  canal  is  much  more  vas- 
cular than  normal,  its  contents  resembling  granulation  tissue.  Toward 
the  extremities  the  trabecular  spaces  are  much  increased  in  size,  so  that 
the  bone  appears  unnaturally  porous.  On  vertical  section  of  one  of  the 
flat  bones — e.  g.,  one  of  the  bosses  ujion  the  skull — there  is  found  a  great 
increase  in  the  size  of  the  trabecular  spaces.  The  bosses  are  made  up  of 
large  spongy  masses,  so  soft  as  to  be  easily  indented  with  the  finger,  and 
on  pressure  there  oozes  blood  and  serum  in  a  considerable  quantity. 

Microscopical  changes. — At  the  junction  of  bone  and  cartilage  at  tlie 
extremity  of  one  of  the  long  bones,  there  are  readily  traced  in  normal 
bone  (Fig.  32)  several  distinct  zones.  Next  to  the  hyaline  cartilage  {a) 
there  is  a  proliferating  zone  (^),  made  up  of  cartilage  cells  and  matrix, 
the  cells  having  no  orderly  arrangement.  Xext  to  this  is  a  columnar 
zone  (c,  </),  in  which  the  cartilage  cells  are  arranged  in  regular  rows  or 
columns.  Adjoining  this  is  the  zone  of  calcification  {e) ;  and,  finally,  there 
is  the  zone  of  ossification  (/,  g),  where  true  bone  is  formed. 

In  rickets  (Plate  IV  and  Fig.  33),  the  principal  changes  are  seen  in  the 
proliferating  and  columnar  zones.  The  proliferating  zone  (Fig.  33,  b)  is 
increased  chiefly  by  the  multiplication  of  new  cells ;  it  is  also  more  vas- 
cular than  normal.  The  columnar  zone  {c)  is  affected  in  a  similar  way 
and  to  a  much  greater  degree.  It  is  less  regular  in  its  formation,  and, 
instead  of  containing  but  few  vessels,  it  shows  large  vascular  channels, 
sometimes  surrounded  by  medullary  spaces  {e).  The  ossification  zone, 
instead  of  being  narrow  and  sharply  outlined,  is  broad  and  very  irregular. 


220 


NUTRITION. 


Calcified  areas  (/)  may  be  seen  in  the  midst  of  regions  which  are  carti- 
laginous, while  masses  of  cartilage  (h)  occupy  areas  which  should  be  com- 
pletely calcified.  In  some  places  there  appears  to  be  a  transformation  of 
cartilage  into  bone-tissue  of  an  inferior  sort  by  a  direct  or  metaplastic 
process.  In  the  shaft  there  is  seen  more  or  less  thickening,  and  an  in- 
creased vascularity  of  the  periosteum.     Beneath  the  inner  layer  there  is 


Fig.  32. — Section  through  ossification  zone  of  normal  bone  rZieizleri.  a,  hyaline  cartilage;  6, 
zone  of  beginning  cartilage  proliferation  ;  c,  columns  of  cartilage  cells  ;  d,  columns  of  hyper- 
trophic cartilage ;  e,  zone  of  temporary  calcification ;  f,  zone  of  primary  medullary  spaces ; 
a,  zone  of  primary  bone  formation ;  A,  fully  developed  spongy  bone ;  i,  blood-vessels ;  i, 
layer  of  osteoblasts. 


excessive  cell-proliferation,  while  calcification  of  this  new  tissue  is  imper- 
fect or  absent,  and  instead  of  hard,  compact  bone,  we  find  irregular,  spongy 
masses.  In  the  spongy  bone  there  is  considerable  thickening,  with  an 
erosion  of  bony  trabeculse,  which  results  in  the  formation  of  large  medul- 
lary spaces  filled  with  blood-vessels  and  connective  tissue  rich  in  cells. 


RICKETS. 


221 


Termination  of  the  rachitic  process. — After  a  variable  time,  usually 
from  three  .to  fifteen  months,  the  active  proliferative  process  going  on  in 
the  cartilage  and  beneath  the  periosteum  ceases,  and  is  gradually  replaced 


^^l5^^^:^«f>S^?% 


-^     "^     .'-     -T 


Fio.  33. — Racliitic  bone  (Ziegler).  LongritucUnal  section  throutrh  ossification  zone  of  the  upper 
diaphysis  of  the  femur  of  a  modcratel.v  rachitic  cliild  one  year  old  (.hicrhly  nia^'iiitied  i.  a, 
unclian^red  hyaline  cartilage  ;  J,  beirinning  cartilaire  proliferation;  c.  columns  of  proliferated 
cartilage  cells;  </,  columns  of  proliferated  hypertfopliic  cells;  f,  medullar.v  spaces  contain- 
ing blood-vessels  lyin?  within  the  cartilage ;./',  calcified  cartilage;  </.  bon.v  tissue;  A,  re- 
mains of  cartilage  within  the  bony  tissue ;  «',  point  of  uncalcitiecT  bony  tissue ;  I;  calcified 
bony  tissue. 

by  ossification.  The  bone  becomes  less  vascular,  and  a  rapid  formation 
of  bone  takes  place  in  the  normal  way.  In  addition,  there  is  in  some 
places  a  direct  transformation  of  cartilage  into  bone.     Condensation  and 


222  NUTRITION. 

contraction  take  place  in  the  spongy  masses  of  bone.  As  the  result  of 
this,  the  affected  bone  may  become  even  harder  than  normal ;  often  it  is 
ivory-like.     Its  structure,  Ijowever,  is  never  quite  like  that  of  healthy  bone. 

In  the  long  bones  the  epiphyseal  swellings  slowly  diminish,  and  may 
quite  disappear;  the  slighter  curvatures  may  be  entirely  overcome,  and 
the  greater  ones  much  lessened.  The  beading  of  the  ribs  becomes  almost 
imperceptible  ;  the  bosses  upon  the  skull  shrink  very  markedly,  and  may 
leave  scarcely  a  trace  of  their  existence.  In  most  cases  the  active  process 
in  rickets  has  come  to  an  end  by  the  time  the  child  is  two  and  a  half  years 
old,  often  at  two  years. 

Visceral  lesions. — These  are  not  infrequent,  but  are  not  essential  to 
rickets.  In  the  lungs  they  are  due  to  deformities  of  the  chest  wall  and 
to  complications.  Beneath  the  deep  lateral  furrows  which  are  so  common, 
there  is  found  a  part  of  the  lung  in  a  state  of  more  or  less  complete  col- 
lapse. This  is  accompanied  by  emphysema  of  the  portion  just  anterior  to 
it.  Acute  and  chronic  bronchitis  and  broncho-pneumonia  are  exceed- 
ino-ly  frequent.  A  low  grade  of  chronic  catarrhal  inflammation  in  the 
stomach  and  intestines  is  common,  and  is  often  associated  with  dilata- 
tion of  these  organs.  The  spleen  is  enlarged  in  most  cases  during  the 
period  of  active  symptoms.  This  is  usually  moderate  in  degree,  although 
marked  enlargement  is  not  at  all  rare.  The  swelling  of  the  spleen  is  due 
to  simple  hyperplasia,  and  not  to  amyloid  degeneration.  Enlargement 
of  the  liver  is  less  frequent,  and  may  occur  with  or  without  that  of 
the  spleen.  There  are  no  constant  changes  in  the  structure  of  these 
organs.  The  lymph  nodes  (lymphatic  glands)  are  frequently  enlarged. 
Eachitic  patients  are  more  prone  to  these  swellings  than  are  other  chil- 
dren. They  are  due  to  simple  hyperplasia,  and  have  no  close  connection 
with  rickets.  Cerebral  changes  are  rare,  and  those  described  are  rather 
of  accidental  occurrence  than  dependent  upon  the  rachitic  process.  As 
stated  under  Symptoms,  enlargement  of  the  head  is  usually  due  to  thick- 
ening of  the  cranial  bones.  Although  hydrocephalus  is  occasionally  seen, 
it  is  extremely  doubtful  whether  it  is  more  frequent  than  in  patients  not 
rachitic.  Hypertrophy  of  the  brain  has  been  described  in  connection 
with  rickets,  but  as  yet  this  does  not  seem  to  be  established  by  sufficient 
pathological  evidence.  The  muscles  are  flabby  from  imperfect  nutrition, 
and  sometimes  atrophied  from  disuse,  but  no  essential  anatomical  changes 
have  been  demonstrated  in  them. 

Symptoms. — A  well-marked  case  of  rickets  makes  a  striking  j^icture 
(Plate  V),  and  one  not  easily  mistaken.  There  are  seen  the  large  head, 
beaded  ribs,  narrow  chest,  prominent  abdomen,  symmetrical  swellings  of 
the  epiphyses  of  the  wrists  and  ankles,  and  curvatures  of  the  extremities. 
The  beginning  of  symptoms  is  nearly  always  insidious,  and  the  patient 
does  not  usually  come  under  observation  until  they  have  existed  for  sev- 
eral weeks,  often  several  months. 


PLATE  V 


TvprCAL    RiCKKTS. 

Showinof  tlie  large  head,  narrow  eliest,  prominent  ahiloinon,  marked  enlargement 
of  the  epiphyses  at  the  wrists  and  ankles.  There  are  also  curvatures  of  the  forearms 
and  legs  which  are  not  so  well  shown. 

The  patient  a  child  two  and  a  half  years  old. 


RICKETS.  223 

Early  Sympforns. — The  most  constant  early  symptoms  are  sweating 
of  the  head,  extreme  restlessness  at  night,  constipation,  beading  of  the 
ribs,  and  cranio-tabes.  The  head-sweating  is  rarely  absent,  and  may  con- 
tinue for  several  months.  It  is  especially  profuse  during  sleep,  the  per- 
spiration standing  out  in  large  drops  upon  the  forehead,  often  being 
sufficient  to  wet  the  pillow.  This  is  one  of  the  causes  of  the  nasal  and 
bronchial  catarrhs  so  common  in  rachitic  infants.  There  is  marked  rest- 
lessness during  sleep :  the  children  tossing  about  the  crib,  kicking  off  the 
clothes,  and  never  having  the  quiet,  natural  slumber  of  healthy  infants. 
Tiiis  may  be  due  to  many  causes,  but  when  persistent  and  associated  with 
marked  perspiration  of  the  head,  rickets  should  be  suspected.  Constipa- 
tion is  frequently  seen  as  an  early  symptom,  although  it  is  more  marked 
ill  the  later  stages  of  the  disease. 

The  beading  of  the  ribs  is  almost  invariably  the  first  appreciable 
change  in  the  bones,  and  it  is  well-nigh  constant.  This  forms  the  so- 
called  "  rachitic  rosary,"  consisting  of  nodules  at  the  line  of  junction  of 
the  costal  cartilages  and  the  ribs.  It  may  be  slight,  or  there  may  be  a 
row  of  knobs  as  large  as  snuill  marbles.  In  many  cases  with  marked 
thoracic  deformity,  little  or  no  beading  of  the  ribs  is  seen  externallv, 
although  at  autopsy  it  is  found  to  be  very  marked  upon  the  internal  sur- 
face of  the  chest  (Plate  VI).  Beading  of  the  ribs  was  noted  in  all  but 
two  of  one  hundred  and  forty-four  successive  cases  of  rickets,  at  the  time 
of  the  first  examination.  In  infants  under  six  months  there  may  be 
found  soft  spots  in  the  cranium,  usually  over  the  occipital  or  posterior 
portions  of  the  parietal  bones.  These  are  from  one  fourth  to  one  inch  in 
diameter,  and  there  are  usually  several  of  them  present.  By  pressure  with 
the  finger  they  give  a  sort  of  parchment-crackling  sensation.  They  are 
known  as  cranio-tabes.  In  my  own  experience  this  has  not  been  a  fre- 
(juent  symptom.  Cranio-tabes  is  more  frequently  seen  when  syphilis  is 
associated  with  rickets,  and  it  is  seen  also  in  syphilitic  cases  which  are  not 
rachitic.  The  rachitic  cachexia  is  not  usually  present  until  the  symptoms 
liave  existed  for  several  months,  and  in  many  cases  it  is  not  seen  at  all. 

Deformities. — The  deformities  of  rickets  are  almost  invariably  sym- 
metrical in  character,  and  usually  numerous.  In  extreme  cases  almost 
every  bone  in  the  body  is  affected. 

Head. — This  usually  appears  to  be  too  large,  and  although  it  may  not 
be  greater  in  circumference  than  that  of  a  healthy  child  of  the  same  age, 
it  is  out  of  proportion  to  the  rest  of  the  body.  In  marked  cases  the 
increase  in  circumference  may  be  nearly  two  inches.  The  enlargement 
is  in  most  cases  due  to  thickening  of  the  cranial  bones.  In  one  case  with 
marked  deformity,  I  found  the  skull  over  the  parietal  bones  half  an  inch 
in  thickness  (Fig.  34).  This  thickening  diminishes  with  recovery,  but 
in  most  cases  the  head  remains  throughout  life  larger  than  it  should 
be.  The  shape  of  the  rachitic  head  is  somewhat  square  (Fig.  35),  owing 
16 


224 


NUTRITION. 


to  the  formation  of  large  bosses  over  the  parietal  and  frontal  eminences. 
It  is  flattened  at  the  occiput  from  pressure,  and  flattened  also  at  the  ver- 
tex. In  extreme  cases,  the  prominences  upon  the  frontal  and  parietal 
bones  may  be  so  great  as  to  produce  quite  a  marked  furrow  along  the  line 
of  the  sagittal  and  frontal  sutures,  and  one  at  right  angles  to  this  along 
the  coronal  suture  (Fig.  36).  This  condition  gives  unusual  prominence 
to  the  forehead.  Marked  deformity  of  the  head  has  been  observed  in 
thirty-three  per  cent  of  my  cases.     The  sutures  may  remain  open  for  an 


Fig.  34. — Rachitic  skull  from  colored  child  two  years  oia,  ii'irizontul   section,  inner  surface; 
showing  thickening  of  the  bones,  especially  the  frontal,  and  open  fontanel. 


unnatural  time,  occasionally  until  the  end  of  the  first  year.  The  fontanel 
is  late  in,  closing,  being  frequently  found  open  at  two  and  a  half,  and 
sometimes  even  at  three  years.  Often  at  eighteen  or  twenty  months 
the  fontanel  is  two  inches  in  diameter.  The  veins  of  the  scalp  are 
often  prominent,  and  the  hair  is  frequently  worn  from  the  occiput, 
owing  to  restlessness  during  sleep.  Occasionally  rickets  and  hydrocepha- 
lus are  associated,  but  this  is  the  least  frequent  of  all  causes  of  enlarge- 
ment of  the  head. 


PLATE  VI. 


Deformity  of  the  Chest  in  Severe  Rickets. 

In  the  upper  picture,  giving  the  external  view,  is  shown  a  deep  oblique  furrow  at 
the  junction  of  the  ribs  and  costal  cartilages,  these  meeting  at  an  acute  angle. 

In  the  lower  picture  the  ribs  have  been  separated  from  the  spine  and  spread  open, 
showing  the  same  deformity  as  it  appears  from  withiii.  looking  forwards. 

From  a  coloured  child  ten  months  old. 


RICKETS. 


225 


Chest, — Beading  of  the  ribs  lias  already  been  mentioned.  This  is  the 
most  characteristic  feature,  but  in  the  majority  of  cases  there  are,  in 
addition,  lateral  depressions  over 
the  lower  third  of  the  chest,  at 
the  line  of  junction  of  the  car- 
tilages with  the  ribs,  with  ever- 
sion  of  the  lower  borders  of  the 
ribs.  In  severe  cases  these  de- 
pressions or  furrows  are  so  great 
as  to  cause  serious  deformity 
(Plate  VI).  Usually  there  is  a 
great  diminution  in  the  trans- 
verse and  an  increase  in  the 
antero-posterior  diameter  of  the 
chest.  Fig.  37  shows  the  out- 
line of  the  chest  of  a  rachitic 
child  of  two  years,  compared 
with  that  of  a  healthy  child  of 
the  same  age.  Another  frequent 
deformity  is  the  "  rachitic  gir- 
dle," which  consists  in  a  trans- 
verse depression  about  two 
inches  broad,  extending  from 
one  side  of  the  chest  to  the 
other,  just  above  its  lower  bor- 
der. A  less  frequent  one  is  a  deep  circular  depression  over  the  ensi- 
form  cartilage.  This  is  sometimes  nearly  an  inch  and  a  half  in  depth. 
Marked  thoracic  deformity  was  seen  in  twenty  per  cent  of  my  cases, 
but  in  only  a  small  proportion  was  the  chest  normal. 

The  factors  in  the  production  of  the  thoracic  deformity  are  atmos- 
pheric pressure  and  soft  chest  walls,  these  sinking  in  at  the  point  where 
they  have  least  resistance,  viz.,  at  the  junction  of  the  costal  cartilages  and 
the  ribs.  When  there  is  any  obstruction  to  the  entrance  of  air,  as  in  bron- 
chitis, hypertrophied  tonsils,  or  adenoid  growths  of  the  pharynx,  the 
thoracic  deformities  are  exaggerated.  Irregular  chest  deformities  depend 
upon  the  coexistence  of  pathological  conditions  in  the  lungs.  Pigeon- 
breast  is  occasionally  seen,  but  it  is  doubtful  if  this  depends  upon  rickets 
alone. 

Spine. — In  very  many  of  the  milder  cases  this  is  normal.  The  most 
characteristic  deformity  consists  in  a  posterior  curve  (kyphosis),  which 
is  a  general  one,  usually  extending  from  the  mid-dorsal  to  the  sacral  re- 
gion. This  existed  in  forty-six  per  cent  of  my  cases.  In  the  early  part 
of  the  disease  it  disappears  entirely  on  suspending  the  chilil,  or  making 
extension  upon  the  extremities;  but  in  cases  of  long  standing  it  may  not 


Fig.  35. — Kaehitic  head;  Italian  child  t«o  years  i 
square,  prominent  forehead  and  flat  vertex. 


226  NUTRITION. 

disappear  entirely  by  these  tests.  Very  mucli  less  frequently  there  is  seen 
a  rotary  curvature.  This,  in  my  experience,  has  been  more  frequently  to 
the  left  side  than  to  the  right — the  opposite  of  the  common  form  of  lat- 


FiG.  3(3. — Kaoliitie  skull  from  child  one  year  old.  showing  frontal  and  parietal  bosses  and  wi.le 

fontanel. 

eral  curvature  seen  in  young  girls.     Marked  lateral  curvature  in  children 
under  three  years  is  usually  rachitic. 

The  clavicle  is  affected   only  in  severe  cases.     The  usual  deformity 
consists  in  an  exaggeration  of  tlie  anterior  curve  at  the  inner  third  of  the 


Fig.  37. — A.  horizontal  section  of  a  rachitic  chest,  child  two  years  old.  showing  lateral  furrows, 
B,  section  of  chest  of  healthy  child  of  the  same  age. 

bone,  which  is  somewhat  shortened  and  its  extremities  enlarged.     It  is 
not  infrequently  the  seat  of  green-stick  fracture. 


RICKETS. 


227 


Deformities  of  the  pelvis  belong  to  obstetrics  rather  than  to  pjediatrics. 
The  most  common  rachitic  change  is  a  diminution  of  the  antero-posterior 
diameter  and  a  narrowing  of  the  subpubic  arch.  Irregular  deformities, 
sometimes  described  as  "crumpling  of  the  jielvis,"  are  not  infrequent. 

Extremities. — Deformities  of  the  ujiper  extremities  are  usually  sym- 
metrical. The  humerus  is  affected  only  in  severe  cases.  It  has  a  forward 
and  outward  curve,  although  rarely  a  very  marked  one.  Both  the  epi- 
physes are  enlarged,  although  the  U2)per  one  can  not  often  be  made  out 
unless  the  child  is  very  thin.  The  radius  and  ulna  are  frequently  affected. 
They  present  a  convexity  upon  their  extensor  surface  (Plate  V),  which  in 
some  cases  is  very  marked,  particularly  in  children  who  have  been  creep- 
ing about.  Green-stick  fractures  here  are  quite  frequent.  Rachitic 
changes  at  the  epiphyses  are  more  common  than  in  the  shaft,  enlarge- 
ment of  the  epiphyses  at  the  wrist  being  one  of  the  most  constant  bony 
deformities  of  rickets  (Plate  V).  It  was  present  in  ninety-five  per  cent 
of  my  cases.  Less  frequently  similar  swellings  are  seen  at  the  elbow. 
Enlargement  of  the  ends  of  the  meta- 
carpal bones  or  the  phalanges  I  have 
seen  in  but  two  or  three  extreme  cases. 

The  lower  extremities  are  rather 
more  frequently  affected  than  the  upper, 
but  in  a  similar  way.  The  femur  is  in- 
volved only  in  severe  cases  ;  it  common- 
ly presents  a  general  forward  and  out- 
ward curve,  which  is  mainly  due  to  the 
weight  of  the  legs  as  the  child  sits. 
Occasionally  there  is  also  an  outward 
rotation  of  the  femur,  where  children 
have  been  allowed  to  sit  much  in  a 
cross-legged  posture.  A\'hen  such  chil- 
dren begin  to  walk,  the  toes  are  turned 
very  far  outward.  The  principal  de- 
formities of  the  lower  extremity  are 
bow-leg  (Fig.  38)  and  knock-knee  (Fig. 
39).  Knock-knee  is  more  common  in 
females,  and  is  believed  to  be  due  to 
an  overgrowth  of  the  inner  condyle  of 
the  femur.  Enlargement  of  both  con- 
dyles can  be  demonstrated  in  most  of 
the  marked  cases  of  rickets.      The  cases 

of  slight  bow-leg  may  be  due  simply  to  swelling  of  the  epiphyses,  the 
shaft  of  the  bone  being  quite  normal.  This  point  I  have  verified  by 
post-mortem  observations.  Such  are  probably  most  of  the  deformities 
which  disappear  spontaneously.     The  most  severe   cases  of  bow-leg  are 


Fk 


.-Tv,,i. 


iw-leiT-'  ot  severe 


228 


NUTRITION. 


often  associated  with  some  degree  of  antero-posterior  curvature,  and  the 
latter  may  be  the  principal  deformity.  An  exaggerated  case  of  this  kind 
is   shown   in  Fig.   40.      Enlargement  of   the  epiphyses  at  the  ankle  is 

usually  present  when 
it  is  seen  at  the  wrists, 
and  nearly  to  the  same 
degree.  Enlargement 
of  the  upper  epiphyses 
of  the  tibia  and  the 
fibula  is  seen  only  in 
severe  cases.  The  cause 
of  the  deformities  of 
the  leg  is  not,  prima- 
rily at  least,  walking 
too  early,  since  they 
are  common  in  chil- 
dren who  have  never 
walked ;  slight  deform- 
ities, however,  may  be 
aggravated  by  early 
walking.  A  change 
which  has  not  been 
sufficiently  emphasized 
is  the  arrested  growth 
of  the  long  bones  ;  this 
is  one  of  the  most  char- 
acteristic features  of 
rickets.  A  rachitic  child  of  three  years  often  measures  in  height  six  or 
eight  inches  less  than  a  healthy  child  of  the  same  age,  the  difference  being 
almost  entirely  in  the  lower  extremities. 

All  the  ligaments,  but  particularly  those  about  the  large  joints,  are  lax 
and  frequently  elongated.  This  may  lead  to  the  deformity  known  as  weak 
ankles,  or  to  an  over-extension  at  the  knee  (genu  recurvatum) ;  also  to 
unnatural  mobility  at  the  hips,  shoulders,  elbows,  and  wrists.  The  condi- 
tion of  the  ligaments  plays  an  important  part  in  the  production  of  spinal 
deformities. 

Muscles. — The  muscular  symptoms  of  rickets  are  almost  as  constant 
and  as  characteristic  as  those  of  the  bones.  The  muscles  are  small,  very 
flabby,  and  poorly  developed ;  hence  rachitic  children  are  unable  to  sit 
erect,  or  to  stand  or  walk  at  the  proper  age.  Of  one  hundred  and  fifty- 
one  cases  in  which  the  date  of  walking  alone  was  investigated,  only  twenty- 
seven,  or  eighteen  per  cent,  walked  before  the  fifteenth  month  ;  forty- 
seven  per  cent  were  not  walking  at  the  eighteenth  month  ;  twenty  per 
cent  not  at  two  years  ;  and  ten  per  cent  not  at  two  and  a  half  years.    Late 


ft 


Fig.  30. — Knock-knee. 


RICKETS. 


220 


walking  i.s  one  of  the  most  connmon  symptoms  for  wliicli  advice  is  sought 
by  parents  with  rachitic  children.  The  muscular  ]iower  in  the  extremities 
is  sometimes  so  feeble  as  to  suggest  paralysis.  1  have  seen  a  number  of 
cases  in  which  the  symptoms  so  resembled  paralysis,  that  even  expert  diag- 
nosticians were  unable  to  differentiate  rickets  from  {xjliomyelitis  except 
by  the  electrical  reactions,  those  in  rickets  being  usually  normal  or  exag- 
gerated. In  other  cases  the  symptoms  may  suggest  cerebral  i)alsy  of  the 
flaccid  type.  The  muscular  symptoms  may  be  marked  when  the  bony 
changes  are  slight,  and  conversely.  As  no  lesions  of  the  muscles  have 
been  demonstrated,  the  symptoms  are  probably  due  to  imperfect  nutri- 
tion. Two  other  symptoms  depend  chiefly  upon  tlie  condition  of  the  mus- 
cles, viz.,  pot-belly  and  constipation. 

Pot-belly  is  quite  an  early  sym{)tom,  and  in  most  cases  a  very  marked 
one  (Plate  V).  It  was  noted  in  sixty  per  cent  of  my  cases.  The  en- 
largement of  the  abdomen  is  uniform.  It  is  everywhere  tympanitic,  and 
it  may  be  as  tense  as 
a  drumhead.  It  is  due 
to  a  loss  of  tone  in 
the  abdominal  mus- 
cles, and  in  the  mus-  / 
cular  walls  of  the  stom- 
ach and  intestine.  It 
is  aggravated  by  chron- 
ic indigestion  and  con- 
sequent intestinal  pu- 
trefaction. The  en- 
largement is  thus 
mainly  from  tympa- 
nites. There  may  be 
a  marked  degree  of 
dilatation  both  of  the 
stomach  and  the  colon. 
To  a  very  small  degree 
only,  does  the  large 
abdomen  depend  upon 
swelling  of  the  liver  or 
spleen. 

The  constipation  of 
rickets,      as      already 

hinted,  dejiends  upon  the  loss  of  tone  in  the  muscular  walls  of  the  intes- 
tines. It  may  alternate  with  diarrhcea.  It  rarely  hapiiens  that  a  rachitic 
child  has  habitually  normal  evacuations  from  the  bowels.  Hard,  dry. 
constipated  stools  frequently  set  up  a  condition  of  chronic  catarrh  of  the 
colon  in  which  larcre  masses  of  mucus  are  discharged. 


C 


Fui.  40. — ExtRiiiu  r:u'liitic  dcforiiiitios  ot'the 


230  NUTRITION. 

During  the  most  active  part  of  the  disease — viz.,  from  the  third  to 
the  ninth  month — tenderness  may  sometimes  be  elicited  by  pressure  upon 
the  epiphyses.  This,  however,  is  not  a  constant  symptom,  and  a  very 
unreliable  one  for  diagnosis.  In  my  own  experience  it  has  been  marked 
in  but  a  very  small  proportion  of  the  cases.  Acute  tenderness  should 
always  suggest  scurvy  rather  than  rickets. 

Fever. — According  to  some  observers  there  is  a  febrile  movement 
which  belongs  to  the  active  stage  of  rickets,  but  I  have  never  been  able  to 
satisfy  myself  of  the  truth  of  this  observation. 

Dentition. — As  a  rule,  dentition  is  late  and  apt  to  be  difficult — i.  e.,  it 
is  associated  with  attacks  of  indigestion  or  other  disturbances  which  may 
be  serious.  Individual  cases,  however,  present  great  variations  in  regard 
to  this  symptom.  A  study  of  the  progress  of  dentition  in  one  hundred 
and  fifty  rachitic  children  gave  the  following  results :  in  fifty  per  cent  the 
first  teeth  were  cut  on  or  before  the  eighth  month,  and  in  thirteen  per 
cent  on  or  before  the  fifth  month  ;  however,  twenty  per  cent  of  the  cases 
had  no  teeth  at  twelve  months,  and  in  eight  per  cent  none  had  appeared 
at  fifteeji  months.  Even  though  the  first  teeth  come  at  the  usual  time, 
the  progress  of  dentition  is  often  arrested  by  the  devejopment  of  rickets, 
and  no  advance  made  for  five  or  six  months.  The  difference  in  the 
cases  appears  to  depend  very  much  uj^on  the  age  of  the  child  wdien  rick- 
ets begins.  Those  who  give  no  evidence  of  it  until  nine  or  ten  months 
old  often  have  a  nearly  normal  dentition,  while  the  cases  developing 
early  show  a  marked  retardation  of  this  process.  The  order  in  which 
the  teeth  appear  may  be  very  irregular,  but  there  is  no  rule  in  this 
respect.  The  character  of  the  teeth  in  rickets,  in  the  great  majority  of 
cases,  is  good.  This  was  true  in  eighty-four  per  cent  of  one  hundred  and 
twenty-six  cases  examined  with  reference  to  this  point.  This  is  in  strik- 
ing contrast  to  hereditary  syphilis,  where  the  tendency  to  early  decay  is 
so  constantly  seen. 

General  appearance. — Rachitic  patients  are  almost  always  ansemic. 
The  blood  is  low  in  hsemoglobin,  often  down  to  thirty  or  forty  per  cent. 
In  some  few  cases  there  is  in  addition  quite  marked  leucocytosis.  The 
number  of  red  globules  is  not  often  nor  uniformly  affected.  The  majority 
of  rachitic  patients  are  fat  and  flabby.  The  tissues  are  soft  and  have  but 
little  resistance.  Earely,  they  may  be  thin,  like  patients  suffering  from 
marasmus. 

Rachitic  patients  are  very  prone  to  suffer  from  hypertrophied  tonsils, 
adenoid  growths  of  the  pharynx,  and  enlargements  of  the  lymph  nodes  of 
the  neck.  In  all  forms  of  acute  illness  the  feeble  resist|ince  of  these 
patients  is  very  evident.  This  is  especially  true  of  acute  disease  of  the 
lungs. 

The  mucous  membranes  are  very  vulnerable  in  all  rachitic  patients. 
From  the  slightest  indiscretion  in  diet  an  attack  of  acute  indisrestion  or 


RICKETS.  231 

diarrhoea  is  brought  on,  and  from  a  very  insignificant  exposure,  catarrhal 
inflammation  of  the  upper  or  lower  air  passages  is  excited.  In  rachitic 
patients  all  such  attacks  are  prone  to  run  a  protracted  course.  Inflamma- 
tion of  the  trachea  and  larger  bronchi  is  liable  to  extend  to  the  smaller 
bronchi  and  the  lungs. 

The  downward  displacement  of  the  liver  and  spleeti  from  contraction 
of  the  chest  should  not  be  mistaken  for  enlargement  of  these  organs. 
Moderate  enlargement  of  the  spleen  is  very  common  during  the  stage  of 
most  active  symptoms — i.  e.,  sixth  to  twelfth  month.  Great  enlargement 
of  either  liver  or  spleen  is  infrequent,  and  when  present  it  is  doubtful 
whether  it  depends  upon  the  rachitic  process.  It  is  rather  to  be  connected 
with  the  condition  of  the  blood  which  is  developed  during  the  disease. 

Urine. — There  are  no  recent  studies  of  the  urine  of  rachitic  patients 
which  are  reliable. 

Xervous  syniptoins  are  among  the  most  frequent  manifestations  of 
rickets.  ^Restlessness  at  night  has  already  been  mentioned  as  a  promi- 
nent early  symptom.  Pain  and  tenderness  are  rare.  A  disposition  to 
muscular  spasm  is  seen  in  many  cases.  There  may  be  laryngismus  strid- 
ulus, tetany,  or  general  convulsions.  The  first  two  are  rare  except  in 
rachitic  patients.  All  of  these  probably  depend  upon  defective  nutrition 
of  the  nervous  centres.  While  in  all  infants,  owing  to  the  irritability  of 
the  nervous  centres,  convulsions  are  easily  excited  from  relatively  slight 
causes,  in  those  who  are  rachitic  this  susceptibility  is  greatly  intensified. 
In  them,  slight  causes  are  sufficient  to  bring  on  either  local  or  general 
convulsions.  As  a  predisposing  cause  of  convulsions  in  infancy,  rickets 
takes  the  first  place.  The  younger  the  child  and  the  more  active  the 
rachitic  j^rocess,  the  more  frequently  do  convulsions  occur.  They  belong 
especially  to  the  first  year,  being  most  frequent  between  the  third  and 
ninth  months.  The  exciting  cause  of  convulsions  in  these  cases  is  usually 
to  be  found  in  the  stomach  or  intestine. 

Course  and  terminatio)!. — Rickets  is  essentially  a  chronic  disease,  and 
its  course  is  measured  by  months.  The  active  symptoms  in  most  cases 
continue  from  three  to  fifteen  months,  although  they  occasionally  last 
a  much  longer  time.  The  duration  of  the  symptoms  probably  depends 
chiefly  upon  the  duration  of  the  exciting  cause.  That  active  symptonjs 
cease  when  a  child  reaches  the  age  of  eighteen  months  or  two  years,  is  no 
doubt  due  chiefiy  to  the  fact  that  at  this  age  the  diet  is  more  general, 
and  is  more  likely  to  furnish  what  the  child  needs,  and  that  more  fresh 
air  is  likely  to  be  secured  than  at  an  earlier  iige. 

The  earliest  symptoms  of  improvement  are  a  diminution  in  the  nerv- 
ous symptoms,  especially  in  the  restlessness  at  night ;  increased  muscular 
power,  as  shown  by  disposition  to  stand  or  walk  ;  diminution  in  the 
head-sweats;  disappearance  of  the  cranio-tabes;  and  improvement  in  the 
an*mia.     The  changes  in  the  deformities  are  very  slow,  and  from  month 


^232  NUTRITION. 

to  month  almost  imperceptible.  When  improvement  once  begins,  how- 
evei",  it  usually  goes  steadily  forward,  relapses  being  exceedingly  rare. 

Congenital  rickets. — Infants  may  present  at  birth  the  characteristic 
deformities  of  rickets,  and  there  may  be  found  even  the  minute  bone 
changes  of  the  disease.  Such  cases  are  reported  to  be  common  in  Vienna 
and  other  large  cities  of  Europe,  where  mothers  during  pregnancy  have 
lived  under  unfavourable  surroundings.  In  America,  however,  congeni- 
tal rickets  is  a  very  rare  disease.  Single  cases  have  been  reported  by 
Jacobi,  J.  Lewis  Smith,  and  lately  by  Townsend.  Cases  of  cretinism  have 
sometimes  been  included  under  this  term. 

Late  rickets. — Bare  instances  have  been  reported  of  bony  deformities 
in  all  respects  like  those  of  rickets,  developing  in  children  from  six  to 
twelve  years  old.  A  number  of  such  have  been  observed  in  England.  I 
have  not  seen  this  disease,  nor  has  a  case  been  seen  during  the  past 
twenty  years  at  the  Hospital  for  Ruptured  and  Crippled,  New  York,  where 
more  deformities  come  under  observation  than  anywhere  else  in  this 
country. 

Acute  rickets. — Although  from  time  to  time  cases  have  been  reported 
under  this  heading,  from  a  study  of  the  histories  it  is  clear  that  the  great 
majority,  if  not  all  of  them,  were  cases  of  infantile  scurvy.  It  is  doubtful 
whether,  strictly  speaking,  there  is  such  a  thing  as  acute  rickets. 

Diagnosis. — The  diagnosis  of  rickets  is  not  usually  difficult,  and  after 
carefully  examining  a  case  one  can  not  often  be  in  doubt.  It  is  the  mild 
cases  and  the  early  stages  of  the  disease  that  are  most  liable  to  be  over- 
looked. The  most  important  early  symptoms  for  diagnosis  are  sweating 
of  the  head,  cranio-tabes,  great  restlessness  at  night,  delayed  dentition, 
and  enlarged  fontanel.  All  these,  taken  separately,  may  mean  something 
else,  but  collectively  they  can  mean  nothing  but  rickets.  In  the  later 
stages  some  of  the  characteristic  deformities  are  usually  present ;  the  most 
constant  are  beading  of  the  ribs,  enlargement  of  the  epiphyses  of  the  wrists 
and  ankles,  and  bow-legs. 

Special  symptoms,  when  unusually  prominent,  may  give  rise  to  diffi- 
culty in  diagnosis.  The  enlargement  of  the  head  may  be  mistaken  for 
hydrocephalus.  The  delayed  dentition  and  large  fontanel  of  the  cretin 
may  be  passed  over  as  rachitic.  Muscular  weakness  may  be  so  great, 
especially  when  affecting  the  legs,  as  to  make  it  easy  to  confuse  a  rachitic 
pseudo-paralysis  for  actual  paralysis  due  to  a  cerebral  or  spinal  lesion. 
When  walking  is  much  delayed,  rickets  may  be  passed  over  as  simple 
backwardness.  In  nearly  all  of  the  last-mentioned  group  of  cases  the 
diagnosis  may  be  cleared  up  by  a  careful  search  for  the  bony  changes, 
and  by  the  fact  that  in  rickets  there  is  only  a  general  weakness  of  all 
the  muscles,  and  not  actual  paralysis  of  any  limb  or  group  of  muscles. 
The  greatest  difficulty  is  usually  found  where  the  muscular  symptoms  are 
marked  and  the  bony  changes  slight,  as  is  not  infrequently  the  case.    Here 


RICKETS.  233 

the  question  is,  whether  rioicets  is  sufficient  to  explain  all  the  symptoms, 
or  whether  in  addition  some  other  condition  is  present.  The  electrical 
reactions  will  decide  the  question  of  poliomyelitis,  while  the  presence  of 
cerebral  symptoms,  exaggerated  knee-jerks,  and  rigidity  of  the  legs,  will 
usually  mark  a  cerebral  birth-palsy.  The  bony  enlargements  of  syphilis 
are  not  likely  to  be  confounded  with  rickets,  if  it  is  remembered  that  the 
early  lesions  of  syphilis  are  more  like  boggy  infiltrations  over  the  bones 
than  actual  swelling  of  the  bone  itself,  and  that  when  the  bone  is  affected 
it  is  not  at  the  extremity,  but  at  the  junction  of  the  epiphysis  and  the 
shaft ;  the  bone  changes  of  late  syphilis  affect  the  shaft  rather  than 
the  extremities  of  the  long  bones ;  where  the  bone  is  enlarged  near 
the  joint  it  is  usually  upon  one  side  only.  In  syphilis  there  may  be 
necrosis,  while  in  rickets  breaking  down  of  bone  is  never  seen.  From 
scurvy,  rickets  is  differentiated  by  the  absence  of  marked  hyperaesthe- 
sia,  ecchymoses,  and  other  haemorrhages,  the  changes  in  the  gums,  and 
most  of  all  by  the  fact  that  anti-scorbutic  diet  produces  no  immediate 
change  in  the  symptoms.  The  diagnosis  of  rachitic  curvature  of  the 
spine  from  vertebral  caries  will  be  considered  in  connection  with  the 
latter  disease. 

Prognosis. — Rickets  per  se  is  never  a  fatal  disease.  It  is,  however,  a 
large  factor  in  the  mortality  of  the  first  two  years,  as  the  cachexia  which 
it  produces  predisposes  strongly  to  every  form  of  acute  disease.  It  is  an 
important  etiological  factor  in  certain  serious  nervous  conditions,  espe- 
cially convulsions.  According  to  Gowers,  ten  per  cent  of  the  cases  of 
epilepsy  are  in  children  who  have  suffered  from  rickets.  Rickets  adds 
very  greatly  to  the  danger  of  all  acute  diseases  of  infancy,  particularly 
those  of  the  respiratory  tract.  This  depends  partly  upon  the  feeble  mus- 
cular power  and  partly  upon  the  thoracic  deformities.  The  encroach- 
ment upon  the  capacity  of  the  lungs  by  a  marked  thoracic  deformity,  may 
in  itself  be  enough  to  keep  a  child  in  a  delicate  condition  and  retard  its 
growth.  At  the  same  time  such  a  condition  is  a  constant  invitation  to 
acute  attacks  of  bronchitis  or  pneumonia.  The  effect  of  rickets  upon 
the  future  health  of  the  child,  depends  chiefly  upon  the. presence  and  ex- 
tent of  the  thoracic  deformity.  When  this  is  absent,  as  a  rule  no  serious 
after-effects  are  visible,  and  although  children  may  remaiii  somewhat 
dwarfed  on  account  of  their  short  legs,  in  other  respects  they  may  be  as 
well  as  if  they  had  never  been  the  subjects  of  rickets. 

Prophylaxis. — As  rickets  is  primarily  due  to  improper  food  or  feed- 
ing, and  secondarily  to  bad  surroundings,  it  may  be  prevented  by  the 
observance  of  proper  rules  of  feediug  as  laid  down  elsewhere,  and  by  re- 
moving children  from  their  faulty  surroundings.  Especial  care  should  be 
given  to  the  later  children  of  a  family  where  the  earlier  ones  have  shown 
even  the  mildest  symptoms  of  rickets,  as  the  predisposition  is  sure  to  in- 
crease with  each  child. 


234  NUTRITION. 

Treatment. — In  considering  tlie  treatment  of  rickets,  the  natural 
course  of  the  disease  is  to  be  kept  in  mind,  viz.,  that  active  symptoms 
frequently  continue  only  until  the  tenth  or  twelfth,  rarely  longer  than  the 
eighteenth  month,  and  that  after  this  time  the  patient  suffers  more 
from  the  results  of  the  disease  than  from  the  disease  itself.  The  most 
important  period  for  treatment,  therefore,  and  the  one  in  which  it  is 
most  effective,  is  from  the  sixth  to  the  fifteenth  month.  The  earlier 
the  treatment  is  begun  the  better  will  be  its  results.  Constitutional  treat- 
ment after  the  fifteenth  or  eighteenth  month,  has  very  little  effect  upon 
the  disease,  for  by  this  time  most  of  the  harm  has  been  done.  The  course 
of  the  disease  when  untreated  is  toward  spontaneous  recovery,  from  the 
changes  in  diet  and  life  which  are  usually  made  when  children  have 
reached  the  latter  half  of  the  second  year.  Most  of  the  cases  seen  in 
private  practice  are  of  a  mild  type  and  recover  without  special  treat- 
ment, often  no  diagnosis  being  made  until  later  in  life,  when  the  bony 
deformities  or  stunted  growth  indicate  the  previous  existence  of  rickets. 
The  first  step  in  treatment  is  to  remove  the  cause,  and  is  therefore  to  be 
directed  to  tlie  diet  and  hygiene  of  the  patient.  The  results  will  depend 
upon  how  completely  these  causes  can  be  removed. 

Diet. — Carbohydrates,  including  sugars,  proprietary  infant-foods,  and 
all  farinaceous  substances,  should  be  reduced  to  the  minimum,  and  in 
some  cases  prohibited.  80  far  as  possible  the  diet  should  consist  of 
nitrogenous  food  and  fats,  especially  milk,  cream,  eggs,  red  meat  and 
fresh  fruit.  These  articles  are  to  be  given  according  to  the  rules  laid 
down  in  the  chapters  on  Infant  Feeding.  In  addition,  cod-liver  oil — 
which  in  these  cases  may  be  considered  quite  as  much  a  food  as  a  medi- 
cine— should  be  administered  as  soon  as  the  stomach  will  tolerate  it. 

Hygiene. — This  is  the  most  difficult  part  of  the  treatment.  In  large 
cities  it  is  almost  impossible  to  secure  for  rachitic  patients  the  surround- 
ings they  require.  Whenever  possible,  such  children  should  be  sent  to  the 
country  ;  but  where  this  is  out  of  the  question,  much  may  be  accom- 
plished by  frequent  excursions  upon  the  water  or  into  the  country,  by 
keeping  children  as  much  as  possible  in  the  parks  and  open  squares  of  the 
city,  and  securing  plenty  of  fresh  air  in  sleeping  rooms.  Mothers  are 
often  very  much  afraid  of  fresh  air,  on  account  of  the  tendency  of  these 
children  to  take  cold.  If  cold  sponge-baths  are  given  every  morning, 
much  can  be  done  to  lessen  this  susceptibility.  Sunshine,  though  diffi- 
cult to  obtain  in  large  cities,  is  a  most  efficient  therapeutic  agent.  The 
establishment  of  suburban  hospitals  and  homes  for  these  cases  would  do 
more  than  anything  else  to  lessen  the  mortality  from  rickets. 

In  a  disease  which  tends  so  uniformly  to  recovery  when  causal  condi- 
tions are  removed,  it  is  difficult  to  estimate  the  real  value  of  medicinal 
treatment.  No  one  thinks  of  relying  upon  drugs  alone  in  the  treatment 
of  rickets,  and  where  they  are  used  in  conjunction  with  other  means  it 


RICKETS.  235 

is  illogical  to  attribute  all  the  improvement  to  the  drugs  employed. 
Those  most  used  are  cod-liver  oil,  phosphorus,  and  various  preparations 
of  lime.  Regarding  the  value  of  cod-liver  oil,  there  can  be  no  question. 
While  it  can  not  be  ranked  as  a  specific  in  rickets,  it  should  be  given 
in  every  case  unless  contra-indicated  by  the  condition  of  the  stomach, 
except  possibly  during  very  hot  summer  weather.  Phos^ihorus  has  been 
popularized  in  the  treatment  of  rickets  by  Kassowitz,  who  regards  it  as  a 
specific  for  the  disease.  I  have  been  unable  to  satisfy  m3'self,  after  five 
years'  experience  with  its  use,  that  in  the  great  majority  of  the  cases  it 
had  any  decided  influence  upon  the  course  of  the  disease.  The  best 
results  from  phosphorus  are  obtained  in  the  early  cases,  where  there  are 
cranio- tabes  and  marked  nervous  symptoms.  But  even  here  I  have  not 
seen  the  striking  benefit  reported  by  others.  In  the  later  stages  of  rick- 
ets, it  has  been  difficult  to  see  any  special  result  from  its  use.  Phos- 
phorus may  be  administered  either  in  the  form  of  the  officinal  oil  of 
phosphorus  diluted  with  olive  oil,  or  as  Thompson's  solution.  The  dose 
^'^  S^'-  Yw  three  times  a  day,  given  after  meals;  it  should  be  continued 
for  several  months.  In  such  doses  I  have  never  seen  it  cause  unpleasant 
symptoms. 

The  absence  of  lime  in  rachitic  bones  has  led  to  the  use  of  various 
preparations  of  lime  as  remedies.  Those  most  employed  are  the  phos- 
phate, the  lactophosphate,  and  the  hypophosphite.  While  these  may  be 
beneficial  as  tonics,  they  are  not  in  any  sense  to  be  classed  as  specifics.  It 
is  probable  that  when  lime  is  given  in  excess  of  the  amount  furnished  by 
ordinary  breast-milk  or  cow's  milk,  this  excess  passes  through  the  bowels 
unabsorbed.  Arsenic  and  iron  are  valuable  in  the  treatment  of  rickets, 
the  special  indication  for  their  use  being  the  presence  of  marked  ana-mia. 
Profuse  sweating  may  be  relieved  by  small  doses  of  atropine — i.  e.,  gr. 
jf^^,  three  or  four  times  a  day,  to  a  child  of  six  months. 

Treatment  of  the  rachitic  deformities. — The  deformities  of  the  chest 
are  less  amenable  to  treatment  than  most  of  the  others.  After  the  third 
year  something  can  be  done  by  gymnastics  to  develop  the  chest  muscles 
and  to  increase  the  pulmonary  expansion.  The  employment  of  the  pneu- 
matic cabinet,  in  which  it  is  sought  to  overcome  these  deformities  by  the 
use  of  rarefied  air,  has  never  been  given  the  trial  which  it  deserves.  From 
the  very  meagre  reports  published,  this  appears  to  be  of  considerable  value. 

The  deformity  of  the  spine  (kyphosis)  may  usually  be  overcome  by 
postural  treatment.  The  patient  should  lie  upon  a  hard  bed ',  no  pillow 
should  be  allowed  under  the  head,  but  in  severe  cases  one  should  be 
placed  beneath  the  back,  so  that  the  head  and  buttocks  are  slightly  lower 
than  the  lumbar  spine.  While  sitting,  the  shoulders  should  be  kept  back 
and  the  trunk  supported.  For  a  few  minutes  each  day  the  child  should 
be  placed  upon  the  face,  and  the  deformity  overcome  by  raising  the  but- 
tocks while  pressure  is  made  upon  the  sjiine.     In  severe  cases,  an  apparatus 


236 


NUTRITION. 


for  giving  spinal  support,  eitlier  by  a  steel  brace  or  a  plaster-of-Paris 
jacket,  may  be  worn  a  few  hours  each  day  when  the  child  is  sitting  up. 
Other  means  should  be  employed,  especially  friction  and  massage,  to 
develop  the  spinal  muscles. 

In  very  many  cases  slight  deformities  of  the  extremities  are  outgrown 
when  the  general  treatment  cau  be  properly  carried  out.  Where  these 
exist,  the  physician  should  take  the  curve  of  the  limbs  by  seating  the 


Fig.  41.— Tracing,  .showing  the  curve  in  a  ca.se  of  bow-legs. 

child  upon  a  flat  surface  and  tracing  their  outline  with  a  pencil  held  per- 
pendicularly (see  Fig.  41).  A  fresh  tracing  should  be  taken  once  a  month. 
If  the  deformity  is  not  very  great  and  no  increase  takes  place,  it  is  safe 
to  continue  with  general  treatment  only.  If  the  deformity  is  marked  or 
if  it  increases  in  spite  of  the  constitutional  treatment,  braces  should  be 
applied.  Something  may  be  done  toward  straightening  the  bones  by 
intelligent  manipulation.  Walking  should  be  discouraged  until  the  bones 
are  quite  firm.  Friction  of  the  extremities,  and  even  the  use  of  electricity, 
will  do  very  much  to  increase  muscular  development.    The  habit  of  sitting 


RICKETS.  237 

cross-legged — a  very  common  one  of  rachitic  children — should  be  pre- 
vented, and  in  fact  any  other  habitual  posture,  on  account  of  the  danger 
of  increasing  certain  deformities.  But  little  is  to  be  expected  from  the 
use  of  apparatus  for  the  correction  of  rachitic  deformities  after  the  child 
is  two  and  a  half  years  old  ;  since  at  this  time,  and  often  even  at  two  years, 
the  bones  are  so  firm  that  no  amount  of  pressure  from  a  steel  brace  will 
have  any  effect. 

Without  going  fully  into  the  question  of  the  surgical  treatment  of 
rachitic  deformities,  for  which  the  reader  is  referred  to  text-books  on 
general  and  orthopaedic  surgery,  I  will  only  state  that  osteotomy  seems  to 
me  to  offer  decided  advantages  over  the  other  means  of  treating  severe 
deformities.  A  vast  amount  of  time  and  patience  is  wasted  in  the  vain 
attempt  to  overcome  very  marked  deformities  by  apparatus.  The  best 
results  in  osteotomy  are  obtained  when  the  operation  is  delayed  until  the 
fourth  or  fifth  year,  by  which  time  the  bones  are  sufficiently  firm  and 
solid.  Oj^erations  in  the  second  year  are  generally  unsatisfactory,  and 
those  in  the  third  year  often  so,  because  of  the  bending  of  the  bones 
which  takes  place  subsequently.  The  deformities  which  require  opera- 
tion are  bow-leg  and  knock-knee,  less  frequently  the  curvatures  of  the 
femur  or  of  the  bones  of  the  forearm. 


SECTION   III. 
DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

CHAPTER   I. 

DISEASES  OF  THE  LIPS,    TONGUE.   AND  MOUTH. 
MALFORMATIONS. 

Harelip. — This  is  one  of  the  most  frequent  congenital  deformities. 
It  is  caused  by  an  incomplete  fusion  of  the  central  process  with  one  or 
both  of  the  lateral  processes  from  which  the  upper  half  of  the  face  is  de- 
veloped. This  deformity  may  be  single  or  double ;  the  fissure  is  never  in 
the  median  line,  but  usually  just  beneath  the  centre  of  the  nostril.  There 
may  be  simply  a  slight  indentation  in  the  lip,  or  the  fissure  may  extend  to 
the  nostril.  Both  single  and  double  harelip-  -more  frequently  the  latter — 
may  be  complicated  by  fissure  of  the  palate.  Double  harelip  is  usually 
accompanied  by  a  fissure  between  the  intermaxillary  and  the  superior 
maxillary  bone  of  each  side. 

Cleft  Palate. — This  is  second  in  frequency  to  harelip.  It  may  involve 
the  soft  palate  only,  or  the  fissure  may  extend  into  the  hard  palate,  pro- 
ducing a  wide  gap  in  the  roof  of  the  mouth.  The  most  frequent  form 
is  that  in  which  only  the  soft  palate  is  affected. 

For  the  surgical  treatment  of  both  these  deformities  the  reader  is  re- 
ferred to  text-books  upon  surgery.  As  to  the  time  of  operation,  in  cases 
of  harelip  it  is  wisest  to  defer  interference  until  the  child  is  well  started  in 
its  growth — that  is,  the  second  or  third  month — and  in  cleft  palate  until  the 
third  or  fourth  year.  The  medical  treatment  of  these  cases  consists  in  the 
care  of  the  mouth  and  in  the  nutrition  of  the  patient.  The  mouth  in  all 
cases  must  be  kept  scrupulously  clean,  but  the  greatest  care  is  necessary 
not  to  injure  the  epithelium.  A  camel's-hair  brush  and  plain  lukewarm 
water,  or  a  weak  alkaline  solution,  are  to  be  recommended.  Both  these 
deformities  are  exceedingly  likely  to  be  complicated  by  thrush.  This  is  a 
serious  menace  to  the  success  of  any  operation,  and  even  to  the  life  of  the 
patient.  The  nutrition  is  always  a  matter  of  much  difiiculty,  and  a  very 
large  number  of  these  cases  die  of  inanition  or  marasmus.  In  cases  of 
harelip,  if  the  fissure  is  so  great  as  to  interfere  with  nursing,  the  child 
may   be  fed   with   a   spoon    or  a   medicine   dropper  until  the  operation 

238 


DISEASES  OF  THE  TONGUE.  239 

can  be  done.  In  cleft  palate  there  may  be  attached  to  the  rubber  nipple 
of  the  nursing  bottle  a  Hap  of  thin  sheet  rubber  in  such  a  way  that  it 
closes  the  fissure  in  the  mouth  when  once  the  nijjple  is  in  place.  This 
flap  should  be  shaped  like  a  leaf,  one  extremity  being  sewed  to  the  neck 
of  the  rubber  nipple  and  the  other  end  left  free.  In  many  cases,  both 
before  and  immediately  after  operation,  gavage  (page  02)  may  be  resorted 
to  with  the  greatest  benefit  and  with  very  little  inconvenience. 

Congenital  Hypertrophy  of  the  Tongue. — This  is  usually  due  to  disease 
of  the  lyiiipli;itics,  and  is  to  be  regarded  as  a  lymphangioma.  In  a  few 
cases  hypertrophy  of  the  muscular  fibres  has  been  present.  The  tongue 
may  reach  an  enormous  size,  so  that  it  is  impossible  for  it  to  be  contained 
within  the  cavity  of  the  mouth,  and  it  may  thus  interfere  with  nursing, 
deglutition,  and  even  with  respiration.  The  treatment  is  surgical.  Cases 
like  the  above  are  to  be  distinguished  from  those  of  enlargement  of  the 
tongue  seen  in  sporadic  cretinism.  In  this  disease  the  tongue  is  consider- 
ably enlarged  and  may  protrude  slightly  from  the  mouth,  but  it  is  rarely, 
if  ever,  large  enough  to  cause  other  symptoms.  It  diminishes  notably 
under  treatment  with  the  thyroid  extract. 

Bifid  Tongue. — These  cases  are  extremely  rare.  Brothers  lias  reported 
to  the  Xew  York  Pathological  Society  a  case  of  cleft  tongue  in  a  child  of 
one  month.     There  was,  in  addition,  a  fissure  of  the  soft  palate. 

Tongue-Tie. — This  deformity  is  due  to  such  a  shortening  of  the  frenum 
that  it  is  impossible  to  protrude  the  tongue  to  a  normal  extent.  It 
ditfers  considerably  in  degree  in  different  cases.  In  some,  the  tongue 
can  not  be  advanced  beyond  the  gums.  Tongue-tie  may  interfere  with 
articulation,  and  even  with  sucking.  The  treatment  consists  in  liberating 
the  tongue  by  dividing  the  frenum  with  scissors  and  completing  the  oper- 
ation with  the  finger  nail.  This  should  be  done  in  every  case  unless  the 
child  is  a  bleeder.  In  many  cases  the  mother  may  think  the  tongue  tied 
when  the  frenum  is  of  normal  length. 

Bifid  Uvula. — This  is  not  very  uncommon.  It  usually  occurs  in  con- 
nection witli  cleft  palate,  but  is  occasionally  seen  when  there  is  no  other 
deformity  present.  It  may  be  complete  or  partial,  and  it  does  not  of  itself 
require  treatment. 

DISEASES   OF   THE   LIPS. 

Herpes. — Herpes  labialis  is  an  exceedingly  common  affection  in. chil- 
dren, occurring  in  acute  febrile  diseases,  particularly  pneumonia,  and 
sometimes  alone.  It  is  the  familiar  "  fever  sore  "  or  "  cold  sore  "  of  do- 
mestic medicine.  The  appearance  is  similar  to  herpes  in  other  parts  of 
the  body.  There  is  first  a  group  of  vesicles,  then  rupture  and  the  forma- 
tion of  crusts.  It  is  often  quite  difficult  to  cure  on  account  of  the  dispo- 
sition of  children  to  pick  the  lip  with  the  fingers.  Although  it  heals  with- 
out treatment,  recovery  is  facilitated  by  the  use  of  some  antiseptic  lotion, 
17 


240  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 

such  as  dilute  boric  acid,  followed  by  a  dusting  powder  of  zinc  oxide  and 
boric  acid.  This  treatment  is  generally  more  successful  than  the  use  of 
ointments.  Young  children  should  wear  mittens  at  night,  to  prevent 
picking  at  the  crusts. 

Eczema  of  the  Lip. — This  is  an  exceedingly  common  condition,  and 
a  very  troublesome  one.  The  vermilion  border  is  dry  and  rough,  and 
prone  to  deep  cracks  or  fissures.  These  are  usually  seen  at  the  angles  of 
the  mouth  or  in  the  median  line.  When  severe  they  are  exceedingly 
painful,  bleed  freely,  and  are  the  cause  of  very  great  discomfort,  especially 
in  the  cold  season.  The  lips  should  be  covered  at  night  by  simple  oint- 
ment, and  this  should  be  used  as  much  as  possible  during  the  day. 
Where  deep  fissures  form,  they  should  be  touched  with  burnt  alum,  or 
with  the  solid  stick  of  nitrate  of  silver.  Syphilitic  fissures  are  considered 
with  the  symptoms  of  that  disease. 

Perleche  {French,  perlecJier  =  to  lick). — This  name  was  first  given  by 
Lemaistre,  in  1886,  to  a  form  of  ulceration  occurring  usually  at  the  angle 
of  the  mouth.  It  begins  in  most  cases  as  a  small  fissure,  which,  by  con- 
stant licking  and  irritation,  to  which  there  is  usually  added  infection,  may 
produce  an  intractable  ulcer  of  considerable  size.  It  often  resembles  the 
mucous  patch  of  hereditary  syphilis.  The  ulcer  is  of  a  grayish  colour,  is 
quite  painful,  and  is  associated  with  considerable  swelling  of  the  lip.  It 
lasts  from  two  to  four  weeks.  The  treatment  is  the  same  as  in  simple 
fissure — viz.,  the  use  of  burnt  alum  or  nitrate  of  silver,  and  covering  the 
part  with  bismuth  or  oxide  of  zinc. 

DISEASES   OF  THE   TONGUE. 

Epithelial  Desquamation. — This  is  a  disease  of  the  lingual  epithelium, 
which  is  characterized  by  the  appearance  upon  the  dorsum  or  margin  of 
the  tongue,  of  circular,  elliptical,  or  crescentic  red  patches,  with  gray 
margins  which  are  slightly  elevated.  It  is  sometimes  improperly  called 
psoriasis  of  the  tongue.     It  is  quite  a  common  condition. 

The  beginning  of  the  disease  is  not  often  seen.  It  is  stated  first  to 
appear  as  a  white  or  gray  patch,  like  thickening  of  the  epithelium.  These 
patches  enlarge  quite  rapidly,  and  are  followed  by  detachment  of  the 
epithelium  and  the  formation  of  bright  red  areas,  which  are  the  parts 
denuded  of  epithelium.  As  usually  seen,  there  exists  upon  the  tongue 
from  two  to  half  a  dozen  of  these  red  patches  surrounded  by  a  gray  bor- 
der, which  is  about  one  twelfth  of  an  inch  wide,  and  slightly  elevated. 
The  outline  of  the  patch  is  nearly  always  crescentic  (see  Fig.  42).  From 
day  to  day  the  configuration  of  the  patches  changes ;  the  gray  lines  advance 
across  the  tongue  from  side  to  side,  or  from  base  to  tip,  disappearing  as 
they  reach  the  border  or  the  extremity.  They  are  followed  by  the  red 
patches,  and  as  the  old  ones  fade  away  new  ones  form  and  run  the  same 
course.     The  white  border  seems  to  be  made  up  entirely  of  epithelium. 


GLOSSITIS. 


241 


The  red  patches  are  of  a  bright  coh>ur  nearest  the  border,  gradually 
shading  olf  into  the  normal  colour  of  the  tongue.  Only  the  epithelium  is 
involved,  the  deeper  structures  being  unaffected.  The  duration  of  the 
disease  is  indefinite;  it  usually  lasts  for  months,  and  often  for  years, 
(Juinon  reports  several  cases  in  which  a  cure  took  place  during  an  inter- 
current attack  of  measles  or  scarlet  fever. 

The  cause  is  unknown.  The  condition  occurs  rather  more  frequently 
in  females  than  in  males,  and  (lubler  has  reported  an  instance  of  several 
members  of  the  same  family  being  affected. 
Most  of  the  cases  are  seen  in  infancy  and 
early  childhood.  The  condition  has  been 
thought  to  depend  upon  nearly  every  disease 
of  this  period.  Parrot  believed  that  it  was 
always  syphilitic,  but  this  view  has  been 
effectually  disproved  by  subsequent  observa- 
tion. The  disease  is  not  accompanied  by 
pain,  salivation,  or  by  other  symptoms  of 
stomatitis,  and  it  is  of  little  practical  impor- 
tance. Its  symptoms  are  so  characteristic 
that  it  can  hardly  be  mistaken  for  any  other 
condition.     Treatment  is  unnecessary. 

Two  other  forms  of  epithelial  desquama- 
tion have  been  observed,  both  much  more 
rare  than  that  described.  In  one  of  these 
the  red  denuded  portion  occupies  the  margin  of  the  tongue,  while  the 
centre  is  gray  or  white  ;  the  irregular  wavy  outline  which  separates  the  two 
suggests  strongly  an  outline  map,  and  the  condition  is  sometimes  called 
the  "  geographical  tongue."  In  another  variety  nearly  the  whole  organ 
may  be  uniformly  red,  from  loss  of  the  epithelium,  there  being  no  borders 
or  patches.  Both  these  varieties  are  of  much  shorter  duration  than  the 
more  common  form,  usually  lasting  only  a  few  weeks.* 

Glossitis. — Inflammation  of  the  tongue  is  not  very  common  in  chil- 
dren. It  is  usually  of  traumatic  origin.  The  injury  may  be  due  to  biting 
the  tongue  in  a  fall  or  in  an  epileptic  seizure.  Glossitis  is  sometimes 
excited  by  the  irritation  of  a  sharp  tooth,  causing  a  wound  which  may  be 
the  avenue  of  infection  ;  or  it  may  result  from  taking  into  the  mouth 
irritant  or  caustic  poisons.  In  a  small  number  of  cases  no  cause  can  be 
found.  The  symptoms  are  marked  swelling  of  the  tongue,  so  that  it  may 
})rotrude  from  the  mouth;  and  it  may  even  be  so  great  as  to  cause  so 
vere  dyspncBa.     There  are  also  profuse  salivation,  difficulty  in  swallowinj 


Fig.  42. — Epitln  lial  ili-siiuamation 
of  the  tongue.     (Guinon.^ 


*  For  a  fuller  description  and  literature  of  the  subject,  see  Guinon.  Revue  Men- 
suelle  (les  Maladies  de  I'P^nfance,  1887,  p.  585 ;  and  Gautier,  Revue  Medicate  de  la 
Suisse,  Romande,  October  and  November,  1881, 


242  DISEASES  OF  TPIE  DIGESTIVE  SYSTEM. 

and  in  articulation,  and  often  considerable  local  pain.  There  may  be  a 
rise  of  temperature  to  102°  or  103°  F.  The  treatment  consists  in  the  use 
of  fluid  food,  which  in  severe  cases  may  be  introduced  through  the  nose 
by  moans  of  a  catheter.  Ice  may  be  used  externally,  or,  better  still,  pieces 
of  ice  should  be  kept  in  the  mouth  continually.  If  there  is  obstruction  to 
respiration,  and  in  all  severe  cases,  scarification  should  be  done  on  the  dor- 
sum along  the  side  of  the  raphe. 

Tongue-swallowing. — This  term  is  used  to  describe  a  rare  condition 
seen  in  infants,  in  which  the  tongue  is  turned  backward  into  the  pharynx, 
so  as  to  obstruct  respiration.  It  may  be  drawn  quite  into  the  oesophagus. 
Several  marked  cases  have  been  collected  by  Hennig.*  One  of  these  will 
suffice  as  an  illustration.  A  well-nourished  infant  of  three  months,  in  the 
course  of  a  severe  paroxysm  of  pertussis,  was  seized  with  convulsions,  fol- 
lowed by  asphyxia,  and  died  in  a  few  minutes.  After  death  the  tongue 
was  found  to  be  doubled  upon  itself,  its  tip  being  tightly  wedged  into  the 
oesophagus.  While  most  frequently  occurring  with  i^ertussis,  tongue- 
swallowing  has  been  seen  in  other  diseases.  I  have  never  met  with  cases 
of  such  severity,  although  in  several  instances  I  have  seen  marked  dysp- 
noea produced  in  young  infants  by  the  folding  backward  of  the  tongue. 
Tongue-swallowing  should  not  be  forgotten  as  one  of  the  explanations  of 
sudden  asphyxia  in  a  young  infant.  The  conditions  necessary  to  its  pro- 
duction are  a  somewhat  relaxed  organ  or  a  long  frenum.  In  none  of  the 
fatal  cases  reported,  however,  had  the  frenum  been  divided.  In  some 
weak  infants,  falling  back  of  the  tongue,  so  that  its  base  partly  covers  the 
epiglottis,  produces  asphyxia,  precisely  as  it  occurs  in  adult  life  under 
full  anesthesia.  The  recognition  of  the  condition  is  a  very  easy  one,  and 
its  treatment  is  to  relieve  the  obstruction  by  drawing  the  tongue  forward 
by  the  finger  or  forceps. 

Ulcer  of  the  Frenum. — The  friction  against  the  sharp  edges  of  the  lower 
central  incisors  frequently  causes  an  ulcer  of  the  frenum  in  infants.  I  have 
never  seen  it  in  older  children.  It  usually  occurs  in  pertussis,  but  is  seen 
in  other  cases.  In  some  it  appears  to  be  produced  by  friction  of  the 
teeth  during  nursing  from  the  breast  or  bottle.  It  is  more  often  seen  in 
children  who  are  delicate  or  cachectic  than  in  those  who  are  healthy  and 
well  nourished.  The  ulcer  may  be  confined  to  the  frenum,  or  it  may 
extend  quite  deeply  into  the  tongue.  It  is  usually  about  one  fourth  of 
an  inch  in  diameter,  and  of  a  yellowish-gray  colour.  When  not  readily 
cured  by  touching  with  alum  or  nitrate  of  silver,  the  child  may  be  fed  by 
gavage  for  several  days,  or  the  teeth  may  be  covered  by  a  bit  of  absorbent 
cotton. 

*  Jahrbuch  flir  Kinderheilkunde,  xi,  299. 


ALVEOLAR  ABSCESS— DIFFICULT  DENTITIOX.  243 


ALVEOLAR  ABSCESS. 

This  is  common  in  children,  especially  among  the  class  of  hospital  and 
dispensary  patients,  in  whom  little  or  no  attention  is  given  to  the  care  of 
the  teeth.  It  causes  severe  pain  and  acute  swelling,  which  may  be  limited 
to  the  gum,  or  it  may  involve  to  a  considerable  extent  the  periosteum  of 
the  jaw,  and  even  cause  swelling  of  the  whole  side  of  the  face.  If  there 
is  retention  of  pus,  there  may  be  quite  severe  constitutional  symptoms, 
such  as  a  chill  and  high  temperature  ;  but  in  most  of  the  cases  these  are 
wanting.  The  abscess  usually  opens  spontaneously  into  the  mouth,  but  it 
may  open  externally  if  the  molar  teeth  are  the  ones  affected.  It  may 
even  lead  to  necrosis  of  the  jaw.  If  its  site  is  the  ujiper  jaw,  the  pus  may 
find  its  way  into  the  nasal  cavity  or  into  the  maxillary  sinus. 

The  treatment  is,  in  the  first  place,  prophylactic.  This  requires  atten- 
tion to  the  teeth  to  prevent  decay,  and  the  removal  of  old  carious  fangs, 
which  are  a  constant  menace  to  the  health  of  the  child  in  more  ways  than 
one.  The  free  use  of  the  toothbrush  and  some  antiseptic  mouth-wash 
will,  in  the  great  majority  of  cases,  i:)revent  the  occurrence  of  this  disease. 
It  is  important  that  the  abscess  be  opened  early  and  free  drainage  secured. 
If  there  is  a  carious  tooth  it  should  be  drawn. 

DIFFICULT  DENTITION. 

The  place  of  dentition  as  an  etiological  factor  in  the  diseases  of  infancy 
is  one  which  has  given  rise  to  much  discussion.  From  a  very  early  period 
the  view  has  descended,  that  a  large  number  of  the  diseases  occurring  be- 
tween the  ages  of  six  months  and  two  years  were  due  to  difficult  dentition. 
The  list  of  such  diseases  is  a  long  one,  but  year  by  year  it  has  been  short- 
ened as  one  after  another  has  been  shown  to  depend  upon  other  causes, 
dentition  being  only  a  coincidence. 

At  the  present  time  many  good  observers  deny  that  dentition  is  ever  a 
cause  of  symptoms  in  children  ;  some  even  going  so  far  as  to  say  that  the 
growth  of  the  teeth  causes  no  more  symptoms  than  the  growth  of  the 
hair.  Without  doubt  the  usual  mistake  made  in  practice  is  in  overlooking 
serious  disease  of  the  brain,  kidneys,  lungs,  stomach,  and  intestines,  because 
of  the  firm  belief  that  the  child  was  "  only  teething."  The  physician  who 
starts  out  with  the  idea  that  dentition  may  produce  all  symptoms  in  in- 
fancy, usually  gets  no  fui-ther  than  this  in  his  etiological  investigations. 
Although  I  strongly  believe  that  the  importance  of  dentition  as  an  etio- 
logical factor  in  disease  has  been  in  the  past  greatly  exaggerated,  and 
although  I  have  formerly  hold  the  opinion  that  simple  dentition  did  not 
and  could  not  produce  syin}rtoms,  within  the  past  few  years  I  have  been 
compelled  by  clinical  observations  to  change  my  opinion  upon  this  sub- 
ject ;  and  I  am  now  willing  to  admit  that  dentition  may  produce  many 
reflex  symptoms,  some  even  of  quite  an  alarming  character. 


24:i  DISEASES  OF  THE  DIGESTIVE  SYSTEM, 

Speaking  from  impressions,  not  from  statistics,  I  should  say  that  in 
my  experience  about  one  half  of  the  healthy  children  cut  their  teeth 
without  any  visible  symptoms,  local  or  general ;  in  the  remainder  some 
disturbance  is  usually  seen,  and  though  in  most  cases  it  is  slight  and  of 
short  duration,  it  may  last  for  several  days  or  even  a  week.  The  symptoms 
most  commonly  seen  are  disturbed  sleep,  or  wakefulness  at  night  and 
fretfulness  by  day,  so  that  children  often  sleep  only  one  half  the  usual 
time.  There  is  loss  of  appetite,  and  much  less  food  than  nsual  is  taken. 
There  is  often,  but  not  always,  an  increase  in  the  salivary  secretion,  a 
slight  amount  of  catarrhal  stomatitis,  and  a  constant  disposition  on  the 
part  of  the  child  to  stuff  the  fingers  into  the  mouth.  The  bowels  are 
often  constipated  or  there  may  be  slight  diarrhoea.  The  thermometer 
may  show  a  slight  elevation  of  temperature  to  100°  to  101-5°  F,  The 
weight  may  remain  stationary  for  a  week  or  two,  and  there  may  even  be 
a  loss  of  a  few  ounces.  The  duration  of  these  symptoms  in  most  cases  is 
but  a  few  days,  and  they  require  no  special  treatment.  If  the  food  is 
forced  beyond  the  child's  inclination,  attacks  of  indigestion  with  vomit- 
ing and  diarrhoea  are  easily  excited. 

Symptoms  more  severe  than  the  above  are  rare  in  healthy  children,  but 
are  not  infrequent  in  those  who  are  delicate  or  rachitic.  In  such  suscep- 
tible children,  even  so  slight  a  thing  as  dentition  may  be  the  cause,  or  at 
least  the  exciting  cause,  of  quite  serious  symptoms.  Often  there  is  some 
other  factor  in  the  case,  such  as  bad  feeding  or  feeble  digestion.  In  deli- 
cate or  rachitic  children  there  may  be  seen  the  symptoms  already  men- 
tioned as  occurring  in  healthy  infants,  but  in  greater  severity ;  and  in 
addition  there  may  be  severe  attacks  of  acute  indigestion.  Occasionr- 
ally  there  is  quite  high  fever,  from  102°  to  104°  F.,  lasting  usually  only 
two  or  three  days,  but  in  rare  cases  for  a  week,  and  accompanied  by  no 
other  symptoms  except  almost  complete  anorexia.  Convulsions  which 
could  fairly  be  attributed  to  dentition  I  have  never  seen,  yet  I  do  not 
doubt  that  they  may  occur  in  rachitic  children.  There  are  certain  cases 
of  eczema  in  which  the  symptoms  undergo  a  distinct  exacerbation  with 
the  eruption  of  each  group  of  teeth.  As  regards  almost  all  the  other  dis- 
eases which  are  commonly  attributed  to  dentition,  I  believe  that  it  is  a 
delusion  to  trace  them  to  this  cause. 

The  physician  should  watch  a  child  carefully,  and  examine  it  fre- 
quently, to  be  sure  that  he  is  not  overlooking  some  serious  local  or  consti- 
tutional disease  before  he  allows  himself  to  make  the  diagnosis  of  difficult 
dentition.  Probably  in  ninety-five  per  cent  of  the  cases  in  which  the 
above  symptoms  are  present,  they  are  due  to  some  cause  other  than  denti- 
tion. When,  however,  symptoms  such  as  any  of  those  mentioned  disap- 
pear immediately  when  the  teeth  come  through,  and  when  we  see  them 
repeated  four  or  five  times  in  the  same  child  with  the  eruption  of  each 
group  of  teeth,  and  accompanied  by  red  and  swollen  gums,  I  think  we  can 


CATARRHAL  STOMATITIS.  245 

not  escape  the  conclusion  that  dentition  has  been  a  factor  in  their  pro- 
duction, though  perhaps  not  the  only  one. 

In  the  treatment  of  this  condition  drugs  occupy  but  a  small  place.  It 
should  be  remembered  that  infants  are  at  this  time  in  a  peculiarly  suscep- 
tible condition,  as  regards  the  digestive  tract,  and  attacks  of  indigestion, 
and  even  severe  diarrhoea,  are  readily  excited  from  slight  causes,  espe- 
cially from  overfeeding.  Special  care  should  be  exercised  in  this  respect. 
Tlie  strength  of  the  food  should  be  reduced,  as  well  as  the  amount 
given.  Tlie  poor  appetite  indicates  a  feeble  digestion,  which  should  not 
be  overtaxed.  As  attacks  of  bronchitis  and  acute  nasal  catarrh  are  read- 
ily induced,  even  slight  exposure  should  be  guarded  against.  The  nervous 
symptoms,  when  severe,  may  be  relieved  by  the  use  of  moderate  doses  of 
bromide  and  phenacetine,  better  than  by  opiates.  All  soothing  syrups 
should  be  discountenanced.  All  the  various  devices  for  making  denti- 
tion easy  are  a  delusion.  In  a  small  number  of  cases  lancing  the  gums 
is  of  decided  value.  I  have  myself  seen  marked  and  undoubted  relief 
given  by  it.  This  is  likely  to  be  the  case  where  the  gums  are  tense, 
swollen,  and  very  red,  with  the  teeth  just  beneath  the  mucous  membrane. 
That  lancing  the  gums  is  often  required  I  do  not  believe ;  that  it  is 
done  by  many  physicians  too  frequently  is  no  doubt  true ;  but  it  should 
still  have  a  place  in  our  therapeutic  measures.  Care  should  always  be 
taken  that  infection  is  not  carried  by  the  lancet. 

CATARRHAL  STOMATITIS. 

This  is  characterized  by  redness  and  swelling  of  the  mucous  mem- 
brane, and  by  increased  secretion  of  the  salivary  and  the  muciparous 
glands  of  the  mouth.  It  usually  involves  a  large  part  of  the  mucous 
membrane. 

Etiology. — Catarrhal  stomatitis  may  result  from  traumatism.  This 
injury  may  be  mechanical,  or  due  to  heat  or  any  irritant  accidentally 
taken  into  the  mouth.  It  frequently  occurs  at  the  time  of  the  eruption 
of  a  tooth.  It  complicates  measles,  scarlet  fever,  diphtheria,  influenza, 
and  many  other  infectious  diseases.  In  these  cases,  and  in  many  others, 
the  disease  is  probably  due  to  direct  infection. 

Lesions. — The  lesions  are  essentially  the  same  as  in  catarrhal  inflam- 
mations of  other  mucous  membranes.  There  are  congestion  with  desqua- 
mation of  epithelial  cells,  and  sometimes  the  formation  of  superficial 
ulcers.  The  process  may  be  a  very  superficial  one,  or  it  may  extend  to 
the  submucous  tissue. 

Symptoms. — The  whole  mucous  membrane  is  intensely  injected,  all 
the  capillaries  are  dilated,  and  small  haemorrhages  easily  excited.  The 
mucous  membrane  is  swollen,  this  being  most  apparent  over  the  gums  or 
about  the  teeth.  Tliere  may  be  some  swelling  of  tlie  lips.  The  mouth 
seems  hot,  and  the  local  temperature  is  certainly  iiicri'iisod.     Tliere  is  con- 


246  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

siderable  pain,  as  shown  by  f  retf  ulness,  but  particularly  by  the  disinclination 
to  take  food  :  infants,  though  evidently  hungry,  either  refusing  the  breast 
or  bottle  altogether,  or  dropping  it  after  a  few  moments.  The  increase  in 
secretion  is  sometimes  marked,  so  that  the  saliva  pours  from  the  mouth, 
irritating  the  lips  and  face  and  drenching  the  clothing.  In  other  cases 
the  saliva  is  swallowed.  On  close  inspection  there  may  be  seen  swelling 
of  the  muciparous  follicles,  and  even  the  formation  of  tiny  cysts  from  the 
accumulation  of  secretion  within  them  (Forchheimer).  The  tongue  is 
usually  coated,  the  edges  reddened,  and  the  papillse  prominent.  In  febrile 
diseases,  such  as  typhoid,  etc.,  we  may  get  an  accumulation  of  dead  epi- 
thelium with  the  formation  of  cracks  and  fissures  of  the  tongue,  and  the 
lips  may  present  a  similar  condition.  The  neighbouring  lymphatic  glands 
are  slightly  enlarged  and  tender.  The  constitutional  symptoms  accom- 
panying simple  stomatitis  are  not  severe,  but  some  disturbance  is  almost 
always  present.  There  may  be  derangement  of  digestion  with  vomiting, 
and  even  a  mild  attack  of  diarrhoea.  In  the  majority  of  cases  the  disease 
runs  a  short  course,  recovery  taking  place  in  a  few  days  when  the  primary 
cause  is  removed.  In  very  delicate  children  it  may  be  prolonged,  and 
from  the  interference  with  nutrition  may  even  lead  to  serious  conse- 
quences. 

Treatment. — The  month  and  teeth  should  be  kept  clean.  Food  is 
more  acceptable  if  given  cold.  In  very  severe  cases,  where  food  is  refused, 
gavage  may  be  resorted  to  three  or  four  times  daily.  In  all  cases  children 
may  be  given  ice  to  suck.  This  is  refreshing,  both  on  account  of  the  cold 
and  from  the  relief  to  the  thirst.  The  mouth  should  be  kept  clean  with 
a  solution  of  boric  acid,  ten  grains  to  the  ounce,  or  an  alkaline  solution,' 
such  as  Dobell's,  diluted  with  an  equal  amount  of  cold  boiled  water ;  or 
simply  water  may  be  used.  In  the  severe  forms,  where  there  is  much 
swelling  and  slight  catarrhal  ulceration,  astringents  are  required.  In  my 
experience  alum  is  the  best ;  this  may  be  applied  in  the  form  of  the  pow- 
dered burnt  alum  mixed  with  an  equal  amount  of  bismuth,  or  in  solution, 
ten  grains  to  the  ounce,  with  a  swab  or  brush.  Where  ulcers  are  slow 
in  healing  and  very  j^ainful,  the  powdered  burnt  alum  may  be  applied 
directly. 

HERPETIC   STOMATITIS. 
Synonyms  :  Aphthous,  vesicular,  follicular  stomatitis. 

In  this  form  of  stomatitis  we  have  the  appearance  first  of  small 
yellowish-white  isolated  spots,  and  subsequently  the  formation  of  super- 
ficial ulcers.  These  ulcers  are  first  discrete,  but  may  coalesce  and  form 
others  of  considerable  size.  It  is  a  self-limited  disease,  usually  running 
its  course  in  from  five  days  to  two  weeks. 

Etiology. — Yery  little  is  as  yet  positively  known  regarding  the  cause 
of  herpetic  stomatitis.     Forchheimer  reports  bacteriological  investigations 


HERPETIC  STOMATITIS.  247 

as  yielding  negative  results,  I  adopt  the  term  herpetic  to  designate  this 
disease,  because  I  believe,  with  Forchheimer*  and  others,  that  it  is  of 
nervous  origin.  There  is  yet  lacking  sufficient  evidence  to  establish  the 
fact  that  it  is  contagious.  It  occurs  most  frequently  about  the  end  of  the 
first  year,  but  may  be  seen  at  any  period  of  childhood,  least  frequently 
in  very  young  infants.  It  is  often  associated  with  disturbances  of  the 
stomach,  and  an  attack  may  be  coincident  with  the  eruption  of  the  teeth. 

Lesions. — The  exact  nature  of  the  lesion  is  still  a  matter  of  dispute. 
The  view  generally  accepted  is,  that  there  is  first  the  formation  of  a 
vesicle,  followed  by  death  of  the  epithelial  cells  covering  it,  and  the  pro- 
duction of  an  epithelial  ulcer;  the  process  being  thus  regarded  as  analo- 
gous to  herpes  of  the  skin.  These  ulcers  may  extend  superficially,  but 
never  deeply ;  they  commonly  heal  quickly  with  the  formation  of  new 
epithelial  cells,  leaving  no  cicatrices  behind  them.  Herpetic  stomatitis  is 
always  associated  with  more  or  less  catarrhal  inflammation. 

Symptoms. — The  symptoms  of  herpetic  stomatitis  may  precede  or 
follow  those  of  a  catarrhal  inflammation.  The  characteristic  feature  is 
the  appearance  of  small,  shallow,  circular  ulcers,  usually  coming  in  suc- 
cessive crops.  While  most  frequent  at  the  border  of  the  tongue  and  the 
inside  of  the  lips,  they  may  be  found  upon  any  part  of  the  mucous  mem- 
brane of  the  mouth  or  the  pharynx.  There  may  be  only  half  a  dozen 
present,  or  the  mouth  may  be  filled  with  them.  They  are  first  of  a  yel- 
lowish colour,  and  on  an  average  about  one  eighth  of  an  inch  in  diameter. 
By  the  coalescence  of  several  smaller  ones  there  may  form  patches  of  con- 
siderable size,  sometimes  nearly  covering  the  lips.  The  older  ulcers  are 
apt  to  have  a  dirty  grayish  colour,  and  in  places  may  look  not  unlike  a 
diphtheritic  membrane.  The  smaller  ones  are  surrounded  by  a  red  areola, 
and  when  healing  the  margin  is  of  a  bright  red  colour.  Their  appearance 
is  often  more  like  that  of  an  exudation  upon  the  mucous  membrane  than 
an  excavation  into  it.  The  other  symptoms  are  much  the  same  as  in 
catarrhal  stomatitis,  but  usually  of  greater  severity.  The  pain  is  particu- 
larly intense,  it  being  often  ditlicult  to  induce  children  to  take  anything  in 
the  form  of  food.  The  tongue  is  frequently  coated,  but  there  is  never  the 
foul  breath  of  ulcerative  stomatitis.  The  duration  of  the  disease  is  from 
one  to  two  weeks,  and,  if  the  child  is  in  good  condition,  complete  recovery 
takes  place  even  without  any  special  treatment.  In  badly  nourished  chil- 
dren the  disease  may  last  for  two  or  three  weeks ;  relapses  may  occur,  and 
the  condition  may  interfere  very  seriously  with  the  child's  nutrition. 

Treatment. — This  is  the  same  as  in  catarrhal  stomatitis,  with  the  addi- 
tion that  to  each  one  of  the  ulcers  finely  powdered  burnt  alum  should  be 
applied  with  a  camel's-hair  brush.  If  this  is  not  effective,  the  solid  stick 
of  nitrate  of  silver  may  be  used.     The  ulcers  will  usually  yield  rapidly  to 

*  Archives  of  Pivdiatrics,  is,  330. 


248  DISEASES   OF  THE   DIGESTIVE  SYSTEM. 

this  treatment.    In  my  experience,  drugs  given  with  the  purpose  of  affect- 
ing the  lesion  in  the  mouth  have  been  without  benefit. 

ULCERATIVE   STOMATITIS. 

This  form  of  stomatitis  is  only  seen  when  teeth  are  present.  It  is 
characterized  by  an  ulcerative  process,  beginning  at  the  junction  of  the 
teeth  and  the  gum,  and  extending  along  the  teeth,  involving  second- 
arily other  parts  of  the  mouth,  but  never  spreading  beyond  the  buccal 
cavity.  It  occurs  from  several  quite  distinct  causes,  and,  while  not  tend- 
ing to  spontaneous  recovery,  it  is  in  most  cases  readily  curable  by  the 
internal  administration  of  chlorate  of  potash,  which  may  be  looked  upon 
as  a  specific  remedy. 

Etiology. — Ulcerative  stomatitis  may  be  due  to  certain  of  the  metallic 
poisons,  particularly  mercury,  lead,  and  phosphorus;  but  from  all  these  it 
is  now  rare,  and  not  so  often  seen  in  children  as  in  adults.  It  sometimes 
occurs  as  a  sequel  of  acute  iufectious  diseases.  Most  of  the  cases  are  seen 
in  hospital  and  dispensary  patients,  in  children  whose  general  health  is 
below  par  and  who  have  suffered  from  the  lack  of  proper  food.  In  jiri- 
vate  practice  among  the  better  classes,  it  is  a  rare  disease.  A  local 
cause  of  much  importance  is  the  common  neglect  among  the  poor  of 
cleanliness  of  the  mouth  and  teeth,  and  the  presence  of  carious  teeth. 
This  is  the  form  of  stomatitis  which  occurs  in  scurvy  ;  and  it  seems  not 
unlikely  that  an  allied  disturbance  of  nutrition,  causing  a  spongy,  swollen 
condition  of  the  gums,  exists  prior  to  many  cases  of  ulcerative  stomatitis. 
Given  this  state  of  things,  it  is  easy  to  see  how  germs  present  in  the 
mouth,  finding  a  ready  entrance,  may  set  up  an  active  inflammatory  pro- 
cess ;  the  diminished  vitality  from  general  condition  taking  the  part  of  a 
primary  cause,  and  infection  that  of  a  secondary  one.  Bacteriological  in- 
vestigations of  these  cases  thus  far  made  have  revealed  only  the  ordinary 
pyogenic  bacteria. 

Lesions. — The  disease  may  begin  at  any  part  of  the  mouth,  but  most 
frequently  upon  the  outer  surface  of  the  gum  along  the  lower  incisor 
teeth.  From  this  point  it  extends  behind  the  teeth,  and  from  the  in- 
cisors to  the  canines  and  molars,  usually  of  one  side  only ;  but  it  may 
involve  the  whole  gum  and  both  jaws.  From  the  gums  the  process  may 
spread  to  the  lips,  affecting  the  fold  of  mucous  membrane  between  the 
gum  and  the  lip,  and  also  to  the  inner  surface  of  the  cheek,  especially 
opposite  the  molar  teeth,  where  large  ulcers  often  form.  In  neglected 
cases  the  disease  may  extend  into  the  alveolar  sockets,  the  teeth  loosening 
and  falling  out.  The  periosteum  of  the  alveolar  process  may  be  involved, 
and  even  superficial  necrosis  of  the  jaw  may  occur,  as  happened  in  three 
cases  that  came  under  my  observation. 

Symptoms. — The  first  things  noticed  are  the  very  offensive  breath  and 
the  profuse  salivation.     It  is  usually  for  one  of  these  that  the  patient 


ULCERATIVE   STOMATITIS.  249 

is  brought  for  treatment.  On  inspection  of  the  mouth,  there  is  seen  in 
the  mild  cases,  swollen,  spongy  gums  of  a  deep  red  or  purplish  colour, 
which  bleed  at  the  slightest  touch.  There  is  a  line  of  ulceration,  usually 
along  the  incisor  teeth,  most  marked  in  the  front,  which  may  extend  to 
any  or  to  all  of  the  teeth  ;  sometimes  it  affects  only  the  gum  along  the 
molar  teeth,  the  incisors  escaping.  At  the  junction  of  the  teeth  and  gum 
is  seen  a  dirty,  yellowish  deposit,  on  the  removal  of  which  free  bleeding 
takes  place.  The  diseased  parts  are  very  painful,  and  the  child  cries, 
and  resists  any  attempt  at  examination.  In  the  more  severe  cases  and  in 
those  of  longer  duration  the  teeth  are  loosened,  sometimes  being  so  loose 
that  they  can  be  picked  from  the  gum.  There  may  be  necrosis  of  the 
jaw,  and  even  a  loose  sequestrum  may  be  found.  The  ulceration  along 
the  gums  in  these  cases  is  deeper,  and  there  may  be  ulcers  in  the  cheek 
opposite  the  molar  teeth,  or  inside  the  lip.  The  swelling  may  be  so  great 
that  the  teeth  are  almost  covered  ;  this  is  seen  particularly  in  the  scorbutic 
form.  The  saliva  pours  from  the  mouth,  adding  greatly  to  the  discomfort 
of  the  patient.  Beneath  the  jaw  are  felt  the  large,  swollen  lymphatic 
glands,  which  are  painful  and  tender  to  the  touch,  but  show  no  tendency 
to  suppurate.  The  tongue  is  somewhat  swollen,  and  shows  at  the  edges 
the  imprint  of  the  teeth ;  it  is  thickly  coated  with  a  dirty  yellow  fur. 
The  general  condition  of  these  patients  is  usually  poor,  and  there  may 
be  quite  a  marked  cachexia.  Other  forms  of  stomatitis,  particularly  the 
herpetic,  may  be  associated,  and  it  should  not  be  forgotten  that  the  gan- 
grenous form  may  follow. 

When  not  recognised  or  not  properly  treated,  ulcerative  stomatitis 
may  last  for  months,  and  seriously  affect  the  patient's  general  health. 
When  properly  treated  it  tends  in  all  recent  cases  to  rapid  recovery,  usu- 
ally in  a  few  days.  No  deformity  of  the  mouth  is  left,  the  only  untoward 
results  being  shrinking  of  the  gum,  sometimes  loss  of  some  of  the  incisor 
teeth,  and  more  rarely  a  superficial  necrosis  of  the  alveolar  process.  All 
these  are  quite  uncommon.  Ulcerative  stomatitis  can  hardly  be  con- 
founded with  any  other  form,  and  not  only  should  a  diagnosis  of  the 
lesion  be  made,  but  the  condition  upon  which  it  depends  should,  if  pos- 
sible, be  discovered;  scorbutus,  particularly,  should  not  be  overlooked. 

Treatment. — The  first  thing  to  be  done  is  to  remove  the  cause.  When 
dependent  upon  metallic  poisoning  the  source  should  be  discovered. 
Scorbutic  cases  should  have  the  usual  anti-scorbutic  diet.  Cleanliness  of 
the  mouth  is  of  great  importance,  and  this  may  best  be  accomplished  by 
the  use  of  peroxide  of  hydrogen  diluted  with  from  two  to  ten  parts  of 
water.  It  should  be  followed  by  plain  water,  and  repeated  several  times  a 
day.  In  other  cases  an  astringent  solution  of  alum,  five  grains  to  the 
ounce,  or  a  mouth -wash  of  chlorate  of  potash,  three  grains  to  the  ounce, 
may  be  employed.  The  only  objection  to  the  last  mentioned  is  the  pain 
which  it  usually  produces. 


250  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 

The  specific  remedy  for  ulcerative  stomatitis  is  clilorate  of  potash. 
The  best  method  of  administration  is  to  give  two  grains  or  one  half  tea- 
spoonful  of  a  saturated  solution,  largely  diluted,  every  hour  during  the 
day  for  the  first  twenty-four  hours  and  subsequently  every  two  hours; 
when  improvement  occurs  the  dose  may  be  still  further  reduced.  Marked 
benefit  is  usually  seen  in  one  or  two  days  even  in  cases  that  have  lasted  for 
several  weeks.  If  the  case  does  not  yield  readily  to  this  treatment  there 
is  probably  disease  at  the  roots  of  the  teeth,  and  when  loose  these  should 
be  removed,  and  the  jaw  examined  to  see  if  there  is  necrosis.  Occasion- 
ally the  ulcers  show  but  little  disposition  to  heal,  and  require  to  be 
touched  with  burnt  alum  or  nitrate  of  silver. 

The  constitutional  and  dietetic  treatment  in  all  these  cases  should 
be  the  same  as  that  employed  in  scurvy — i.  e.,  plenty  of  fruit,  fresh  vege- 
tables, and  sometimes  the  internal  administration  of  mineral  acids,  espe- 
cially aromatic  sulphuric  acid.     Iron  is  indicated  in  most  of  the  cases. 

Ulceration  of  the  Hard  Palate. — This  is  usually  seen  in  the  first  few 
weeks  of  life,  but  may  occur  in  any  child  suffering  from  marasmus.  The 
primary  cause  may  be  the  injury  inflicted  in  cleansing  the  mouth.  In 
other  cases  it  is  due  to  the  friction  of  the  rubber  nipple,  or  something 
else  which  the  child  is  allowed  to  suck.  In  still  others  it  is  apparently 
produced  by  the  habit  of  tongue-sucking  frequently  observed  in  these 
young  infants.  The  appearances  are  quite  characteristic  :  there  is  found, 
rather  far  back  upon  the  hard  palate,  usually  upon  both  sides,  a  super- 
ficial ulcer,  from  a  fourth  to  a  half  inch  in  diameter.  There  are  no  signs 
of  acute  inflammation.  Thrush  may  coexist,  but  it  has  no  relation  to  the 
production  of  the  disease.  Spontaneous  recovery  usually  occurs  in  from 
one  to  three  weeks,  provided  the  cause  can  be  removed.  In  children  suf- 
fering from  marasmus  these  ulcers  are  very  intractable,  and  in  many 
instances  their  cure  is  practically  impossible.  It  is  therefore  especially 
important  to  prevent,  if  possible,  their  formation  by  care  in  cleansing  the 
mouth,  and  in  avoiding  the  other  causes  referred  to.  When  ulcers  have 
appeared  they  should  be  treated  as  cases  of  herpetic  stomatitis. 

THRUSH, 

Synonyms:  Sprue;  German,  Soor;  French,  muguet. 

Thrush  is  a  parasitic  form  of  stomatitis  characterized  by  the  appear- 
ance upon  the  mucous  membrane,  usually  of  the  tongue  or  of  the  cheeks, 
of  small  white  flakes  or  larger  patches.  It  is  common  in  infants  of  the 
first  two  or  three  months,  and  in  all  the  protracted  exhausting  diseases  of 
early  life. 

Etiology. — The  parasite  which  produces  thrush  is  a  form  of  fungus, 
but  the  exact  class  to  which  it  belongs  has  not  yet  been  definitely  settled. 
It  is  now  known  that  it  is  not  the  o'idium  albicans,  but  that  it  belongs  to 


THRUSH. 


251 


the  group  of  the  saccharomyces,  and  the  term  saccharomyces  albicans 
has  been  given  to  it.  If  a  little  of  the  exudate  from  the  mouth  is  placed 
upon  a  slide  and  a  drop  of  liquor  potassae  added,  the  structure  of  the 
fungus  is  readily  seen.  With  the  low  power  of  the  microscope  there 
can  be  made  out  fine  threads  (the  mycelium)  and  small  oval  bodies  (the 
spores).  With  a  high  power  the  threads  can  be  seen  to  be  made  up  of  a 
number  of  shorter  rods,  at  the  ends  of  which  the  spore  formation  takes 
place  (Fig.  43).  The  mycelium  is  produced  from  the  spores.  The  spores 
of  this  fungus  are  of  very 
common  occurrence  in  the  at- 
mosphere. The  conditions  in 
the  mouth  which  favour  its 
growth  are  any  pathological 
condition  of  the  epithelium, 
particularly  a  slight  amount 
of  catarrhal  stomatitis,  a  scan- 
ty salivary  secretion  and  want 
of  cleanliness.  The  fungus 
may  grow  in  a  medium  of  any 
reaction,  but  best  in  one  which 
is  slightly  alkaline  or  neutral. 
The  nature  of  the  process 
which  it  produces  is  in  all 
probability  a  sugar  fermenta- 
tion, the  acid  reaction  of  the 
mouth  being  the  result  of  the  growth  rather  than  its  cause.  Infection 
may  come  from  another  joatient  by  means  of  a  rubber  7iipple  or  a  cloth 
which  has  been  used  for  the  infected  mouth,  from  the  nipple  of  the  nurse, 
or  directly  from  the  air.  The  disease  is  an  exceedingly  common  one  in 
foundling  asylums,  in  all  places  where  many  young  infants  are  congre- 
gated, and  where  cleanliness  of  mouths,  bottles,  etc.,  is  neglected.  It  is 
especially  frequent  in  children  suffering  from  malnutrition,  marasmus,  or 
other  wasting  diseases,  and  in  those  who  have  hare-lip,  or  any  deformity 
of  the  mouth. 

Lesions. — According  to  Forchheimer,  the  spores  lodge  between  the  epi- 
thelial cells  and  gradually  separate  the  different  layers.  This  occurs  be- 
fore the  formation  of  the  white  pellicle.  Later  the  disease  spreads  to 
the  surface  of  the  mucous  membrane,  and  also  somewhat  to  the  deeper 
layers.  It  is  stated  by  Wagner  that  it  may  invade  the  blood  vessels  and 
be  carried  to  distant  parts.  Although  the  saccharomyces  albicans  is  com- 
monly found  upon  flat  epithelium,  its  growth  is  not  confined  to  it.  It 
usually  begins  at  many  isolated  spots  upon  the  mucous  membrane,  and 
gradually  spreads  until  coalescence  takes  place ;  a  continuous  membrane 
may  be  formed.     No  pus  is  produced  by  the  process. 


Fi<    43 — 'Ihru'rih  fungus  (lu_'lil\  in  ignihid      am\ 
celium;    6,   spores;    c,   epithelial   cells    from   the 
mouth;  </,  leucocytes ;  e,  detritus.     (Jaksch.) 


252  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

The  usual  seat  is  the  tongue,  the  inside  of  the  cheeks,  and  the  hard 
palate,  but  not  infrequently  it  involves  the  lips,  the  tonsils,  the  pillars  of 
the  fauces,  and  the  pharynx.  Further  extension  than  this  is  very  rare, 
although  cases  are  on  record  in  which  thrush  has  been  found  in  the 
oesophagus,  in  the  stomach  and  intestines,  and  even  in  the  lower  respiratory 
tract.  I  have  never  seen  extension  farther  than  the  CBsophagus,  and  this 
but  once  or  twice.  I  know  of  but  one  reported  case  in  this  country 
(Northrup's)  in  which  thrush  has  been  seen  in  the  stomach.  Cases 
involving  the  oesophagus  and  the  stomach  appear  from  reports  to  be  much 
more  common  in  Europe. 

S3rmptoms. — The  essential  symptoms  of  thrush  are  the  appearance 
upon  the  mucous  membrane  of  the  month — usually  beginning  upon  the 
tongue  or  the  inner  surface  of  the  cheek — of  small  white  flakes  which 
resemble  deposits  of  coagulated  milk,  but  which  differ  from  them  in  the 
fact  tliat  they  can  not  be  wiped  off.  If  forcibly  removed,  they  usually 
leave  a  number  of  bleeding  points.  There  may  be  only  a  few  scattered 
patches,  or  the  mouth  and  pharynx  may  be  covered.  The  mouth  is  gen- 
erally dry,  the  tongue  coated ;  food  may  be  refused  on  account  of  pain, 
and  there  may  be  some  difficulty  in  swallowing.  The  other  symptoms 
depend  upon  the  conditions  with  which  the  thrush  is  associated. 

Diagnosis. — This  is  rarely  difficult.  The  deposit  may  be  mistaken  for 
coagulated  milk,  but  is  distinguished  by  the  features  just  mentioned. 
When  existing  upon  the  pharynx  and  fauces  it  has  been  confounded  with 
diphtheria,  although  this  mistake  can  hardly  be  made  if  all  the  features 
of  the  case  are  taken  into  consideration — the  age  of  the  patient,  the  in- 
volvement of  the  lips  and  tongue,  the  dry  mouth,  the  absence  of  glandular 
enlargement,  etc.  In  any  case  of  doubt  the  examination  of  the  deposit 
under  the  microscope  at  once  reveals  its  true  nature. 

Prognosis. — Thrush  is  not  in  itself  a  dangerous  disease,  except  in  the 
very  rare  instances  where  it  may  obstruct  the  oesophagus,  and  this  can 
hardly  occur  except  iu  a  condition  of  exhaustion  which  is  necessarily 
fatal.  In  a  feeble  and  delicate  infant,  thrush  may  be  a  serious  complica- 
tion by  interfering  with  the  taking  of  sufficient  nourishment.  With 
proper  treatment  most  of  the  cases  involving  only  the  mouth  are  readily 
cured. 

Treatment. — Thrush  may  be  prevented  in  almost  every  case  by  due 
attention  to  cleanliness  of  the  mouth,  rubber  nipples,  bottles,  cloths,  etc. 
All  rubber  nipples  should  be  kept  in  a  solution  of  borax  or  salicylate  of 
soda,  and  the  child's  mouth  should  be  cleansed  several  times  a  day.  On 
no  account  should  a  feeding-bottle  be  passed  from  one  child  to  another. 

In  the  treatment  of  the  disease  the  essential  things  are  cleanliness,  and 
the  use  of  some  mild  antiseptic  mouth-wash.  The  routine  treatment  which 
I  have  followed  for  many  years  both  iu  hospital  and  private  practice,  is  to 
cleanse  the  mouth  carefully  after  every  feeding  or  nursing  with  a  solution 


GONORRHO^^AL  STOMATITIS.  253 

of  borax  or  bicarbonate  of  soda,  ten  grains  to  the  ounce,  and  to  apply  four 
times  a  day  to  the  affected  mucous  membrane  a  saturated  solution  of  boric 
acid.  Both  these  applications,  however,  should  be  carefully  made,  so  as 
not  to  injure  the  epithelium.  The  best  method  is  by  the  finger  wrapped 
in  absorbent  cotton,  or  by  a  swab.  Applications  to  be  especially  avoided 
are  those  mixed  with  honey  or  any  syrup.  In  several  hospital  eases  the 
disease  seemed  to  be  prolonged  by  the  irritation  of  the  rubV)er  nipple  of 
the  feeding-bottle.  In  such  cases  it  has  been  our  practice  to  feed  by 
gavage  for  two  or  three  days,  as  all  cases  improved  much  more  rapidly 
when  this  was  done. 

GOXORRHCEAL  STOMATITIS. 

There  has  been  described'  by  Dohru  and  Rosinski  a  form  of  stomatitis 
in  the  newly  born,  due  to  a  gonorrhoea!  infection.  This  is  not  likely  to 
take  place  unless  the  epithelium  has  been  removed.  The  infection  in  all 
cases  occurred  from  the  mother.  The  lesion  consists  in  the  formation  of 
yellowish-white  patches  upon  the  tongue  or  hard  palate — regions  in  which 
the  epithelium  is  likely  to  be  injured  by  rough  attempts  at  cleansing  the 
mouth.  There  may  be  other  evidences  of  gonorrhoeal  infection,  such  as 
ophthalmia.  The  diagnosis  rests  upon  the  discovery  of  the  gonococcus  in 
the  exudate.  In  all  the  above  cases  the  general  health  was  not  affected, 
and  recovery  followed  in  the  course  of  a  week  or  ten  days. 

The  treatment  consists  in  thorough  cleanliness  and  in  the  application 
of  a  saturated  solution  of  boric  acid,  as  in  thrush. 

SYPHILITIC   STOMATITIS. 

The  buccal  svmptoms  of  hereditary  syphilis  are  important  both  from  a 
diagnostic  and  therapeutic  standpoint.  The  most  frequent  lesions  are  fis- 
sures, ulcers,  and  mucous  patches.  Fissures  are  found  upon  the  lips,  most 
frequently  at  the  angle  of  the  mouth,  and  are  usually  multiple.  They 
may  be  quite  deep  and  cause  frequent  ha?morrhages.  Mucous  patches  are 
superficial  ulcers  developing  from  papules  which  form  upon  the  mucous  or 
muco-cutaneous  surface.  In  cases  of  acquired  syphilis  in  children  the  pri- 
mary sore  may  be  seen  upon  the  tongue,  the  lip,  or  the  tonsil.  All  these 
symptoms  are  more  fully  considered  in  the  chapter  on  Syphilis. 

DIPHTHERITIC  STOMATITIS. 

In  severe  cases  of  diphtheria  the  membrane  is  found  not  only  upon  the 
pharvnx  and  tonsils,  but  it  may  appear  anywhere  upon  the  buccal  mucous 
membrane  or  the  lips.  It  is  questionable  whether  the  diphtheritic  process 
ever  begins  in  the  mucous  membrane  of  the  mouth,  or  whether  it  is  ever 
confined  to  this  part.  In  my  own  experience  diphtheritic  stomatitis  has 
always  been  associated  with  deposits  ujion  the  tonsils  and  pharynx.  It 
is  seen  only  in  the  severest  cases,  and  in  those  which,  from  other  con- 


254:  DISEASES  OP   THE   DIGESTIVE  SYSTEM. 

ditions  which  are  present,  are  almost  necessarily  fatal.  Bearing  in  mind 
the  above  points,  it  can  liardly  be  mistaken  for  any  other  variety  of  stoma- 
titis, although  not  infrequently  the  mistake  is  made  of  regarding  as  diph- 
theritic, cases  of  herj^etic  stomatitis  in  which  the  ulcers  have  coalesced. 
The  treatment,  so  far  as  the  mouth  is  concerned,  consists  in  cleanliness  by 
frequent  gargling  or  syringing  with  a  saturated  solution  of  boric  acid. 
Forcible  removal  of  the  membrane  is  not  to  be  advised. 

GANGRENOUS   STOMATITIS. 

Synonyms  :  Cancrum  oris,  noma. 

This  is  a  gangrenous  process  which  begins  usually  upon  the  gums  or 
upon  the  inside  of  the  cheek,  and  extends  with  great  rajiidity,  causing  ex- 
tensive destruction  of  the  tissues  of  the  mouth,  often  perforation  of  the 
cheek,  and  usually  terminating  fatally.  It  is  fortunately  a  rare  disease. 
Although  this  is  usually  classed  among  the  diseases  of  the  mouth,  the  same 
process  may  occur  elsewhere.  I  have  known  it  to  affect  jDrimarily  the  nose 
and  the  external  auditory  meatus.  Cases  affecting  the  female  genitals  are 
even  more  common. 

Etiology. — Gangrenous  stomatitis  is  usually  a  secondary  disease,  occur- 
ring most  frequently  as  a  complication  of  measles,  but  sometimes  with 
other  exhausting  diseases  of  infancy  and  childhood.  It  is  not  often  seen 
except  in  institutions  for  children.  Whether  or  not  there  is  a  specific  form 
of  infection  has  not  yet  been  established.  In  a  recent  case  occurring  in 
the  Babies'  Hospital  streptococci  were  found  in  pure  culture.  Strep- 
tococci chiefly  were  found  in  observations  by  Cornil  and  Babes,  and  by 
Ranke.  The  factors  necessary  for  the  production  of  the  disease  are  a  very 
low  vitality  of  the  tissues,  and  infection,  which,  with  our  present  knowl- 
edge, is  most  probably  by  streptococci  of  a  peculiarly  virulent  type. 

Gangrenous  stomatitis  often  follows  some  other  form,  usually  the 
ulcerative,  although  the  two  can  hardly  be  considered  as  the  same  disease, 
differing  only  in  severity. 

Lesions. — The  process  is  one  of  rapidly  spreading  gangrene.  In  most 
of  the  cases  there  are  thrown  out  inflammatory  products  in  quite  large 
amount,  but  there  is  little  or  no  tendency  to  limitation  of  the  disease. 
This  usually  advances  steadily  until  death  occurs.  In  a  small  number  of 
cases  a  line  of  demarcation  finally  forms,  and  the  slough  separates,  leaving 
a  large  area  to  be  partly  filled  in  by  granulation  and  cicatrization.  Other 
infectious  processes  are  likely  to  accompany  the  disease,  particularly 
broncho-pneumonia. 

Symptoms. — The  general  symptoms  are  those  of  profound  prostration 
and  sepsis.  The  constitutional  depression  may  be  great  at  the  very  be- 
ginning, or  the  children  at  first  may  be  in  fair  condition,  but  rapidly 
grow  worse  in  the  course  of    two  or  three  days.      The  temperature  is 


(JANGRENOUS  STOMATITIS. 


255 


usually  elevated  to  102"  or  103°  F.,  and  sometimes  to  104""  or  105""  F. 
There  are  dulness,  apathy,  feeble  pulse,  muscular  relaxation,  and  very 
often  diarrha}a.     Before  death  the  temjjerature  may  be  subnormal. 

Of  the  local  symptoms,  often  the  first  to  attract  attention  is  the  odour 
of  the  breath  ;  sometimes  it  is  the  dusky  spot  on  the  cheek  or  lip.  On 
examination  of  the  mouth,  there  usually  is  found  upon  the  gum  or  inside 
of  the  cheek  a  dark,  greenish-black  necrotic  mass,  surrounded  by  tissues 
which  are  swollen  and  a-dematous,  so  that  the  cheek  or  lips  may  be 
two  or  three  times  their  normal  thickness.  Externally  the  parts  are 
tense  and  brawny  from  the  swelling,  this  infiltration  always  extending  for 


^m 


Fit,.  44.— Gaugrenous  stomatitis,  follovvine  measles.     (From  a  photograph  lent  by 
Dr.  Henry  Motfat.) 


some  distance  beyond  tlie  gangrenous  part.  As  the  process  extends,  the 
teeth  loosen  and  fall  out ;  there  may  be  necrosis  of  the  alveolar  process  of 
the  jaw  and  perforation  of  one  or  both  cheeks  or  lower  lip.  Extensive 
sloughing  of  the  face  may  take  place,  usually  upon  one  side,  sometimes 
ui)on  both,  giving  the  patient  a  horrible  appearance,  as  shown  in  Fig. 
4-4.  In  this  patient  the  process  began  in  the  right  cheek,  subsequently 
involving  the  left ;  perforation  occurred  in  both  cheeks,  and  before  death 
a  large  part  of  the  face  was  gangrenous.  The  odour  from  a  severe  case 
is  very  offensive,  and,  in  spite  of  all  efforts  at  disinfection,  it  may  fill  the 
ward  or  even  the  house.  Pain  is  rarely  severe,  and  in  many  cases  it  is 
absent.  Extensive  hemorrhages  are  rare. 
18 


256  DISEASES  OP  THE   DIGESTIVE  SYSTEM. 

The  usual  duration  of  the  disease  is  from  three  to  seven  days ;  in  some 
cases  it  may  last  two  weeks.  If  recovery  takes  place,  there  is  seen  a  line 
of  demarcation ;  then  the  slough  is  thrown  off,  and  granulation  and  cica- 
trization begin,  but  require  a  long  time,  usually  leaving  an  unsightly 
deformity. 

The  prognosis  is  very  bad,  about  three  fourths  of  the  cases  proving 
fatal.  The  results  depend  not  only  upon  the  disease  itself,  but  upon  the 
condition  of  the  patient  with  which  it  is  associated. 

Gangrenous  stomatitis  can  hardly  be  mistaken  for  any  other  form  of 
disease  occurring  in  the  mouth,  and  early  recognition  is  of  great  impor- 
tance, since  only  early  treatment  is  likely  to  be  successful. 

Treatment. — Much  can  be  done  to  prevent  the  disease  by  careful 
attention  to  all  the  milder  forms  of  stomatitis,  particularly  to  the  ulcera- 
tive variety.  Frequent  and  thorough  cleansing  of  the  mouth  in  all  acute 
infectious  diseases,  is  a  part  of  the  treatment  which  is  too  frequently 
neglected.  This  should  be  a  matter  of  routine  in  every  severe  illness  in  a 
young  child.  Recognising  the  malignant  nature  of  gangrenous  stoma- 
titis, its  treatment  should  be  radical  from  the  very  outset.  Of  the  meas- 
ures which  have  been  proposed,  that  which  seems  to  offer  the  best  chance 
of  arresting  the  process  is  excision  with  cauterization.  This  should  be 
done  under  anesthesia.  In  excising,  one  should  go  some  distance  into 
tissues  apparently  healthy,  for  the  reason  that  the  process  has  always 
advanced  farther  in  the  subcutaneous  tissues  than  in  the  skin.  The  edges 
of  the  wound  should  then  be  thoroughly  cauterized,  best  by  the  Paquelin 
cautery.  Of  the  other  means  employed,  the  use  of  strong  nitric  acid  is 
probably  the  best.  This  is  to  be  used  after  excising,  or  curetting  the 
necrotic  tissue.  The  mouth  should  be  kept  as  clean  as  possible  by  the 
use  of  peroxide  of  hydrogen  or  permanganate  of  potash.  The  general 
treatment  should  be  supporting  and  stimulating.  As  the  possibility  of 
contagion  exists,  every  case  should  be  isolated. 


CHAPTER   II. 
DISEASES   OF   THE  PHARYNX. 

ACUTE   PHARYNGITIS. 

Acute  pharyngitis  may  exist  as  a  primary  disease,  or  with  any  of  the 
infectious  diseases,  particularly  scarlet  fever,  measles,  diphtheria,  and 
influenza.  Secondary  pharyngitis  will  be  considered  in  connection  with 
these  different  diseases. 

Acute  primary  pharyngitis  is  often  attributed  to  cold  and  exposure, 
but  it  is  probable  that  a  large  number  of  these  cases  will  ultimately  be 


ACUTE   PHARYNGITIS.  257 

shown  to  depend  upon  some  form  of  infection.  Certain  children  have  a 
constitutional  predisposition  to  attacks  of  pharyngitis,  and  contract  it 
upon  the  slightest  provocation.  In  some  of  them  there  is  a  strongly 
marked  rheumatic  diathesis.  Attacks  are  frequently  associated  with  dis- 
turbances of  digestion. 

In  acute  catarrhal  pharyngitis  the  inllammation  may  involve  the  en- 
tire mucous  membrane  of  the  tonsils,  fauces,  uvula,  posterior  and  lateral 
pharyngeal  walls,  or  any  part  of  it.  It  may  exist  alone,  or  in  connection 
with  a  similar  inflammation  in  the  rhino-pharynx  or  in  the  larynx.  In 
the  beginning  there  is  seen  an  acute  erythematous  blush,  usually  involv- 
ing the  entire  pharynx.  This  may  entirely  subside  after  twenty-four 
hours,  or  it  may  be  followed  by  the  usual  changes  of  acute  catarrhal  in- 
flammation— dryness,  swelling,  and  oedema.  Later  there  is  increased 
secretion  of  mucus,  and  finally  there  may  be  muco-pus.  Occasionally 
slight  hajmorrhages  are  present. 

There  is  pain  at  the  angle  of  the  jaws,  which  is  increased  by  swallow- 
ing, a  sensation  of  dryness  and  roughness  in  the  pharynx,  and  often  an 
irritating  cough.  There  may  be  slight  swelling  of  the  neighbouring 
lymphatic  glands.  The  constitutional  symptoms  in  young  children  are 
often  severe.  Not  infrequently  there  is  a  sudden  onset  with  vomiting, 
and  a  rise  of  temperature  to  103°  or  even  105°  F.  These  symptoms  are 
usually  of  short  duration,  frequently  less  than  twenty-four  hours,  and  in 
two  or  three  days  the  patient  may  be  quite  well.  In  other  cases  the 
pharyngitis  may  be  accompanied  or  followed  by  laryngitis. 

The  chief  point  in  diagnosis,  when  symptoms  like  the  above  are  seen, 
is  to  exclude  scarlet  fever  and  measles.  A  positive  diagnosis  is  impossible 
until  a  sufficient  time  has  elapsed  for  the  eruption  to  come  out.  The  pa- 
tient should  be  closely  watched  for  the  first  sign  of  its  appearance.  If  scarlet 
fever  is  prevalent,  a  child  with  the  symptoms  of  severe  pharyngitis  should 
at  once  be  isolated  while  waiting  for  the  diagnosis  to  be  settled.  There  is 
commonly  less  difficulty  in  excluding  measles,  for  in  that  disease  the  early 
redness  is  more  upon  the  hard  palate  than  upon  the  fauces,  and  usually 
consists  of  minute  red  spots  rather  than  a  uniform  blush.  There  is, 
besides,  a  history  of  a  previous  catarrh  for  two  or  three  days. 

The  first  step  in  treatment  of  acute  pharyngitis  is  to  open  the  bowels 
freely  by  means  of  calomel,  castor  oil,  or  magnesia.  The  child  should  be 
kept  in  bed,  and  the  diet  should  be  fluid,  or,  in  the  case  of  infants,  the 
amount  of  food  should  be  much  reduced.  Pieces  of  ice  may  be  swallowed 
frequently  for  the  relief  of  j)ain  and  thirst.  Internally  there  may  be  given 
two  grains  of  phenacetine  every  three  hours  to  a  child  of  three  years.  It 
is  important  at  the  outset  to  induce  free  perspiration.  The  disease  is  not 
serious,  and  the  indications  are  to  make  the  child  as  comfortable  as  pos- 
sible during  the  short  attack.  I  have  seen  but  little  benefit  from  the 
use  of  aconite,  although  for  years  I  saw  it  used  as  a  routine  treatment. 


258  DISEASES  OF   THE   DIGESTIVE  SYSTEM. 

UVULITIS. 

Acute  inflammation  of  the  uvula,  with  swelling  and  oedema,  occurs  as 
a  part  of  the  lesion  in  acute  pharyngitis.  In  rare  instances  the  uvula  may 
be  the  principal  or  only  seat  of  inflammation.  Huber  (New  York)  has 
reported  two  cases,  one  of  which  is  unique.  An  infant  ten  months  old 
was  apparently  well  until  two  hours  before  it  was  seen,  when  there  was 
noticed  a  constant  irritating  cough,  accompanied  by  considerable  gagging. 
A  little  later  there  could  be  seen  in  the  mouth  a  prominent  red  mass, 
which  was  the  enlarged  and  elongated  uvula.  It  was  accompanied  by 
paroxysms  of  cough,  which  interfered  both  with  nursing  and  deglutition. 
The  general  symptoms  were  quite  alarming,  and  the  child  was  in  con- 
siderable distress.  On  examination,  the  uvula  was  found  to  be  fully  one 
inch  long  and  half  an  inch  wide ;  it  was  red  and  oedematous ;  in  other 
respects,  however,  the  throat  was  normal.  The  symptoms  were  relieved 
by  multiple  needle  punctures  and  the  use  of  ice  externally  and  internally. 

ELONGATED  UVULA. 

Probably  this  is  primarily  a  congenital  condition.  It  is  increased  by 
repeated  attacks  of  acute  or  subacute  inflammation.  The  degree  of 
elongation  difllers  very  much  in  different  cases  ;  in  some  it  may  reach  an 
inch  in  length.  According  to  Bosworth,  only  the  mucous  membrane  is 
involved  in  the  elongation.  The  symptoms  are  those  of  local  irritation, 
especially  a  cough  upon  lying  down,  and  the  sensation  of  a  foreign  body 
in  the  pharynx.  In  some  cases  it  may  be  a  reflex  cause  of  asthma,  or, 
more  frequently,  of  catarrhal  spasm  of  the  larynx.  The  diagnosis  is  very 
easily  made  by  inspecting  the  throat.  The  treatment  consists  in  grasping 
the  tip  of  the  uvula  with  forceps  and  cutting  off  the  excess  with  the 
scissors,  or  a  uvulatome.  Core  should  be  taken  not  to  cut  off  too  much 
of  the  uvula,  or  severe  hgemorrhage  may  occur. 

RETRO-PHARYXGEAL   ABSCESS. 

Two  distinct  varieties  are  seen  :  (1)  the  so-called  idiopathic  abscesses 
which  belong  to  infancy,  and  (2)  abscesses  secondary  to  caries  of  the  cer- 
vical vertebra. 

Retro-pharyngeal  Abscess  of  Infancy. — All  of  the  later  investigations 
reo"ardiug  this  disease  go  to  show  that  primarily  it  is  not  a  cellulitis,  but  a 
suppurative  inflammation  of  the  lymph  nodes  (lymphatic  glands)  with  a 
surrounding  cellulitis.  Jules  Simon  has  described  the  retro-pharyngeal 
lymph  nodes  as  forming  a  chain  on  either  side  of  the  median  line  between 
the  pharyngeal  and  the  prevertebral  muscles.  These  nodes  are  said  to 
undergo  atrophy  after  the  third  year,  and  in  some  cases  to  disaj^pear 
entirely.     Retro-pharyngeal  abscess — or  more  properly  retro-pharyngeal 


RETRO-PIIARYNGEAL   AliSCESS.  259 

adenitis,  since  the  process  does  not  invariably  go  on  to  suppuration — is 
probably  never  primary,  but  secondary  to  infectious  catarrhs  of  the  phar- 
ynx, and  is  set  up  by  the  entrance  of  pyogenic  bacteria.  Its  pathology  is 
the  same  as  the  more  frequent  suppurative  inflammation  of  the  external 
cervical  lymph  nodes,  with  which  it  is  sometimes  associated.  Usually  only 
a  single  node  is  involved,  but  sometimes  two  or  three  are  atfected,  and 
these  may  be  situated  upon  opposite  sides.  I  have  seen  retro-pharyngeal 
adenitis  so  severe  as  to  give  rise  to  marked  local  symptoms,  although  it 
did  not  go  on  to  suppuration.  This  is  rare ;  Kormann's  observations, 
however,  show  that  swelling  of  these  glands  in  diseases  of  the  mouth  and 
throat,  is  very  much  more  common  than  is  generally  supposed.  Similar 
abscesses  from  suppurative  inflammation  of  other  lymph  nodes  in  the 
neighbourhood  of  the  pharynx  may  occur.  I  have  recently  seen  one  situ- 
ated between  the  ej^iglottis  and  the  base  of  the  tongue. 

Etiology. — These  cases  are  almost  invariably  seen  in  infancv.  Fully 
three  fourths  of  those  that  have  come  under  my  observation  have  been  in 
patients  under  one  year.  Bokai  (Buda-Pesth)  reports  that  of  sixty  cases 
observed,  forty-two  occurred  during  the  first  year,  eleven  during  the  sec- 
ond year,  and  only  seven  at  a  later  period.  The  primary  disease  is  usually 
a  severe  rhino-pharyngitis,  or  an  attack  of  epidemic  influenza,  but  rarely 
it  occurs  as  a  sequel  of  scarlet  fever  or  measles.  In  six  hundred  and  sixty- 
four  cases  of  scarlet  fever,  Bokai  noted  retro-pharyngeal  abscess  in  seven 
cases.  After  measles  it  is  even  more  rare.  Retro-pharyngeal  abscess  usu- 
ally occurs  in  winter  or  spring,  on  account  of  the  prevalence  of  the  dis- 
eases upon  which  it  depends.  It  is  seen  in  children  previously  robust,  but 
more  often  in  those  who  are  delicate  and  who  in  consequence  are  prone  to 
severe  catarrhal  affections. 

Symptoms. — The  early  symptoms  in  most  cases  are  only  those  of  an 
ordinary  rhino-pharyngeal  catarrh.  After  this  has  subsided  the  tempera- 
ture may  remain  slightly  elevated,  often  for  a  week  or  more,  before  local 
symptoms  are  noticeable.  Sometimes,  without  any  distinct  history  of  pre- 
vious catarrh,  there  are  seen  quite  high  temperature,  from  102°  to  104°  F., 
loss  of  flesh,  and  prostration.  A  careful  examination  may  be  required,  and 
sometimes  observation  for  a  day  or  two,  before  the  explanation  of  these 
constitutional  symptoms  is  discovered.  In  other  cases  the  early  consti- 
tutional symptoms  are  so  slight  as  to  escape  notice,  and  the  physician  is 
summoned  on  account  of  the  local  symptoms,  usually  the  dyspna>a,  which 
in  a  short  time  may  assume  an  alarming  character.  The  duration  of  the 
inflammatory  process  before  abscess  forms  is  generally  five  or  six  days,  but 
it  may  be  two  or  three  weeks.  The  temperature  is  invariably  elevated, 
usually  from  100°  to  103°  F. ;  occasionally  it  may  be  104°  or  105°  F.,  with 
symptoms  of  prostration  seemingly  out  of  all  proportion  to  the  local  dis- 
ease, but  which  are  to  be  explained  by  the  tender  age  and  feeble  resistance 
of  the  patient. 


260  DISEASES  OP  THE   DIGESTIVE  SYSTEM. 

The  first  local  symptom  may  be  a  sudden  attack  of  dyspnoea  severe 
enough  to  cause  asphyxia.  This  is  due  to  the  pressure  forward  of  the  ab- 
scess which  encroaches  upon  the  opening  of  the  larynx.  Usually  before 
this  occurs  the  breathing  is  noisy,  especially  during  sleep,  and  on  account 
of  the  obstruction  to  nasal  respiration  the  patient  breathes  with  the  mouth 
open.  The  mouth  may  be  dry,  or  there  may  be  a  copious  secretion  of 
pharyngeal  mucus.  The  dyspncea  is  in  most  cases  greater  on  inspiration, 
and  in  some  it  is  noticed  only  then,  expiration  being  normal.  The  dysp- 
ncea is  sometimes  increased  by  attempts  at  swallowing.  The  degree  to 
which  deglutition  is  interfered  with  depends  upon  the  size  and  the  position 
of  the  tumour.  It  is  more  difficult  when  the  tumour  is  low  down.  The 
child  may  find  it  impossible  to  swallow,  and  in  consequence  may  refuse  to 
nurse;  or  the  difficulty  in  nursing  may  depend  upon  the  nasal  obstruc- 
tion. Sometimes  there  is  regurgitation  of  food  through  the  nose  or 
mouth.  The  voice  is  usually  nasal.  There  is  not  generally  hoarseness, 
but  a  peculiar  short  cry  which  is  quite  characteristic  and  which  has  been 
compared  to  the  "  quack  "  of  a  duck.  There  may  be  complete  aphonia ; 
often  there  is  a  short,  dry  cough.  In  many  of  the  cases  a  tumour  is  to  be 
seen  externally,  just  below  the  angle  of  the  jaw  and  in  front  of  the  sterno- 
mastoid  muscle.  It  is  rarely  so  large  as  to  attract  attention.  The  head 
is  thrown  back  in  order  to  relieve  the  pressure  uj^on  the  larynx,  and  is  held 
somewhat  rigidly.  In  one  or  two  cases  I  have  noticed  torticollis  as  an 
early  symptom. 

A  positive  diagnosis  is  made  by  an  examination  of  the  throat.  On  in- 
spection there  is  seen  a  distinct  bulging  of  the  lateral  wall  of  the  pharynx, 
usually  a  little  above  the  base  of  the  tongue.  The  swelling  may  be  so 
great  as  to  crowd  the  uvula  to  one  side  and  nearly  fill  the  pharynx.  It  is 
rarely  if  ever  in  the  median  line.  There  is  usually  redness  of  the  mucous 
membrane  and  oedema  of  the  uvula  and  of  the  adjacent  parts.  On  digital 
examination  the  swelling  is  made  out  even  better  than  by  inspection.  If 
it  is  lower  down  it  may  not  be  visible  at  all.  In  the  early  stage  there  may 
be  felt  only  a  localized  induration  or  a  somewhat  diffuse  swelling,  but  by 
the  time  the  swelling  is  large  enough  to  produce  marked  symptoms,  fluc- 
tuation can  generally  be  discovered. 

Prognosis. — When  left  to  itself  the  abscess  usually  opens  into  the  phar- 
ynx, the  pus  being  swallowed  or  expectorated.  The  cavity  closes  rapidly 
by  granulation,  and  the  patient  in  a  few  days  is  entirely  well.  It  is  rare 
for  much  burrowing  to  occur.  In  young  or  very  delicate  infants  the  con- 
stitutional symptoms  may  be  so  severe  that  the  child  continues  to  fail 
even  after  the  evacuation  of  the  abscess,  and,  gradually  sinking,  dies  usu- 
ally from  broncho-pneumonia.  In  other  children  a  fatal  result  is  gen- 
erally due  to  the  fact  that  the  disease  is  not  recognised. 

Death  before  rupture  may  occur  from  asphyxia  due  to  pressure  upon 
the  larynx  or  oedema  of  the  larynx,  or  to  rupture  of  the  abscess  into  the 


RETRO-rriARYNGEAL   ABSCESS.  261 

air  passages,  especially  if  this  occurs  during  sleep.  Carmichael,  Bokai, 
and  others  have  reported  deaths  from  ulceration  into  the  carotid  artery  or 
one  of  its  large  branches.  Carmichael's  patient  was  only  five  weeks  old. 
The  general  mortality  of  the  disease  is  about  five  per  cent ;  most  of  the 
deaths  are  owing  to  a  failure  to  make  the  diagnosis.  Gautier  has  col- 
lected ninety-five  cases,  wdth  forty-one  deaths.  In  my  own  experience  a 
fatal  termination  has  been  very  rare ;  but  alarming  symptoms  have  often 
been  present. 

Diagnosis. — Ketro-pharyngeal  abscess  is  to  be  suspected  if  there  is  dif- 
ficulty in  swallowing  associated  with  dyspnoea  or  mouth-breathing.  A 
positive  diagnosis  is  possible  only  by  a  digital  examination  of  the  pharynx. 
The  mistake  most  often  made  in  diagnosis  has  been,  that  the  physician, 
called  to  a  young  child  suflfering  from  great  dyspnoea,  has  jumped  to  the 
diagnosis  of  laryngeal  stenosis,  and  forthwith  performed  tracheotomy  or 
intubation,  without  taking  the  trouble  to  get  the  history  or  to  make  a 
careful  examination  of  the  pharynx.  Many  such  cases  are  reported  in 
which  the  child  has  died  during  the  operation  or  immediately  afterward, 
the  autopsy  first  revealing  the  nature  of  the  disease.  If  the  possibility  of 
this  mistake  is  kept  in  mind,  the  error  can  hardly  be  made.  A  sudden 
attack  of  dyspnoea  with  difficulty  in  swallowing  may  also  be  due  to  the 
impaction  of  a  foreign  body  in  the  pharynx  ;  but  a  digital  examination  in 
this  case  will  enable  one  to  make  a  correct  diagnosis. 

Treatment. — Before  the  abscess  has  pointed,  hot  applications  should  be 
made  to  the  throat  to  relieve  the  symptoms  and  to  hasten  the  formation 
of  pus,  since  resolution  is  so  rare  as  not  to  be  expected.  Spontaneous 
opening  should  never  be  waited  for,  on  account  of  the  danger  of  the  rapid 
development  of  serious  symptoms  from  pressure  or  cedema,  or  of  suffoca- 
tion from  an  opening  into  the  air  passages,  especially  during  sleep. 

As  soon  as  the  diagnosis  is  made  the  case  should  be  carefully  watched, 
and  as  soon  as  well-marked  fluctuation  is  detected,  the  pus  should  be  evac- 
uated. External  incision  has  few  if  any  advantages  and  very  obvious  ob- 
jections. In  opening  through  the  mouth  the  patient  should  be  seated  in 
an  upright  position  and  the  head  firmly  held.  A  gag  should  not  be  intro- 
duced, but  a  tongue  depressor  may  be  nsed,and  a  bistoury  which  has  been 
guarded  to  its  point  plunged  into  the  abscess  at  its  thinnest  point  and  the 
incision  made  toward  the  median  line.  The  head  should  then  be  bent  for- 
ward, to  allow  the  pus  to  escape  through  the  mouth.  It  is  well  to  insert 
the  finger  into  the  cavity  and  break  down  any  septa ;  for  after  a  simple 
puncture  the  abscess  may  refill.  Incision,  although  usually  easy,  in  some 
cases  may  be  quite  difficult  on  account  of  the  swelling  and  the  small 
pharynx  of  the  infant.  For  the  past  few  years  I  have  adopted  the  plan 
of  opening  these  abscesses  with  the  finger  nail,  a  procedure  simple,  effi- 
cient, and  free  from  danger.  "While  the  patient  is  held  as  above  described, 
the  wall  of  the  abscess  is  perforated  by  the  nail  of  the  forefinger,  which 


262  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

has  been  sharpened  to  a  cutting  pohit.  I  have  yet  to  see  a  case  in  which 
this  was  at  all  difficult.  The  amount  of  pus  evacuated  is  from  one 
drachm  to  half  an  ounce.  In  the  majority  of  cases  no  after-treatment  is 
required.  The  relief  of  the  dyspnroa  and  dyspliagia  is  immediate,  and  re- 
covery rapid. 

An  instructive  accident,  which  came  near  being  fatal,  occurred  in  a  case 
at  the  New  York  Infant  Asylum.  An  infant  seven  months  old  had  shown 
for  twenty-four  hours  steKtorous  breathing,  difficulty  in  swallowing,  and 
had  refused  to  nurse.  Examination  showed  the  presence  of  quite  a  large 
abscess  in  the  right  pharyngeal  region.  A  gag  was  introduced  by  the 
house  surgeon  preparatory  to  the  evacuation  of  the  abscess  by  incision, 
when  the  child  became  asphyxiated,  and  respiration  ceased  although  the 
gag  was  immediately  removed.  Intubation  was  performed,  but  with  a 
good  deal  of  difficulty  on  account  of  the  displacement  of  the  larynx, 
and  artificial  respiration  was  required  for  several  minutes  before  the 
patient  was  resuscitated.  The  abscess  was  incised  half  an  hour  later 
without  the  introduction  of  a  gag,  and  the  intubation  tube  removed. 
The  attack  of  asphyxia  was  evidently  produced  by  the  stretching  of  the 
mouth  by  the  gag,  and  the  increased  pressure  thereby  jDroduced  upon  the 
larynx. 

Retro-pharyngeal  Abscess  from  Pott's  Disease. — This  form  is  rare  in 
comparison  with  that  just  described,  and  under  three  years  of  age  it  is 
extremely  so.  These  abscesses  are  usually  larger,  and  the  amount  of  pus 
contained  may  be  from  four  to  eight  ounces.  They  form  very  much  more 
slowly,  often  lasting  for  months,  and,  like  other  secondary  abscesses,  the 
constitutional  symptoms  are  seldom  severe.  The  swelling  is  frequently 
in  the  median  line,  and  is  not  so  circumscribed  as  in  the  idiopathic  cases. 
The  pus  often  burrows  along  the  spine  for  several  inches. 

The  symptoms  of  Pott's  disease  of  the  cervical  region  are  usually  pres- 
ent for  several  months  before  the  appearance  of  the  abscess.  Sometimes 
the  abscess  precedes  the  deformity,  and  it  may  be  the  first  intimation  of 
the  existence  of  bone  disease.  The  local  symptoms  resemble  those  of  the 
idiopathic  cases,  but  they  develop  more  slowly,  and  sudden  attacks  of 
fatal  asphyxia  are  very  rare.  External  swelling  is  usually  seen,  and  it 
may  be  quite  large,  extending  almost  from  one  ear  to  the  other,  forming  a 
distinct  collar.  On  digital  exploration  there  may  be  found  an  irregularity 
of  the  anterior  surfaces  of  the  cervical  vertebrae,  and  occasionally  a  marked 
angular  prominence. 

When  left  to  themselves  these  abscesses  may  open  externally  in  front 
of  the  sterno-mastoid  muscle,  just  below  the  jaw,  sometimes  nearly  as  low 
as  the  clavicle  ;  they  may  rupture  internally  into  the  pharynx,  the  oesopha- 
gus, or  the  air  passages ;  or  they  may  burrow  a  long  distance  in  front  of  the 
spine.  Death  may  result  from  pressure  upon  the  larynx,  or  from  rupture 
into  the  larynx,  trachea,  or  pleura ;  all  these,  however,  are  rare.     The 


ADENOID   VEGETATIONS.  263 

abscesses  not  infrequently  refill  after  they  are  evacuated,  and  occasionally 
a  discharging  sinus  is  left  for  many  months. 

Treatment. — These  abscesses  should  be  opened  as  soon  as  they  are 
large  enough  to  give  rise  to  local  symptoms.  The  external  incision  just 
in  front  of  the  sterno-mastoid  muscle  is  generally  to  be  preferred  to 
opening  through  the  mouth,  since  it  gives  better  drainage,  and  the  after- 
treatment  is  more  easily  carried  on ;  and  a  sinus  opening  externally  is  less 
objectionable  than  one  opening  into  tlie  pharynx. 

ADENOID  VEGETATIONS  OF  THE  VAULT  OF  THE  PHARYNX. 

This  is  a  very  common  and,  by  the  general  practitioner,  a  much  neg- 
lected condition.  It  is  the  source  of  more  discomfort  and  the  origin  of 
more  minor  ailments  than  almost  any  other  pathological  condition  of 
childhood. 

There  is  a  mass  of  lymphoid  tissue  situated  at  the  vault  of  the  pharvnx 
which  in  structure  closely  resembles  the  tonsils.  It  is  often  spoken  of  as 
the  "  pharyngeal  tonsil."  Like  the  faucial  tonsils,  and  under  similar  con- 
ditions, this  may  become  greatly  hypertrophied,  so  as  to  form  a  tumour, 
which  may  be  so  large  as  to  fill  the  rhiiio-pharynx  completel}'.  These 
tumours  have  a  broad  base,  and  are  attached  sometimes  more  to  the  roof, 
and  sometimes  more  to  the  posterior  wall  of  the  pharynx.  The  term 
udeiioid  vegetations  was  given  to  them  by  Meyer,  who  first  described 
them  in  1868.  These  growths  may  be  soft,  vascular,  and  spongy,  or  hard, 
firm,  and  fibrous.  The  first  variety  is  that  usually  seen  in  infancy,  and 
the  second  more  often  in  older  children.  In  a  very  considerable  propor- 
tion of  the  cases  there  is  associated  hypertrophy  of  the  tonsils.  As  a  re- 
sult of  the  growth  there  is  sometimes  present  a  very  high  palatine  arch 
amounting  almost  to  deformity. 

Etiology. — That  condition  spoken  of  in  another  chapter  as  the  lym- 
phatic diathesis,  or  "  lymphatism,"  is  the  one  upon  which  these  growths 
most  frequently  depend.  Often  every  member  of  a  large  family  of  chil- 
dren is  affected,  and  frequently  both  parents  also.  This  may  occur 
when  there  are  no  other  evidences  of  disease  except  this  tendency.  Deli- 
cate and  rachitic  children  are,  however,  more  prone  than  others  to  this 
affection.  It  is  most  common  in  damp,- changeable  climates.  The  first 
symptoms  usually  follow  an  attack  of  influenza,  measles,  scarlet  fever, 
diphtheria,  or  repeated  attacks  of  ordinary  coryza.  They  generally  begin 
to  be  troublesome  when  children  are  about  two  years  old ;  there  are 
many  cases,  however,  in  which  it  seems  pretty  clear  that  the  condition  is 
a  congenital  one.  Many  observers  hold  this  view  regarding  most  of  the 
cases. 

Symptoms. — The  symptoms  of  adenoid  growths  are  those  which  relate 
to  the- chronic  rhino-pharyngeal  catarrh  and  to  the  mechanical  obstruc- 
tion.     In  infants  and  very  young  children  the  catarrhal  symptoms  are 


264  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

apt  to  predominate;  in  older  children,  the  obstructive  symptoms.  The 
chronic  catarrh  shows  itself  by  a  persistent  nasal  discharge,  which  is  of  a 
sero-mncous  or  muco-purulent  character,  very  rarely  tinged  with  blood. 
This  may  be  continuous,  with  exacerbations  which  occur  with  every  fresh 
cold  and  with  every  period  of  damp  weather,  or  there  may  be  intervals  in 
which  the  symptoms  are  absent.  In  dry  weather  and  in  summer  the  dis- 
charge usually  ceases  entirely,  coming  on  again  when  the  damp  Weather 
of  autumn  and  winter  returns.  This  is  the  condition  which  underlies  the 
repeated  severe  head-colds  from  which  so  many  children  suffer  every  cold 
season.  The  symptoms  of  obstruction  are  mouth-breathing,  nasal  voice, 
and  difficulty  in  blowing  the  nose,  sometimes  total  inability  to  do  so.  The 
mouth-breathing  may  be  constant,  or  it  may  be  noticed  only  during  sleep, 
being  accompanied  by  loud,  stertorous  respiration.  The  difficulty  in 
breathing  is  increased  when  the  child  lies  upon  the  back.  In  consequence 
of  this,  children  sleep  in  all  sorts  of  positions — lying  upon  the  face,  some- 
times upon  the  hands  and  knees,  and  often  toss  restlessly  about  the  crib 
in  the  vain  endeavour  to  find  some  position  in  which  respiration  is  easy. 
Such  symptoms  should  always  arouse  suspicion  of  a  lymphoid  growth  in 
the  pharynx.  In  a  case  under  recent  observation  the  attacks  of  dyspnoea 
at  night  amounted  almost  to  complete  asphyxia.  The  child  would  rise 
upon  the  hands  and  knees  and  struggle  violently  for  breath,  often  without 
waking;  sometimes  respiration  would  cease  for  several  seconds,  and  lie 
would  awake  exhausted  and  covered  with  perspiration.  The  mucus  and 
saliva  were  drawn  back  and  forth  until  the  lips  and  mouth  were  covered 
with  a  white  foam.  During  the  day  the  symptoms  of  obstruction  may 
scarcely  be  noticed.  The  continued  inability  to  blow  the  nose,  if  asso- 
ciated with  nasal  discharge,  should  always  be  regarded  as  a  suspicious 
symptom.     In  several  cases  this  has  been  the  first  symptom  noticed. 

Two  other  symptoms  are  common  in  very  young  children — frequent 
attacks  of  otitis  and  persistent  hoarseness  or  huskiness  of  voice  which 
may  lead  to  the  suspicion  that  the  larynx  is  the  seat  of  the  disease. 

In  older  children  and  in  neglected  cases  the  symptoms  are  often  more 
marked.  The  patients  are  mouth-breathers,  both  by  day  and  night.  The 
expression  of  the  face  is  dull,  stupid,  often  semi-idiotic  (Fig.  46).  Sleep 
is  never  deep,  and  is  always  accompanied  with  stertorous  respiration  and 
constant  tossing  from  side  to  side.  The  voice  is  thick,  nasal,  and 
"  wooden."  ^  In  severe  cases  nervous  symptoms  of  quite  a  serious  character 
may  be  present.  The  children  are  languid,  listless,  sometimes  depressed 
and  prone  to  melancholy,  suffering  from  frequent  headaches  and  from 
attacks  of  indisposition,  and  often  passing  for  very  stupid  children. 

The  hearing  is  impaired  in  a  very  large  number  of  the  cases.  Blake 
(Boston)  found  this  true  of  thirty-nine  out  of  forty-seven  cases  examined, 
and  in  thirty-five  of  these  marked  improvement  in  hearing  followed 
operation  upon  the  growths.     Deafness  may  be  due  to  mechanical  causes, 


ADENOID  VEGETATIONS.  265 

or  to  otitis.  Where  the  condition  has  existed  from  infancy  there  is  often 
marked  deformity  of  the  chest.  There  may  be  simply  a  marked  pigeon- 
breast  and  prominent  sternum  with  deep  hiteral  depressions  (Fig.  45),  or 
there  may  be  a  deep  depression  over  the  lower  portion  of  the  sternum. 
Deformities  are  most  marked  in  rachitic  patients.  Tiiese  growths  often 
produce  anicmia  and  general  malnutrition  owing  to  the  constant  interfer- 
ence with  sleep  and  obstruction  to  respiration,  and  they  may  be  a  reflex 
cause  of  many  neuroses,  such  as  chorea,  incontinence  of  urine,  asthma, 
catarrhal  spasm  of  the  larynx,  and  sometimes  even  epileptiform  seizures. 


,«*(^^- 


Fio.  45. — Fitreon-breast  due  to  udeiioids  of  tlii.'  pharynx. 

These  patients  are  always  better  in  summer  and  worse  in  winter. 
The  natural  course  of  the  growths  if  left  to  themselves  is  to  increase  up 
to  a  certain  point  and  then  to  remain  stationary  until  puberty.  After 
this  time  they  usually  undergo  atrophy,  and  the  small  ones  may  disap- 
pear entirely.  In  the  more  severe  cases  the  symptoms  persist,  aggravated 
from  time  to  time  during  attacks  of  acute  catarrh.  A  removal  to  an  ele- 
vated region  with  a  dry  atmosph.ere  will  often  result  in  a  disappearance  of 
all  the  symptoms,  and  the  growth  may  cease  to  increase  in  size,  but  unless 
such  a  change  in  residence  is  permanent  the  symptoms  are  liable  to  re- 


266  DISEASES  OP   THE   DIGESTIVE   SYSTEM. 

turn.  Under  ordinary  circumstances  there  is  little  or  no  tendency  to 
spontaneous  recovery.  Patients  with  adenoid  growths  contract  diphtheria 
more  easily  than  do  others,  and  in  them  attacks  of  diphtheria,  scarlet 
fever,  measles,  and  whooping-cough  are  all  likely  to  be  more  severe. 

Diagnosis. — In  a  well-marked  case  the  condition  is  usually  evident  from 
the  history,  and  can  scarcely  be  overlooked.  The  intractable  nasal  ca- 
tarrh, upon  which  no  treatment,  local  or  general,  has  more  than  a  tem- 
porary influence,  the  mouth-breathing,  the  disturbed  sleep,  and  the  slight 
deafness — all  are  characteristic.  In  some  even  of  the  marked  cases  atten- 
tion may  be  drawn  to  the  larynx  or  to  the  ears  as  the  seat  of  disease.  At 
other  times  the  patients  come  for  treatment  on  account  of  the  general 
symptoms — the  nervous  depression,  the  headaches,  or  the  anaemia.  In 
rare  cases  the  leading  symptom  may  be  epistaxis.  The  symptoms  do  not 
always  depend  upon  the  size  of  the  growth,  for  in  a  small  cavity  quite  a 
small  growth  may  cause  very  marked  symptoms. 

Although  the  history  is  in  most  cases  clear,  only  an  examination  can 
make  us  certain  that  a  lymphoid  growth  exists.  The  best  method  of  ex- 
amination consists  in  a  digital  exploration  of  the  pharynx ;  but  this 
requires  a  little  practice  before  it  is  very  satisfactory.  The  head  is  stead- 
ied by  the  right  hand,  and  the  left  forefinger  is  passed  up  behind  the  pal- 
ate. The  growth  is  ordinarily  felt  as  an  irregular,  soft,  velvety  mass,  and 
the  finger,  when  withdrawn,  is  almost  invariably  covered  with  blood.  The 
physician  must  make  his  diagnosis  by  the  first  examination,  as  the  child 
will  allow  no  repetition.  By  anterior  rhinoscopy,  after  the  use  of  cocaine, 
the  growth  can  usually  be  seen  distinctly. 

Treatment. — Absorption  by  internal  medication  is  possible  in  but  few 
cases.  Bosworth  reports  the  best  results  from  the  syrujD  of  the  iodide  of 
iron,  which  must  be  given  in  doses  of  from  ten  to  fifteen  drops  three  times 
a  day  for  a  long  period.  This  should  be  combined  with  cold  sponging 
and  general  precai^tions  to  prevent  a  recurrence  of  colds,  and,  if  possible, 
the  child  should  pass  the  winter  in  a  warm,  dry  climate.  These  measures 
may  succeed  when  the  growths  are  small,  and  where  the  symptoms  are 
more  catarrhal  than  obstructive.  In  larger  growths  and  in  cases  of  longer 
standing,  only  temporary  improvement  is  likely  to  follow  such  treatment. 
An  attempt  to  reduce  by  local  application,  growths  of  any  considerable 
size,  is  a  waste  of  time  and  not  to  be  recommended.  My  experience  has 
been  that,  in  spite  of  prolonged  local  treatment,  every  marked  case  has 
ultimately  required  operation. 

Operation  during  the  spring  or  summer  is  generally  preferable,  but 
may  be  performed  at  any  time  except  during  attacks  of  acute  catarrh. 
Some  very  expert  operators  prefer  to  do  without  an  anaesthetic,  and  no 
doubt  there  are  a  few  of  large  experience  who  can  operate  satisfactorily  in 
most  of  the  cases  without  ansesthesia.  Except  for  very  young  children 
complete  anaesthesia  is  to  be  preferred,  and  by  chloroform  rather  than 


ADENOID    VEGETATIONS   OF   THE    PHARYNX. 


267 


ether.  An  exception  should  be  made  of  cases  where  the  growths  are  small, 
soft,  and  very  spongy.  These  may  sometimes  be  rubbed  off  with  the 
pulp  of  the  finger  or  scraped  away  by  the  finger  nail,  without  giving  the 
patient  or  friends  any  idea  that  an  operation  has  been  done  ;  and  this  can 
frequently  be  accomplished  under  the  plea  of  simply  making  a  digital 
examination. 

The  instruments  required  are  Lowenberg's  cutting  forceps,  Gott- 
stein's  curette,  and  a  mouth-gag  like  that  used  for  intubation.  After  full 
anaesthesia  is  reached,  the  gag  is  introduced  and  the  soft  palate  drawn  for- 
ward by  a  blunt  hook  of  hard  rubber,  or,  better,  by  the  forefinger  of  the 
left  hand,  which  at  the  same  time  acts  as  a  guide  to  the  introduction  of 
the  forceps.     These  are  introduced  closed  and  passed  up  along  the  poste- 


Before  operation.  Three  inontlis  at'tfr  operation. 

Figs.  46  and  47. — Adenoid  vegetations  of  the  pharynx;  girl  twelve  years  old.     (Hooper.) 

rior  pharyngeal  wall,  and  the  mass  seized  and  torn  away  piecemeal.  The 
first  bite  of  the  forceps  will  often  bring  away  the  greater  part  of  the 
growth  when  it  is  of  small  size  ;  if  large,  eight  or  ten  repetitions  may  be 
necessary.  After  the  greater  part  has  been  removed  by  the  forceps  the 
curette  is  introduced  and  the  pharyngeal  vault  scraped  clean.  In  a  large 
number  of  the  cases  with  growths  of  small  or  moderate  size,  the  entire 
mass  may  be  removed  by  one,  or  at  most  two,  applications  of  the  curette, 
without  previously  using  the  forceps.  This  has  the  advantage  that  it  can 
be  done  much  more  quickly.  In  most  cases  the  entire  operation  does  not 
consume  more  than  two  or  three  minutes.  The  child  is  turned  upon  his 
face,  in  order  that  the  blood,  which  flows  freely,  may  escape  from  the 
mouth  and  nose.  Tiie  head  should  be  kept  low  during  the  operation,  to 
prevent  the  blood  from  entering  the  larynx.  Hooper  and  some  other 
writers  prefer  to  operate  with  the  patient  in  the  sitting  posture.  Each 
position  has  its  advantages. 


268  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

The  dangers  of  operation  are  practically  none.  Excessive  hemorrhage 
is  extremely  rare,  although  there  are  two  or  three  recorded  cases  in  which 
serious  and  even  fatal  htemorrhage  occurred.  Attacks  of  acute  tonsillitis 
or  otitis  occasionally  develop  after  operation.  No  after-treatment  is 
necessary.  The  patient  remains  in  bed  during  the  day  of  operation,  and 
in  the  house  for  three  or  four  days,  or  longer  if  the  weather  is  unpleasant. 
No  local  applications  are  required.  It  is  probably  not  necessary  that 
every  particle  of  the  growth  should  be  removed,  since  if  the  major  part  is 
taken  away,  what  remains  generally  undergoes  rapid  atroj^hy.  A  recur- 
rence of  the  growths  is  very  rare. 

The  improvement  after  the  operation  is  in  proportion  to  the  severity 
of  the  previous  symptoms.  The  respiration  is  freer;  the  sleep  becomes 
quiet ;  the  mouth  is  soon  habitually  closed ;  the  voice  improves ;  and  the 
benefit  to  the  general  health  is  in  a  short  time  apparent.  The  whole  ap- 
pearance of  the  child  is  often  transformed  in  a  few  months  (Figs.  46  and 
47). 


CHAPTER   III. 
DISEASES   OF   THE   TONSILS. 

The  tonsils*  are  lymphoid  structures  closely  resembling  Peyer's 
patches,  but,  instead  of  having  a  flattened  surface,  the  lymphoid  tissue  in 
the  tonsil  is  folded  upon  itself,  forming  quite  deejj  de^Dressions — the  ton- 
sillar crypts.  These  crypts,  like  the  surface  of  the  tonsils,  are  lined  by 
epithelial  cells.  They  contain  lymphoid  cells,  desquamated  epitheliam, 
particles  of  food,  and  bacteria.  Under  normal  conditions  the  tonsils 
take  no  part  in  absorption  from  the  mouth.  When,  however,  their  epi- 
thelium is  rarefied  or  removed,  the  tonsils  absorb  with  very  great  facility 
every  sort  of  poison  which  the  mouth  may  contain.  Such  poisons  are 
taken  up  by  the  lymphatics,  and  through  them  reach  the  general  circu- 
lation. 

Acute  inflammation  of  the  tonsils,  like  that  of  the  pharynx,  occurs 
regularly  in  diphtheria,  scarlet  fever,  and  measles,  less  frequently  in  the 
other  infectious  diseases.  The  secondary  forms  will  be  considered  with 
the  diseases  with  which  they  are  associated. 

Acute  catarrhal  tonsillitis,  or  inflammation  of  the  mucous  membrane 
covering  the  tonsils,  occurs  as  a  primary  disease  as  a  part  of  the  lesion  in 
acute  pharyngitis,  but  very  rarely  is  seen  alone.  Occasionally  the  whole 
mucous  membrane  covering  the   tonsils  is  inflamed  and  fibrin  may  be 

*  For  a  critical  study  of  the  anatomy  and  physiology  of  the  tonsil,  see  paper  by 
Hodenpyl,  American  Journal  of  the  Medical  Sciences,  March,  1891. 


FOLLICULAR  TONSILLITIS.  269 

poured  out  iu  sufficient  quantity  to  form  a  distinct  pseudo-membrane. 
These  cases,  formerly  classed  as  "  croupous  tonsillitis,"  will  be  considered 
elsewhere  under  the  head  of  Pseudo-diphtheria. 

FOLLICULAR   TONSILLITIS. 

This  is  the  most  frequent  and  most  characteristic  form  of  inflamma- 
tion of  the  tonsil.  It  is  essentially  an  inflammation  of  the  tonsillar 
crypts,  and  secondarily  of  the  whole  glandular  structure. 

Etiology. — There  is  seen  in  certain  children  a  predisposition  to  attacks 
of  tonsillitis,  so  that  from  very  slight  exciting  causes  these  occur,  some- 
times traceable  to  exposure,  sometimes  to  derangement  of  the  stomach, 
and  sometimes  without  any  evident  reason.  Children  with  a  rheumatic 
inheritance  appear  to  be  more  susceptible  than  others.  One  attack  pre- 
disj)oses  to  a  second.  Patients  suffering  from  chronic  hypertrophy  of  the 
tonsils  are  exceedingly  prone  to  acute  tonsillitis.  It  is  not  very  common 
in  infancy,  but  after  this  period  it  is  very  frequent  throughout  childhood. 
The  disease,  in  all  probability,  begins  as  an  infectious  inflammation  at  the 
bottom  of  the  crypts,  due  to  the  presence  of  streptococci  or  staphylococci, 
which  readily  enter  from  the  mouth,  and  excite  an  attack  whenever  favour- 
able conditions  are  present. 

Lesions. — As  a  result  of  the  inflammation,  the  tonsillar  crypts  are 
filled  with  epithelial  cells,  pus  cells,  mucus,  and  bacteria.  These  form 
masses  which  appear  at  the  mouth  of  the  crypts  as  small  yellow  dots, 
often  miscalled  ulcers.  Sometimes,  in  addition,  fibrin  is  poured  out,  and 
forms,  with  the  other  inflammatory  products,  little  plugs  which  project 
somewhat  from  the  surface  of  the  mucous  membrane,  and  which  can 
easily  be  pressed  out.  Accompanying  the  changes  in  the  mucous  mem- 
brane above  mentioned,  there  are  acute  congestion  and  swelling  of  the 
whole  tonsil,  with  more  or  less  proliferation  of  the  lymphoid  tissue.  Fol- 
licular tonsillitis  is  always  bilateral.  Although  the  pathological  process  is 
generally  limited  to  the  tonsils,  there  may  be  more  or  less  pharyngitis 
associated. 

Symptoms. — The  general  symptoms  usually  appear  before  the  local 
ones,  and  are  often  quite  severe.  The  onset  is  abrupt,  with  chilly  sensa- 
tions, occasionally  a  distinct  rigour.  In  infants  there  is  often  vomiting, 
and  sometimes  diarrhcea.  There  is  pain  in  the  back,  in  the  muscles  of 
the  extremities,  and  in  the  head.  Sometimes  there  is  ])ain  in  the  lateral 
cervical  muscles.  The  temperature  rises  rapidly  to  10"2°  or  1U3°  F. ;  often 
it  touches  104°  or  105°  F. 

The  first  local  symptoms  are  some  swelling  of  the  tonsils  and  the  ap- 
pearance of  isolated  yellow  spots  a  little  larger  than  a  pin's  head.  Often 
these  can  be  wiped  off  with  a  swab,  or  the  little  plugs  can  be  squeezed 
out,  leaving  a  slight  depression.  Later  there  is  acute  congestion  of  the 
tonsil,  with  more  swelling.     Even  when  the  disease  is  at  its  height  the 


270  DISEASES  OP   THE   DIGESTIVE   SYSTEM. 

local  pain  and  discomfort  are  only  moderate,  and  in  many  cases  scarcely 
noticeable.  The  swelling  and  tenderness  of  the  lymph  glands  behind  the 
angle  of  the  jaw  are  not  great,  and  may  be  absent. 

The  constitutional  symptoms,  as  a  rule,  last  three  days,  and  are  most 
severe  upon  the  first  day.  The  local  symptoms  last  somewhat  longer,  but 
usually  by  the  end  of  the  fourth  day  the  exudate  has  disappeared,  although 
enlargement  of  the  tonsil  may  persist  for  a  week  or  even  longer. 

Diagnosis. — Tonsillitis  may  be  confounded  at  its  onset  with  scarlet 
fever.  We  must  wait  for  the  rash  before  deciding  positively.  Its  consti- 
tutional symptoms  in  the  beginning  closely  resemble  an  attack  of  malaria, 
influenza,  or  pneumonia.  The  great  frequency  of  tonsillitis  makes  inspec- 
tion of  the  throat  imperative  in  every  case  of  acute  illness  in  children. 
The  diagnosis  from  diphtheria  is  considered  in  connection  with  that 
disease. 

Treatment. — Follicular  tonsillitis  is  a  mild  disease  without  danger  to 
life,  and  one  which  runs  a  short,  self-limited  course.  The  indications  are, 
therefore,  to  make  the  patient  as  comfortable  as  possible  by  the  relief  of 
individual  symptoms.  Older  children,  particularly  those  who  are  rheu- 
matic, should  be  treated  with  salol ;  four  grains  every  three  hours  being 
given  for  the  first  twenty-four  hours,  and  later  smaller  doses.  In  infants 
this  drug  is  somewhat  difficult  of  administration  on  account  of  its  tend- 
ency to  upset  the  stomach,  and  had  better  be  omitted.  The  general 
aching  pains  of  the  first  day  are  best  relieved  by  phenacetine,  two  grains 
every  four  hours  to  a  child  three  years  old.  Later  it  may  be  used  in 
smaller  doses,  but  enough  should  be  given  to  make  the  patient  com- 
fortable. 

Local  treatment  is  not  absolutely  necessary,  and  in  infants  may  be 
omitted.  Older  children  may  use  a  gargle  of  boric  acid  or  a  weak  bichlo- 
ride solution — i.  e.,  1  to  10,000.  In  all  doubtful  cases  the  patient  should 
be  isolated,  and  the  same  treatment  adopted  as  in  a  case  of  diphtheria, 
until  all  doubt  is  removed. 

PHLEGMONOUS   TONSILLITIS— PERITONSILLAR  ABSCESS— QUINSY. 

This  is  an  inflammation  of  the  cellular  tissue  surrounding  the  tonsil, 
sometimes  invading  the  tonsil  itself.  It  may  terminate  in  resolution,  but 
usually  goes  on  to  the  formation  of  an  abscess.  Phlegmonous  tonsillitis  is 
much  less  common  in  children  than  in  adults,  and,  compared  with  the 
other  forms,  it  is  a  rare  disease  in  early  life.  It  is  the  only  variety  which 
is  regularly  unilateral.  In  most  cases  the  inflammatory  process  is  circum- 
scribed, but  in  rare  instances  there  is  seen  a  diffuse  phlegmonous  inflam- 
mation of  the  pharynx. 

In  certain  patients  there  exists  a  constitutional  predisposition  to  the 
disease,  which  is  often  associated  with  rheumatism.  The  exciting  causes 
may  be  exposure,  or  anything  which  may  reduce  the  patient's  general 


PHLEGMONOUS  TONSILLITIS. 


271 


health,  to  which  there  is  added  local  infection.  Catarrhal  pharyngitis 
predisposes  to  this  disease. 

Symptoms.— The  onset  resembles  that  of  follicular  tonsillitis,  except 
that  the  general  symptoms  are  usually  less  marked,  the  temperature  is 
commonly  not  so  high,  and  the  aching  pains  and  prostration  less  severe. 
The  local  symptoms,  however,  are  more  marked.  There  is  very  severe 
pain  in  the  throat,  which  is  increased  by  deglutition,  and  finally  may  be 
so  great  that  swallowing  is  almost  impossible.  It  is  difficult  to  open  the 
mouth.  There  is  pain  in  the  lateral  muscles  of  the  neck,  and  often  ten- 
derness. In  the  beginning  but  little  can  be  seen  on  inspection,  even 
though  the  patient  complains  of  a  very  sore  throat.  This  is  always  a 
suspicious  circumstance,  and  should  lead  one  to  look  out  for  quinsy.  It  is 
due  to  the  fact  that  the  inflammation  begins  in  the  deeper  tissues,  and  that 
the  mucous  membrane  is  affected  later.  After  twenty-four  or  forty-eight 
hours  there  is  usually  quite  marked  swelling,  which  is  rather  more  behind 
the  tonsil  than  elsewhere,  pushing  it  upward  and  forward  ;  sometimes 
it  is  more  in  front  of  the  tonsil.  A  little  later  there  is  intense  inflamma- 
tion of  the  mucous  membrane  covering  the  tonsil,  fauces,  and  uvula,  with 
marked  congestion  and  oedema ;  the  uvula  may  be  pushed  to  one  side,  and 
the  isthmus  of  the  fauces  diminished  to  less  than  one  half  its  natural  size. 
In  one  of  my  own  cases  marked  torticollis  was  present,  and  existed  for 
two  or  three  days  before  the  diagnosis  of  quinsy  could  be  made  by  the 
other  symptoms. 

In  most  cases  the  recognition  of  quinsy  is  quite  easy  by  attention  to  the 
symptoms  above  mentioned.  By  inspection  of  the  throat,  less  information 
is  sometimes  obtained  than  by  palpation  ;  by  this  means  a  fulness,  and 
later  a  point  of  fluctuation,  can  readily  be  made  out.  Acute  phlegmonous 
tonsillitis  generally  involves  no  danger  to  life.  In  very  young  infants 
serious  results  may  follow  spontaneous  rupture  during  sleep ;  and  in 
older  children  occasionally  there  may  be  oedema  of  the  glottis.  If  not 
treated,  abscess  usually  forms  in  from  five  to  seven  days,  and  opens  spon- 
taneously. 

Treatment. — If  an  early  diagnosis  is  made  an  attack  of  quinsy  may 
occasionally  be  aborted.  For  this  many  drugs  have  been  advocated,  but 
to  my  mind  the  best  is  salol,  which  should  be  given  in  doses  of  two 
grains  every  two  hours  to  a  child  of  five  years.  In  some  patients  larger 
doses  may  be  used.  This  may  be  combined  with  small  doses  (gr.  ^)  of 
Dover's  powder.  Eelief  may  be  afforded  by  very  hot  or  cold  applications, 
according  to  the  sensations  of  the  patient.  The  holding  of  ice  in  the 
mouth  and  the  application  of  an  ice-bag  externally,  often  give  great  com- 
fort. In  other  cases,  gargling  with  very  hot  water  and  the  application  of 
hot  flaxseed  poultices  externally,  will  be  preferred.  As  soon  as  fluctuation 
is  detected  an  incision  should  be  made  with  a  guarded  bistoury.  If  made 
too  early,  only  a  small  amount  of  pus  is  evacuated  and  the  abscess  may 
19 


272  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

refill.     After  spontaneous  rupture  the  relief  to  symptoms  is  usually  im- 
mediate. 

CHRONIC  HYPERTROPHY  OF  THE  TONSILS.— CHRONIC   TONSILLITIS. 

The  condition  known  as  chronic  hypertrophy,  is  a  permanent  enlarge- 
ment due  to  a  proliferation  of  the  lymphoid  tissue  of  the  tonsils,  and  an 
increase  in  the  connective-tissue  stroma.  If  the  increase  in  the  connective 
tissue  is  slight,  the  tonsil  is  soft ;  if  it  is  great,  the  tonsil  is  firm  and  hard, 
almost  like  a  fibrous  tumour.  All  degrees  are  found.  Associated  with 
hypertrophy  of  the  tonsils  there  are  frequently  found  adenoid  growths  of 
the  pharynx,  both  of  these  depending  upon  similar  local  and  constitu- 
tional conditions.  There  is  in  nearly  all  marked  cases  a  chronic  pharyn- 
geal catarrh  which  may  involve  the  Eustachian  tubes. 

Etiology. — Hypertrophy  of  the  tonsils  is  an  exceedingly  common  con- 
dition in  the  cities  of  the  seacoast  and  lake  districts  of  the  temperate 
zone.  In  a  routine  examination  of  2,000  New  York  school  children, 
Chappell  found  enlargement  of  the  tonsils  sufficiently  marked  to  be  con- 
sidered pathological,  in  270  cases.  The  causes  are  constitutional  and  local. 
The  constitutional  causes  relate  to  the  conditions  described  in  the  chapter 
upon  Lymphatism.  This  is  often  found  in  certain  families  for  several 
generations.  The  condition  is  not  connected  with  tuberculosis.  It  oc- 
curs in  children  who  are  in  other  respects  healthy.  Hyjiertrophy  of  the 
tonsils  is  often  a  congenital  condition,  increasing  slowly  during  infancy, 
so  as  to  produce  marked  symptoms  by  the  time  the  child  is  two  years  old. 
The  most  important  of  the  local  causes  are  attacks  of  acute  or  subacute 
pharyngitis.  While  it  is  true  that  attacks  of  acute  inflammation  are  often 
the  cause  of  hypertrophy,  it  is  also  true  that  hypertrophy  is  one  of  the 
most  frequent  predisposing  causes  of  acute  attacks,  and  that  it  may  be 
seen  in  children  who  have  never  had  tonsillitis. 

Symptoms. — Hypertrophy  of  the  tonsils  is  rarely  marked  enough  to 
cause  any  decided  symptoms  before  the  end  of  the  second  year,  although 
I  once  saw  in  a  younger  child  enlargement  sufficient  to  bring  the  two  ton- 
sils into  contact.  The  most  important  local  symptoms,  formerly  ascribed 
to  hypertrophied  tonsils,  are  now  known  to  depend  upon  adenoid  growths 
of  the  pharynx.  As  these  conditions  are  so  frequently  associated,  it  is 
somewhat  difficult  to  determine  which  symptoms  are  due  to  tlie  tonsils 
alone.  In  a  marked  case,  the  most  prominent  symptoms  are  mouth- 
breathing,  disturbed  sleep  accompanied  by  snoring,  and  nasal  voice — the 
patient  in  some  cases  talking  as  tliough  he  had  food  in  his  mouth.  There 
may  be  some  difficulty  in  swallowing  solid  food.  Enlarged  tonsils  may 
often  be  felt  externally.  As  a  consequence  of  the  obstruction  of  the 
Eustachian  tubes  there  may  be  deafness.  Deformities  of  the  chest,  such 
as  pigeon-breast,  are  occasionally  seen,  but  probably  depend  more  upon 
obstructed  respiration  by  adenoids  than  by  the  tonsils. 


CHRONIC   HYPERTROPHY  OF  THE   TONSILS.  273 

The  soft  tonsils  may  diminish  somewhat  in  size  spontaneously.  They 
sometimes  shrink  very  decidedly  after  an  attack  of  acute  tonsillitis,  scarlet 
fever,  or  diphtheria.  As  a  rule  the  tonsils  become  firmer  and  harder 
as  time  pusses.  They  usually  increase  in  size  up  to  a  certain  point, 
and  then  remain  nearly  stationary  until  about  puberty,  when  they  may 
diminish  considerably.  During  intercurrent  attacks  of  inflammation,  the 
swelling  is  much  increased  and  the  symptoms  are  proportionately  aggra- 
vated. In  cases  of  marked  enlargement  very  little  spontaneous  improve- 
ment is  to  be  looked  for  during  childhood. 

Treatment. — Very  large  tonsils  are  a  source  of  continued  danger  to  the 
patient,  and  in  every  case  of  marked  hypertrophy  treatment  should  be 
advised.  The  danger  may  be  from  Eustachian  catarrh  and  deafness,  or 
from  repeated  attacks  of  acute  tonsillitis.  But  quite  as  important  as 
these  is  the  fact  that  they  increase  the  liability  to  contract  diphtheria,  and 
add  to  the  dangers  both  of  diphtheria  and  scarlet  fever.  If  the  patient  is 
removed  from  the  locality  in  which  acute  tonsillitis  is  likely  to  occur,  to  a 
high,  dry  climate,  considerable  improvement  is  likely  to  result  in  a  voung 
child  in  whom  the  tonsils  are  soft,  but  not  much  is  to  be  expected  in 
older  children  with  hard,  fibrous  tonsils,  except,  perhaps  a  cure  of  the 
accompanying  pharyngeal  catarrh. 

The  only  internal  remedy  offering  much  chance  of  benefit  is,  in  my 
experience,  the  syrup  of  the  iodide  of  iron,  which  must  be  given  in  quite 
large  doses  (twenty  drops  three  times  a  day  to  a  child  of  five  years),  and 
continued  for  several  months.  In  a  small  number  of  cases  marked  im- 
provement is  seen  from  this  treatment,  but  in  the  majority  but  little 
change  occurs.  Astringent  applications  may  accomplish  something  in 
recent,  but  practically  nothing  in  old  cases.  In  a  marked  case,  operation 
is  the  only  thing  which  can  be  relied  upon  to  effect  a  cure.  In  those  in 
which  it  is  decided  not  to  operate,  or  in  which  operation  is  refused,  a 
faithful  trial  may  be  made  with  the  other  measures  referred  to.  The 
question  to  be  decided  always  is  whether  or  not  operation  shall  be  done. 
For  convenience  of  consideration,  the  cases  may  be  divided  into  three 
groups:  (1)  those  in  which  the  tonsils  are  nearly  or  quite  in  contact ;(2) 
those  in  which  tliey  project  not  more  tlian  one  fourth  of  an  inch  beyond 
the  faucial  pillars;  (3)  the  intermediate  cases.  All  of  the  first  group 
should  unquestionably  be  operated  upon,  unless  the  patient's  general  con- 
dition is  such  as  to  forbid  operation  of  any  kind.  Of  the  second  group, 
few  if  any  require  operation.  Whether  an  operation  is  done  in  the  third 
group  will  depend  upon  the  individual  case.  If  there  are  frequent  attacks 
of  acute  tonsillitis,  and  some  deafness,  an  operation  should  be  performed. 
If  little  or  no  local  discomfort  is  experienced  it  may  be  postponed. 

Of  the  various  operations  proposed,  excision  with  the  guillotine  is  the 
one  which  has  in  children  superseded  all  others  in  the  practice  of  New 
York  physicians.     The  risk  of  haemorrhage  at  this   age  is  very  slight. 


274  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

The  child  is  held  as  for  the  operation  of  intubation,  except  that  the  head 
is  thrown  backward.  No  after-treatment  is  required,  excepting  fluid  diet 
and  confinement  to  the  house  for  two  or  three  days.  Excessive  haemor- 
rhage may  be  controlled  by  digital  pressure,  or  by  the  application  of 
styptic  cotton  upon  a  swab ;  in  extreme  eases,  by  transfixing  the  tonsil 
stump  with  a  hare-lip  pin  and  the  aj^plication  of  a  ligature.  I  have  more 
than  once  seen  physicians  greatly  alarmed  at  the  gray  wound  on  the  day 
following  tonsillotomy,  the  appearance  being  such  as  to  lead  in  several 
cases  to  the  diagnosis  of  diphtheria.  This  mistake  will  not  be  made  if 
the  possibility  of  it  is  borne  in  mind.  It  is  seldom  that  any  but  good 
results  follow  the  operation  of  tonsillotomy  if  properly  performed.  It  is 
too  often  neglected.  Where  adenoids  of  the  pharynx  are  also  present,  the 
symptoms  may  depend  more  upon  them  than  upon  the  enlarged  tonsils, 
and  little  benefit  is  seen  until  the  adenoid  growths  also  are  removed. 
Both  may  be  operated  upon  at  a  single  sitting,  or  at  two  sittings  if  pre- 
ferred. 

It  is  not  usually  necessary  to  remove  the  tonsil  to  a  point  even  with  the 
faucial  pillars,  but  the  more  nearly  we  can  come  to  this  the  better.  The 
amount  of  shrinkage  from  cicatrization  after  operation  has  been,  in  my 
experience,  generally  less  than  was  expected.  As  a  rule,  enlargement 
of  the  tonsil  subsequent  to  an  operation  is  not  seen  ;  but  one  should  be 
careful  about  promising  parents  that  it  will  not  occur.  I  have  seen  it  in 
two  or  three  instances  to  a  striking  degree,  and  think  it  more  likely  to 
occur  if  children  operated  on  are  very  youngj— i.  e.,  before  the  third  year. 


CHAPTER   IV. 
DISEASES  OF  THE  (ESOPHAGUS. 

MALFORMATIONS. 

Congenital  anomalies  of  the  oesophagus  are  much  less  frequent  than 
those  of  the  lower  part  of  the  respiratory  tract,  with  which,  however,  they 
are  often  associated. 

There  may  be,  (1)  Congenital  fistula  of  the  neck,  due  to  a  want  of 
closure  between  the  second  and  third  branchial  arches.  This  gives  an 
external  opening  just  above  and  to  the  outside  of  the  sterno-clavicular 
articulation,  which  communicates  wdth  the  upper  part  of  the  oesophagus 
or  the  lower  part  of  the  pharynx.  (2)  The  oesophagus  may  be  absent, 
the  pharynx  ending  in  a  blind  pouch.  (3)  The  oesophagus  may  be  oblit- 
erated in  certain  portions,  being  represented  only  by  a  fibrous  cord.  (4) 
There  may  be  stenosis  and  dilatation  or  diverticula.     (5)  There  may  be  a 


ACUTE  (ESOPHAGITIS.  275 

fistulous  communication  with  the  trachea,  existing  either  alone  or  asso- 
ciated with  some  of  the  other  deformities  mentioned. 

Congenital  narrowing  of  the  a'sophagus  and  fistula  of  the  neck  are 
amenable  to  surgical  treatment.  The  cases  of  complete  obstruction  in  the 
oesophagus  are  almost  of  necessity  fatal,  the  patients  dying  from  inanition 
two  or  three  days  after  birth. 

The  symptoms  of  oesophageal  obstruction  are  regurgitation  on  attempts 
at  swallowing  and  the  impossibility  of  passing  the  stomach  tube. 

ACUTE  (ESOPHAGITIS. 

It  is  quite  remarkable,  considering  the  frequency  of  pathological  pro- 
cesses in  the  ^iharyux,  that  these  so  rarely  extend  to  the  oesophagus. 
Thrush,  when  very  extensive  in  the  pharynx,  may  involve  the  upper  part 
of  the  oesophagus  ;  but  there  it  gives  rise  to  new  symptoms.  Diphtheria 
and  pseudo-diphtheria  of  the  pharynx  may  invade  the  oesonhagus,  but 
this  is  seen  only  in  very  rare  instances.  In  about  seventy-five  autopsies 
which  I  have  seen  in  cases  of  diphtheria,  the  oesophagus  was  involved  in 
but  one,  and  in  this  case  for  three  or  four  inches  only.  Diphtheria  of 
the  oesophagus  produces  no  symptoms,  and  can  not  be  diagnosticated  dur- 
ing life. 

Catarrhal  (Esophagitis  is  very  rarely  met  with.  It  may  be  caused  by 
lacerations  due  to  swallowing  a  foreign  body,  which  may  excite  a  simple 
catarrhal  inflammation,  or,  if  the  foreign  body  is  sharp  and  angular, 
lacerations  may  be  produced  which  result  in  ulcerations  of  variable  depth. 
The  chief  symptoms  of  catarrhal  oesophagitis  are  soreness  and  pain  on 
swallowing.  These  lacerations,  when  slight,  are  healed  in  a  few  days,  and 
are  rarely  followed  by  any  after-effects. 

Corrosive  GEsophagitis. — This  is  altogether  the  most  frequent  form, 
and  the  only  one  wliich  is  of  clinical  importance.  The  usual  causes  are 
the  same  ^  of  corrosive  gastritis,  viz.,  the  swallowing  of  caustic  alkalies  or 
strong  acids.  It  is  often  in  the  oesophagus  that  the  most  extensive  injury 
is  done.  The  effects  are  superficial  or  deep,  according  to  the  amount 
of  the  irritant  swallowed  and  its  degree  of  concentration.  There  may 
be  simply  a  destruction  of  the  epithelial  layer,  which  is  followed  by  no 
serious  consequences,  or  the  mucous  membrane  may  be  destroyed  and  the 
submucous  coat  invaded ;  rarely,  however,  does  the  injury  extend  to  the 
muscular  layer.  If  the  patient  survives  the  dangers  incident  to  the 
irritant  poisoning  and  the  acute  inflammation  which  follows,  healing  by 
granulation  and  cicatrization  takes  place,  the  contraction  of  the  cicatrix 
gradually  narrowing  the  lumen  of  the  oesophagus  until  stricture  is  pro- 
duced. 

The  early  symptoms  of  corrosive  oesophagitis  are  mingled  with  those 
of  inflammation  of  the  mouth,  pharynx,  and  stomach.  There  is  a  burn- 
ing pain  in  the  parts,  great  thirst,  spasm  of  the  oesophagus  on  attempts  at 


276  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

swallowing,  so  that  deglutition  may  be  almost  impossible.  There  follows 
a  period  of  acute  inflammation  of  several  days'  duration,  in  which  the 
chief  local  symptoms  are  dysphagia  and  pain,  and  in  which  the  prin- 
cipal danger  is  that  of  suffocation  from  oedema  of  the  glottis.  After  this 
period  has  passed,  the  patient  may  be  comparatively  well  until  the  symp- 
toms of  stricture  begin,  usually  in  from  three  to  six  months  after  the 
injury. 

The  indications  for  treatment  in  the  early  stage,  are  to  neutralize  the 
caustic  in  order  to  prevent  if  possible  its  deep  action,  and  in  all  cases  to 
give  oils,  demulcent  drinks,  and  ice  for  the  local  effect,  and  morphine  for 
the  pain. 

The  treatment  of  oesophageal  stricture  is  jnirely  surgical,  and  for  this 
the  reader  is  referred  to  surgical  text-books. 

RETRO-CESOPHAGEAL  ABSCESS. 

Retro-oesophageal  abscess  may  result  from  the  breaking  down  of 
tuberculous  lymph  nodes  in  the  posterior  mediastinum,  and  may  give  rise 
to  symptoms  like  those  which  result  from  an  abscess  due  to  Pott's  disease, 
from  which  it  can  not  be  diagnosticated.  Retro-oesophageal  abscess  or 
peri- oesophagitis  may  occur  in  children  after  measles,  scarlet  fever,  influ- 
enza, or  with  syphilis.  Here  its  pathology  is  the  same  as  retro-pharyngeal 
abscess,  differing  only  in  location.  Retro-oesophageal  adenitis,  or  enlarge- 
ment of  the  lymph  nodes  in  the  posterior  wall  of  the  oesophagus,  not 
going  on  to  suppuration,  is  a  rare  condition.  I  have  recently  met  with  a 
case  in  which  a  tumour  nearly  an  inch  in  diameter  was  formed  at  the 
upper  part  of  the  oesophagus,  and  which  caused  pressure  symptoms,  neces- 
sitating tracheotomy.  The  growth  was  at  first  believed  to  be  of  a  malig- 
nant character,  but  it  completely  disappeared  after  four  or  five  months  of 
general  treatment,  including  a  summer  in  the  country. 

Perforation  of  the  oesophagus,  and  a  food-fistula  connecting  the  oeso- 
phagus and  the  trachea,  may  result  from  ulceration  caused  by  a  tracheal 
canula  or  by  a  foreign  body.     This  may  be  accompanied  by  abscess. 

The  most  common  variety  of  retro-oesophageal  abscess  is  that  due  to 
Pott's  disease  of  the  lower  cervical  or  upper  dorsal  region.  The  symptoms 
are  obscure,  and  an  exact  diagnosis  is  not  often  made  during  life.  Death 
may  occur  quite  suddenly  where  the  previous  symptoms  have  been  so 
slight  as  to  be  easily  overlooked.  The  following  is  a  fair  example  of  such 
a  case  : 

A  little  girl  two  years  old,  of  a  tuberculous  family,  was  admitted  to  the 
Babies'  Hospital  in  December,  1892,  with  spinal  caries  of  the  upper 
dorsal  region.  The.  symptoms  were  of  two  months'  duration,  and  already 
there  was  a  spinal  deformity  consisting  of  a  small  knuckle.  The  patient 
was  kept  in  bed  and  a  plaster-of-Paris  jacket  applied.  A  slight  febrile 
action  of  irregular  type  was  present.     About  a  month  after  admission 


RETRO-CESOPHAGEAL  ABSCESS.  277 

dyspnoea  was  first  observed  ;  this  was  at  times  qnite  intense,  and  again 
almost  absent.  It  was  always  on  inspiration,  expiration  being  easy.  No 
explanation  for  this  was  found  in  the  lungs.  There  was  no  difficulty  in 
swallowing,  and  very  little  cough.  After  these  symptoms  had  lasted  for 
about  a  week,  the  child  while  eating  was  suddenly  seized  with  violent 
dyspn(]ea,  and  in  a  few  moments  became  completely  asphyxiated.  Trache- 
otomy was  immediately  done,  and  by  means  of  artificial  respiration  the 
patient  was  restored  to  comparative  comfort.  About  two  hours  later  a 
second  attack  occurred,  and  the  patient  died  in  an  hour.  At  the  autopsy 
there  was  found  an  abscess  a  little  larger  than  a  hen's  egg,  containing 
about  two  ounces  of  curdy  pus,  overlying  the  bodies  of  the  first  three 
dorsal  vertebrae  and  communicating  with  them.  These  vertebrae  were 
carious.  The  right  pueumogastric  nerve,  an  inch  and  a  half  above  the 
bifurcation  of  the  trachea,  was  compressed  between  the  abscess  and  a 
large  tuberculous  lymph  node,  with  the  capsule  of  which  it  was  blended. 
In  the  lungs  were  a  few  small  tuberculous  deposits  and  the  usual  condi- 
tions found  in  death  by  asphyxia.  The  dyspnoea  seems  to  have  been  of 
nervous  and  not  of  mechanical  origin,  and  caused  by  irritation  of  the 
pueumogastric.  The  fatal  issue  was  apparently  from  an  increase  of  the 
pressure  upon  the  nerve. 

A  case  almost  identical  with  this  has  been  reported  by  Chapin,  and 
others  quite  similar  by  Eipley,  Eichards,  and  Jarisch.  In  none  of  these 
was  diflficulty  in  swallowing  present,  probably  because  the  oesophagus  was 
compressed  only  upon  one  side.  In  all  there  were  symptoms  of  irritation 
of  the  pueumogastric,  or  the  recurrent  laryngeal  branch — stridulous  breath- 
ing, inspiratory  dyspnoea,  and  spasmodic  cough,  with  or  without  slight 
hoarseness.  In  one  case  only  was  there  aphonia.  After  such  symptoms  as 
these  have  existed  for  a  few  days  or  weeks  there  usually  comes  a  sudden 
attack  of  asphyxia.  The  first  attack  may  be  fatal,  or  there  may  be  several 
of  a  milder  character  before  the  fatal  one.  In  two  cases  this  followed 
a  full  meal,  probably  from  the  increase  of  pressure  due  to  distention  of 
the  stomach.  In  two  cases  tracheotomy  was  done,  but  gave  temporary 
relief  only. 

The  diagnosis  of  this  condition  is  very  difficult,  and  a  positive  diag- 
nosis almost  impossible.  It  may  be  suspected  in  cases  of  Pott's  disease  of 
the  lower  cervical  or  upper  dorsal  regions,  when  there  is  spasmodic  inspi- 
ratory dyspnoea,  especially  if  accompanied  by  irritative  cough.  It  should, 
however,  be  remembered  that  precisely  similar  symptoms  may  depend 
upon  the  irritation  of  a  tuberculous  node,  and  that  the  sudden  asphyxia  is 
exactly  like  that  caused  by  the  ulceration  of  such  a  node  into  the  trachea 
or  a  large  bronchus.  The  latter,  however,  may  occur  without  the  pres- 
ence of  Pott's  disease.  If  the  abscess  is  higher  up,  there  may  be  a  lateral 
swelling  on  either  side  of  the  neck,  just  above  the  clavicle.  In  most  of 
the  cases  there  are  no  external  signs  of  disease.     Such  abscesses  are  too 


278  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

low  to  be  reached  by  digital  examination  of  the  pharynx.  The  attack 
of  asphyxia  may  also  be  confounded  with  that  due  to  the  presence  of  a 
foreign  body  in  the  larynx. 

The  prognosis  in  cases  of  retro-oesophageal  abscess  is  exceedingly  bad. 
Death  usually  results  from  pressure  upon  the  pneumogastric,  as  in  the 
cases  reported.  The  abscess  may  rupture  into  the  oesophagus  and  recov- 
ery follow.  This  termination  is  very  rare,  but  such  a  case  has  been  re- 
ported by  Knight.  A  fatal  one  is  reported  by  Loschner  and  Lambl.  The 
abscess  may  burrow  along  the  oesophagus  into  the  abdominal  cavity  and 
excite  peritonitis ;  finally,  it  may  open  externally. 

But  little  is  to  be  said  under  the  head  of  Treatment.  The  symptoms 
are  rarely  definite  enough  to  justify  a  radical  surgical  operation.  Trache- 
otomy gives  but  temporary  relief  to  the  asphyxia.  This  operation  should 
be  performed,  however,  in  every  case,  because  of  the  impossibility  of 
making  an  exact  diagnosis  of  retro-oesophageal  abscess  from  other  condi- 
tions in  which  the  operation  might  be  curative. 


CHAPTER   V. 

DISEASES  OF   THE  STOMACH. 

It  is  difficult,  wholly  to  separate  diseases  of  the  stomach  from  those  of 
the  intestines.  Although  in  older  children  they  are  often  quite  distinct, 
in  infancy  they  are  more  frequently  associated  ;  but  at  one  time  the  gastric 
symptoms  may  be  prominent,  and  at  another  the  intestinal  symptoms. 
Functional  disorders  particularly,  are  likely  to  involve  the  whole  tract. 
Serious  organic  lesions  are  more  frequently  limited  in  their  extent  either 
to  the  stomach  or  to  the  intestine.  The  former  are  rare,  while  the  latter 
are  very  common.  The  diseases  in  which  the  stomach  is  alone  or  chiefly 
involved  will  be  considered  by  themselves.  Those  in  which  both  the 
stomach  and  intestine  are  involved  are  classed  with  the  intestinal  diseases, 
as  the  intestinal  symptoms  usually  predominate. 

DIGESTION   IN  INFANCY. 

The  first  step  in  the  process  of  digestion  in  the  newly-born  infant  is 
sucking.  During  this  act  the  nipple  is  grasped  between  the  lower  lip  and 
tongue  below,  and  the  upper  lip  and  jaw  above.  The  back  of  the  mouth 
is  closed  by  the  fall  of  the  palate.  A  strong  downward  movement  of  the 
lower  jaw  rarefies  the  air  in  the  mouth,  and  produces  the  suction  force 
which  causes  the  milk  to  flow.  Sacking  can  be  carried  on  only  when  the 
nose  is  free  for  respiration  and  the  palate  and  upper  jaw  intact.  Children 
with  deformities  of  the  mouth,  like  cleft  palate  and  harelip,  suck  only 


PLATE  VII 


E  Different  Periods  of  Infancy. 
;e,  from  photographs. 


DIGESTION   IN"  INFANCY. 


279 


with  the   greatest    difficulty,  and    complete    nasal    obstruction   prevents 
nursing. 

The  Saliva. — This  is  present  at  birth  only  in  very  small  quantity,  and 
the  part  which  it  plays  in  digestion  in  early  infancy  is  an  insignifi- 
cant one.  During  the  third  and  fourth  months  it  increases  markedly  in 
amount,  and  at  this  time  it  possesses  quite  actively  the  power  of  trans- 
forming starch  into  sugar.  This  property  is  present  only  to  a  very  slight 
degree  during  the  first  eight  or  ten  weeks.  "With  the  advent  of  the  teeth 
there  is  a  further  increase  in  the  amount  of  saliva  secreted,  indicating  a 
change  in  the  digestion  of  the  infant. 

The  Stomach. — The  position  of  the  stomach  in  the  foetus  is  nearly 
vertical.  In  the  newly-born  child  it  lies  obliquely  in  the  abdomen,  and 
at  the  end  of  infancy  has  almost  reached  the  transverse  position.  The 
stomach  at  birth  is  nearly  cylindrical,  but  the  fundus  increases  quite 
rapidly  during  the  first  year,  although  it  does  not  reach  its  full  develop- 
ment until  quite  late  in  childhood.  In  Plate  VII  are  shown  the  actual 
size  and  shape  of  the  stomach  at  the  various  periods  of  infancy.  In  the 
following  table  are  given  the  results  of  post-mortem  measurements  of  the 
stomach,  which  I  have  personally  made  in  ninety-one  infants  under  four- 
teen months  of  age  : 

The  Capacity  of  the  Stomach. 


Age. 

Number 
of  cases. 

Average 
capacity. 

Age. 

Ntiniber 
of  cases. 

Average 
capacity. 

Birth 

5 

7 
4 
11 
4 
2 

1-20OZ. 
1-50  " 
2-00  " 
2-27  " 
3-37  " 
4-25  " 

12  weeks 

14  to  18  weeks... 
i  5  to  6  months. . . 

7  to  8        "      ... 

10  to  11  "  ... 
1  12  to  14     "      ... 

6 
12 

14 
9 

7 
10 

4-50  ozv 

2  weeks 

5-00    " 

4      "     

5-75    " 

6      "     

6-88   " 

8      "     

8-14   " 

10    "     

8-90    " 

In  brief,  the  average  capacity  was,  at  birth,  one  and  one  fifth  ounce ; 
at  three  months,  four  and  a  half  ounces;  at  six  months,  six  ounces;  at 
twelve  months,  nine  ounces. 

Gastric  digestion. — The  part  taken  by  the  stomach  in  digestion  is 
smaller  than  was  formerly  supposed,  and  not  so  important  in  infants  as  in 
adults.  The  food  leaves  the  stomach  so  rapidly  that  a  large  part  of  the 
casein  must  pass  into  the  intestine  before  it  is  converted  into  peptones. 
The  opinion  has  been  steadily  gaining  ground  that  the  function  of  the 
stomach  is  largely  that  of  a  reservoir,  into  which  the  milk  is  received  and 
from  which  it  is  allowed  to  pass  gradually  into  the  intestine ;  and  that  the 
gastric  process  is  only  a  preliminary  and  partial  one,  even  in  the  digestion 
of  proteids,  this  being  completed  in  the  intestine. 

The  only  part  of  the  food  acted  on  in  the  stomach  is  the  proteids, 
which  are  transformed  successively  into  acid-albumin,  albumoses,  and 
peptones.     This  is  accomplished  by  the  agency  of  the  pepsin  and  the  acid 


280  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

of  the  gastric  juice — generally  hydrochloric  acid,  although  lactic  acid  may 
take  its  jDlace.  Pepsin  is  found  in  the  stomach  at  birth,  and  even  in 
the  embryo  as  early  as  the  fourth  month  (Kriiger).  The  reaction  of  the 
stomach  in  fasting  is  acid,  and  at  this  time  usually  free  hydrochloric  acid 
can  be  demonstrated.  Soon  after  a  meal  of  human  milk  it  is  alkaline  or 
neutral;  after  one  of  cow's  milk  it  is  acid  or  neutral.  In  fifteen  minutes 
after  feeding  the  reaction  is  always  acid  (Leo).  Free  hydrochloric  acid 
can  not  usually  be  demonstrated  until  about  an  hour  after  feeding,  then 
only  in  small  quantities,  and  in  very  many  cases  not  at  all.  Some  good 
observers  go  so  far  as  to  say  that  in  health  free  acid  is  never  found  during 
digestion.  The  reason  for  this  apparently  is,  that  the  acid  combines  with 
the  casein  of  the  milk,  that  of  cow's  milk  in  particular  having  a  very 
great  power  of  combining  with  hydrochloric  acid. 

Lactic  acid  is  feebler  in  its  digestive  power  than  hydrochloric  acid. 
It  is  more  abundant  early  in  infancy  than  later,  and  its  source  is  the  milk 
sugar.  It  is  rarely  found  as  free  acid  ;  never  in  health,  according  to  many 
observers. 

The  coagulation  of  milk  in  the  stomach  is  accomplished  through  the 
agency  of  the  rennet  ferment  (the  lab-ferment  of  Hammarsten).  -This  is 
independent  of  both  the  pepsin  and  the  acid  of  the  stomach.  It  acts  in 
acid,  alkaline,  and  neutral  media.  Coagulation  is  the  first  change  in  the 
milk  in  the  stomach.  Human  milk  coagulates  in  loose  flocculi  and  quite 
imperfectly,  more  firmly  if  the  stomach  is  very  acid.  Cow's  milk,  unless 
diluted,  coagulates  in  firm,  compact  masses.  Under  the  influence  of  pepsin 
and  hydrochloric  acid,  solution  of  this  coagulum  now  begins  ;  but  this  is 
only  partially  accomplished  in  the  stomach.  It  goes  forward  much  more 
rapidly  in  the  case  of  human  milk,  because  the  amount  of  casein  is  less 
and  because  of  the  smaller  curds.  The  milk  begins  to  leave  the  stomach 
very  soon  after  the  meal,  and  even  during  the  first  half  hour  a  consider- 
able part  passes  into  the  intestine.  At  the  end  of  an  hour  the  stomach 
in  a  young  infant  is  often  empty.  In  the  case  of  cow's  milk,  not  only 
are  the  coagula  firmer,  but  the  amount  of  casein  present  is  much  larger, 
and  hence  the  milk  is  detained  in  the  stomach  a  longer  time ;  even 
then  a  considerable  portion  of  it  must  pass  but  little  changed  into  the 
intestine. 

The  duration  of  gastric  digestion  varies  with  the  age  of  the  infant 
and  with  the  food.  During  the  first  month  the  stomach  of  healthy 
nursing  infants  is  usually  found  empty  in  an  hour  and  a  half  after  feed- 
ing; often  after  one  hour.  In  those  taking  cow's  milk  the  average  is 
at  least  half  an  hour  longer.  In  infants  from  two  to  eight  months  old 
the  average  is  two  hours  for  those  receiving  breast  milk,  and  two  and  a 
half  to  three  hours  for  those  fed  upon  cow's  milk.  This  is  influenced  by 
the  size  of  the  meal  taken.  This  period  is  very  much  longer  in  all  cases 
of  disordered  digestion. 


DIGESTION   IN  INFANCY. 


281 


The  bacteria  of  the  stomach  are  very  few  as  compared  with  the  intes- 
tine, and  no  varieties  are  constantly  present  (Booker). 

The  Intestines. — The  length  of  the  small  intestine  at  birth  is  about 
nine  feet ;  tliat  of  the  large  intestine  about  eighteen  inches.  The  great 
length  of  the  sigmoid  flexure  is  the  most  striking  peculiarity,  this  beino- 
nearly  one  half  the  length  of  the  large  intestine.     (See  page  G4). 

Intestinal  digestion. — All  the  important  elements  of  food — proteids, 
carbohydrates,  and  fats — are  acted  upon  by  the  pancreatic  Juice.  The 
proteids  are  converted  into  peptones  by  the  trypsin,  which  is  active  only 
in  an  alkaline  medium.  How  much  of  the  proteids  of  the  milk  is  left 
for  intestinal  digestion,  depends  upon  how  well  the  stomach  has  done  its 
part.  In  every  case  something  is  left ;  in  most  cases  a  large  part  of  the 
proteids  passes  but  little  changed  into  the  intestine.  The  diastatic  fer- 
ment of  the  pancreas  has  the  power  of  converting  starch  into  sugar. 
This  action  is  feeble  during  the  first  six  months,  and,  according  to 
Koronin  and  Zweifel,  it  is  entirely  absent  in  early  infancy.  Fats  are 
emulsified  by  a  third  ferment  in  the  pancreatic  juice,  in  connection  with 
bile,  which  probably  furnishes  the  needed  alkali.  Some  of  the  fats  are 
also  saponified.  The  pancreatic  juice  actively  emulsifies  fat,  even  at 
birth. 

The  very  large  size  of  the  liver  in  the  newly  born  indicates  how  im- 
portant are  its  functions  in  digestion.  The  biliary  secretion  is  present  as 
early  as  the  third  month  of  foetal  life  (Zweifel).  Bile  assists  in  the  diges- 
tion and  absorption  of  fats,  as  has  already  been  mentioned.  In  addition 
it  is  a  stimulus  to  peristalsis,  and  in  this  way  aids  in  the  absorption  of  all 
kinds  of  food.  Its  antiseptic  cfTect  is  very  doubtful.  It  has  a  feeble 
diastatic  action  upon  starch.  Tiie  greater  part  of  the  bile  is  reabsorbed 
from  the  intestine. 

Milk  sugar  is  changed  into  galactose  (Biedert),  cane  sugar  into  dex- 
trose and  levulose,  all  three  being  closely  allied  substances.  Through 
what  agency  these  changes  are  accomplished  is  not  now  positively  known, 
but  it  is  probably  the  pancreatic  juice. 

The  action  of  the  intestinal  juice  is  not  perfectly  understood ;  its  chief 
function  is  thought  to  be  diastatic.  It  is  alkaline  in  reaction,  and  prob- 
ably facilitates  the  action  of  the  trypsin,  the  diastatic  ferment,  and  the 
absorption  of  fats. 

Absorption. — From  the  stomach,  absorption  of  water,  salts,  sugar,  and 
peptones  may  take  place  directly  into  the  blood.  From  the  small  intestine, 
in  addition  to  the  above  elements,  fat  is  absoi'bed  especially  by  the  villi. 
Absorption  is  less  active  than  secretion  in  the  small  intestine,  except  in 
the  duodenum.  It  is  accomplished  through  the  agency  of  the  villi  and 
the  simple  follicles  of  the  mucous  membrane.  It  is  perhaps  partly  by 
filtration  and  endosmosis,  but  chiefly  through  the  activity  of  the  epithelial 
cells  themselves  (Hoppe-Seyler,  Haidenhain).     Absorption  from  the  large 


282  DISEASES  OP  THE  DIGESTIVE   SYSTEM. 

intestine  is  quite  imperfect.  There  are  no  villi,  and  hence  fat  absorption 
is  very  slight.  Sugar,  salts,  and  peptones,  however,  may  be  absorbed  with 
moderate  facility.  Since  there  is  little  or  no  digestive  activity  in  the 
large  intestine,  if  this  is  used  as  a  means  of  nutrition,  the  food  must  be 
given  in  a  condition  in  which  it  is  ready  for  absorption. 

Even  in  healthy  nursing  infants  complete  absorption  takes  place  only 
of  the  milk  sugar.  From  two  to  five  per  cent  of  the  proteids  and  fats 
taken,  pass  through  the  intestinal  canal.  In  infants  taking  cow's  milk  the 
fat-residue  is  from  one  to  three  per  cent  ^greater  than  in  those  who  are 
breast-fed  (Uffelmann).  Even  when  the  amount  of  fat  given  is  consid- 
erably greater  than  that  usually  present  in  cow's  milk,  it  may  be  almost 
entirely  absorbed.  In  infants  taking  cow's  milk  the  proteid  residue  is 
relatively  much  greater  than  that  of  the  fat. 

In  cases  of  indigestion  the  increase  in  the  food-residue  in  most  cases 
is  first  in  the  proteids,  next  in  the  fat,  and  least  in  the  sugar.  In  some 
of  the  chronic  cases  the  principal  increase  may  be  in  the  fat-residue. 

Intestinal  Bacteria. — For  the  fundamental  work  upon  this  subject  we 
are  indebted  to  the  researches  of  Escherich.  Bacteria  are  absent  from 
the  entire  gastro-enteric  tract  at  birth.  They  quickly  enter  by  the  mouth, 
and  by  the  end  of  twenty-four  hours  they  are  usually  found  in  all  parts  of 
the  intestinal  tract.  The  meconium-bacteria  are  derived  from  the  in- 
spired air,  and  hence  vary  somewhat  with  surroundings.  As  soon  as  the 
ingestion  of  milk  begins  these  varieties  are  displaced,  and  throughout  the 
period  in  which  the  infant  has  this  food  exclusively,  there  have  been  found 
in  healthy  conditions  but  two  varieties  which  are  constantly  present. 
These  are  the  bacterium  lactis  aerogcnes  and  the  bacterium  coli  commune. 
The  first  is  found  most  abundantly  in  the  upper  part  of  the  small  intes- 
tine, diminishing  as  we  descend,  in  small  numbers  only  in  the  colon,  and 
usually  none  are  in  the  f^ces.  It  seems  to  require  for  its  growth  the  pres- 
ence of  milk  sugar,  hence  its  absence  from  that  part  of  the  intestine  where 
milk  sugar  is  not  found.  Milk  sugar  is  decomposed  by  it  with  the  forma- 
tion of  lactic  acid  (acetic,  according  to  Baginsky),  carbon  dioxide,  hy- 
drogen, and  methane.  This  action  is  not  hindered  by  the  bile.  The 
h.  lactis  lias  no  action  of  importance  on  either  the  fat  or  casein  of  the 
milk. 

The  h.  coli  commune  is  found  in  but  small  numbers  in  the  upper 
small  intestine,  becoming  more  abundant  as  we  descend.  In  the  colon 
and  in  the  faeces  it  is  present  in  immense  numbers,  and  in  the  fa?ces  is 
sometimes  almost  the  only  variety.  The  activity  of  the  h.  coli  commune 
apparently  begins  where  that  of  the  h.  lactis  ends,  viz.,  in  the  lower  part 
of  the  small  intestine.  It  does  not  seem  to  depend  for  its  growth  upon 
any  part  of  the  food,  but  upon  the  intestinal  secretions.  A  change  from 
a  milk  diet  to  a  mixed  diet  of  meat  and  farinaceous  food,  produces  a  con- 
stant change  in  the  bacteria  of  the  intestine.     The  b.  /rtc/is  disappears; 


DIGESTION   IN   INFANCY.  283 

the  h.  coU  commu?ie,  however,  continues  to  be  found  as  the  principal  form 
of  the  colon. 

Regarding  the  meaning  of  these  bacteria  but  little  is  as  yet  known. 
"We  do  not  know  whether  they  are  essential  to  healthy  digestion  or  preju- 
dicial to  it.  The  b.  ladis  is  believed  not  to  be  pathogenic.  There  seems 
to  be  accumulating  evidence  in  favour  of  the  view  that  the  h.  coli  com- 
mutie,  though  not  ordinarily  pathogenic,  may  under  certain  conditions 
become  so. 

Faeces. — The  first  discharges  after  birth  are  called  meconium  ;  this  is 
of  a  dark  brownish-green  colour,  semi-solid,  and  usually  passed  from 
four  to  six  times  daily  during  the  first  two  or  three  days.  On  the  third 
day  the  stools  begin  to  change  in  character,  and  by  the  fourth  or  fifth 
day  they  have  usually  assumed  the  appearance  of  healthy  milk-faeces.  Un- 
der many  abnormal  conditions  the  stools  may  continue  to  have  the  char- 
acter of  meconium  for  a  week  or  more.  The  composition  of  meconium, 
according  to  Forster,  is  intestinal  mucus,  bile,  the  vernix  caseosa,  epithe- 
lial cells  from  the  epidermis,  hairs,  fat-globules,  and  cholesterin  crystals. 
For  its  formation  tliere  are  necessary  the  secretions  of  the  intestine 
and  the  liver  and  the  swallowing  of  a  considerable  amount  of  amniotic 
fluid. 

MUk-fwces. — The  normal  amount  of  faeces  discharged  daily  by  a 
healthy  nursing  infant  is  from  two  to  three  ounces.  Such  stools  have  the 
colour  of  the  yolk  of  egg.  They  are  smooth,  homogeneous,  of  a  soft,  but- 
ter-like consistency,  with  an  acid  reaction,  and  a  slightly  acid  but  not 
unpleasant  odour.  The  reaction  is  due  to  the  presence  of  fatty  acids 
(Biedert)  or  lactic  acid  (Uffelmann).  The  colour  depends  upon  bilirubin. 
The  stools  of  an  infant  fed  upon  cow's  milk  may  differ  in  no  respect  from 
those  described  ;  they  are,  however,  commonly  firmer,  paler,  and  may  be 
neutral  or  even  alkaline  in  reaction,  depending  upon  the  decomposition  of 
casein.  In  fact,  all  these  differences  depend  chiefly  upon  the  presence 
of  undigested  casein. 

The  only  gases  present  are  hydrogen  and  carbon  dioxide  (Escherich). 
Sulphuretted  hydrogen  and  marsh  gas,  to  which  the  odour  of  adult  stools 
is  largely  due,  are  not  present.  The  following  is  the  chemical  composition 
as  given  by  Wegscheider  : 

Water 85-13 

Solidsi  ^''^^"'^ ^^'^W 14-87 

(  Inorganic 1-16)  

100-00 

The  proteids  of  breast  milk  are  almost  entirely  absorbed.  According 
to  Uffelmann,  they  form  but  1-5  per  cent  of  the  dry  residue  of  the  faeces. 
The  stools  of  infants  fed  upon  cow's  milk  are  usually  larger,  and  invari- 
ably contain  casein.  If  the  casein  in  the  milk  as  fed  is  excessive,  it  may 
be  present  in  the  fseces  in  large  amount,  the  stools  then  being  of  a  pale 


284  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

yellow  or  white  colour,  quite  dry,  often  formed,  and  with  an  odour  some- 
times cheesy,  at  other  times  foul. 

Fat  is  always  present,  and  forms,  according  to  Wegscheider  and  Uffel- 
mann,  from  9  to  25  per  cent  of  the  dry  residue  of  milk  faeces.  According 
to  Tschernoff  and  some  other  recent  observers,  the  proportion  is  as  high 
as  28  to  35  per  cent.  It  is  present  as  neutral  fat,  fatty  acids,  and  soaps. 
Sugar  is  not  found,  but  its  derivative,  lactic  acid,  may  be  present  in  a 
small  amount.  Inorganic  salts  form  about  8  per  cent  of  the  dry  residue. 
They  are  chiefly  the  salts  of  lime.  Of  the  biliary  elements  there  are  hydro- 
bilirubin,  unchanged  bilirubin,  and  cholesterin  in  considerable  amount. 
The  presence  of  biliary  acids  is  doubtful.  Mucus  is  always  present  in  con- 
siderable quantity  ;  also  columnar  intestinal  epithelium.  Leucin,  tyrosin, 
and  other  products  of  albuminous  decomposition — phenol  and  skatol — 
are  absent;  indol  is  rarely  found  (Uft'elmann). 

Microscopically  there  are  seen  epithelial  cells,  chiefly  of  the  columnar 
variety,  a  few  round  cells,  mucous  corpuscles,  fat-globules  and  crystals  of 
fatty  acids,  cholesterin,  mucin,  protein  substance,  crystalline  inorganic 
salts,  sometimes  bilirubin  in  crystals,  yeast  fungi,  and  bacteria  in  immense 
numbers,  chiefly  the  h.  coli  commune. 

If  the  infant  is  taking  a  food  containing  starch,  this  will  appear  to  a 
greater  or  less  extent  in  the  stools,  a  larger  amount  in  the  case  of  very 
young  infants.  Starch  is  recognised  by  the  blue  reaction  with  iodine, 
or  the  violet  reaction  if  the  starch  has  been  converted  into  dextrine,  as  is 
often  the  case.    .  Starch  granules  may  be  seen  under  the  microscope. 

The  number  of  stools  during  the  first  two  weeks  is  from  three  to  six 
daily.  After  the  first  month  two  stools  a  day  are  the  average ;  many 
infants  have  three,  many  others  but  one. 

As  soon  as  an  infant  is  put  upon  a  mixed  diet,  the  2">eculiar  characters 
of  the  stools  cease,  and  they  come  to  resemble  more  closely  those  of  the 
adult,  though  remaining  softer  throughout  infancy.  They  become  darker 
in  colour  and  assume  the  adult  odour,  while  retaining  their  acid  reaction. 
The  bacteria,  while  still  in  great  numbers,  are  no  longer  of  the  single 
variety  met  with  almost  exclusively  in  milk-faeces. 

MALFORMATIONS  AND   MALPOSITIONS  OF   THE  STOMACH. 

These  are  much  less  frequent  than  those  of  other  parts  of  the  alimen- 
tary tract.  There  may  be  atresia  or  stenosis  at  either  orifice,  usually  the 
pyloric  ;  sLill  more  rarely  a  constriction  has  been  found  near  the  middle 
of  the  organ,  dividing  it  into  compartments.  The  symptoms  of  atresia  at 
either  orifice  are  persistent  vomiting,  and  death  in  a  few  days  from  inani- 
tion. The  stomach  is  sometimes  in  the  thoracic  cavity  in  cases  of  dia- 
phragmatic hernia.  It  may  be  found  in  a  vertical  (foetal)  position, 
variously  adherent  to  the  colon  and  small  intestine. 


VOMITING.  285 


VOMITING. 

Vomiting  is  exceedingly  frequent  in  infants  and  young  children,  and 
although  seen  in  many  forms  of  disease,  it  is  the  one  particular  symptom 
to  attract  attention  to  the  stomach.  The  physician  must  have  in  mind 
both  its  common  and  its  uncommon  causes.  Vomiting  takes  place  with 
great  facihty  in  young  infants  even  from  slight  causes,  owing  to  the  posi- 
tion and  sliape  of  the  stomach. 

1.  Vomiting  from  overfilling  of  the  stomach. — This  is  often  seen  in 
nursing  infants,  and  there  may  be  no  other  symptom  of  disease.  It  is 
characterized  by  the  fact  that  it  comes  within  a  few  minutes  after  nurs- 
ing, that  it  is  easy  and  without  effort,  and  that  the  food  is  but  little 
changed.  It  may  be  excited  by  moving  the  child  or  making  undue  pres- 
sure upon  the  stomach.  It  often  comes  with  eructations  of  gas  or  air 
which  has  been  swallowed.  Vomiting  from  overdistention  may  be  re- 
garded as  a  safety-valve,  and  requires  no  treatment  except  to  diminish 
the  quantity  of  food. 

2.  Vomiting  is  almost  invariably  present  in  cases  of  acute  gastric  indi- 
gestion, whether  there  is  inflammation  of  the  stomach  or  not.  It  does 
not  usually  come  immediately  after  feeding,  and  it  may  be  delayed  for 
several  hours.  It  is  often  preceded  by  fever  and  by  marked  prostration, 
which  in  young  infants  may  approach  collapse.  It  may  cease  when  the 
contents  of  the  stomach  have  been  evacuated,  but  often  mucus,  serum, 
and,  in  severe  cases,  bile,  may  be  vomited  for  some  time  afterward.  In 
these  cases  vomiting  is  due  to  the  irritation  of  undigested  food,  and  to 
the  exaggerated  reflex  irritability  of  the  stomach  from  congestion  of  the 
mucous  membrane. 

3.  In  acute  intestinal  obstruction  vomiting  is  rarely  absent,  and  in 
most  cases  it  is  persistent.  In  the  newly  born,  persistent  vomiting  is 
almost  invariably  dependent  upon  congenital  obstruction  of  the  intestine, 
which  is  most  frequently  in  the  duodenum.  In  malformations  of  the 
colon  and  rectum  it  is  less  constant  and  appears  later.  In  intussuscep- 
tion, vomiting  is  forcible,  immediately  excited  by  the  taking  of  food,  and 
is  at  first  bilious,  but  later  may  become  fa3cal.  The  vomiting  in  intes- 
tinal obstruction  is  associated  with  general  symptoms  of  marked  prostra- 
tion, and  usually  with  obstipation. 

4.  Vomiting  is  a  frequent  and  almost  a  constant  symptom  of  general 
peritonitis.  It  is  then  associated  with  abdominal  distention,  tenderness, 
and  fever. 

5.  In  certain  nervous  diseases,  especially  tumour  of  the  brain  and  acute 
meningitis  whether  simple  or  tuberculous,  vomiting  is  very  common.  It 
may  be  the  earliest,  and  for  some  time  the  only  marked  symptom.  As  in 
the  vomiting  from  intestinal  obstruction,  tins  is  likely  to  be  sudden,  forci- 
ble, or  projectile.     It  may  occur  after  taking  food,  or  it  may  have  no  rela- 


286  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

tion  to  meals.  The  vomited  matters  are  not  characteristic,  and  the  tongue 
may  be  clean.  Headache,  dulness,  slight  fever,  constipation,  and  irregular 
pulse  and  respiration  are  usually  present  sooner  or  later,  and  serve  to 
make  the  diagnosis  complete. 

6.  In  infants,  vomiting  is  one  of  the  most  frequent  symptoms  to 
mark  the  onset  of  acute  infectious  diseases.  It  is  not  quite  so  common 
in  older  children.  It  is  most  frequent  at  the  onset  of  scarlet  'fever, 
pneumonia,  and  malaria.  In  these  cases  vomiting  may  be  due  simply 
to  the  arrest  of  digestion,  or  to  the  effects  of  the  poison  upon  the  nerve 
centres. 

7.  An  accumulation  in  the  blood  of  various  toxic  materials  may  pro- 
voke vomiting ;  the  most  frequent  example  is  uraemia.  In  cyclic  vomiting 
it  is  quite  probable  that  the  cause  is  the  accumulation  of  some  toxic  agent 
in  the  blood.  The  absorption  of  ptomaines  and  other  poisons  taken  in 
with  milk  or  other  food,  or  developed  in  the  gastro-enteric  tract,  may  ex- 
cite vomiting.  In  some  of  these  conditions  it  is  possible  that  the  vomiting 
may  be  eliminative — an  effort  on  the  part  of  Nature  to  get  rid  of  the 
toxic  materials.  The  cases  dependent  upon  renal  disease  are  discovered 
by  frequent  and  careful  examination  of  the  urine.  The  other  forms  are 
often  exceedingly  obscure,  and  recognised  only  by  the  exclusion  of  all 
other  frequent  and  infrequent  causes  of  vomiting. 

8.  Vomiting  may  be  reflex  from  irritation  in  the  pharynx.  This  is 
frequent  in  young  infants,  Avho  may  induce  vomiting  by  stuffing  the 
fingers  into  the  mouth.  In  certain  cases  the  irritation  from  worms  in  the 
intestinal  trace  may  cause  vomiting,  and  it  is  possible  that  even  dentition 
may  produce  it. 

9.  Habit  is  a  frequent  cause  in  cases  of  chronic  vomiting.  I  have 
seen  a  child  who  had  the  power  of  vomiting  at  will  anything  in  the  nature 
of  food  which  he  did  not  like,  yet  whose  stomach  at  the  same  time  would 
bear  large  doses  of  quinine,  to  which  he  had  no  aversion,  without  the 
slightest  disturbance.  In  young  infants  a  habit  of  regurgitating  the 
food  may  be  acquired,  so  that  this  takes  place  more  or  less  during  the 
process  of  digestion  after  every  meal.  This  is  sometimes  preceded  by  a 
movement  of  the  mouth  and  fauces  resembling  swallowing,  until  finally 
the  milk  appears  in  the  mouth.  Habit  is  a  potent  cause  in  continuing 
vomiting  where  it  has  occurred  frequently.  In  children  who  have  this 
habit  the  most  trivial  cause  will  provoke  it.  It  may  be  present  without 
any  other  sign  of  gastric  disease,  and  appears  simply  to  depend  upon 
exaggerated  reflex  irritability  of  the  organ.  These  are  exceedingly 
troublesome  cases  to  control.  Sometimes  small  quantities  of  food  are 
better  borne,  and  sometimes  larger  meals  are  retained  when  small  ones 
are  vomited.  In  some  of  these  children  gavage  is  the  only  means  by 
which  the  vomiting  can  be  controlled. 

10.  Chronic  vomiting  may  depend  upon  habit,  as  just  described,  or 


CYCLIC  VOMITING.  287 

upon  chronic  indigestion,  or  it  may  bo  associated  with  chronic  pulmonary 
disease ;  vomiting  here  being  excited  by  the  attacks  of  cough,  at  first  only 
when  the  paroxysms  are  severe,  and  later  even  when  they  are  slight.  In 
chronic  indigestion  the  vomited  matters  always  are  characteristic,  they 
have  a  distinct  relation  to  meals,  and  they  are  accompanied  by  other 
symptoms  of  deranged  nutrition. 

The  diagnosis  of  a  case  in  which  vomiting  is  the  chief  symptom 
may  be  difficult.  The  first  important  distinction  to  be  made  is  between 
cases  in  which  the  vomiting  is  of  gastric  origin,  and  those  in  which 
it  depends  upon  other  conditions,  like  intestinal  obs,truction,  cerebral 
disease,  toxic  conditions,  etc.  It  is  only  by  a  careful  consideration 
of  the  other  symptoms  associated  that  an  accurate  diagnosis  can  be 
reached. 

The  treatment  of  vomiting  is  the  treatment  of  the  cause  upon  which 
it  depends. 

CYCLIC  VOMITINa. 

This  condition  is  one  which  has  received  but  little  attention.  It  is 
classed  by  some  as  a  gastric  neurosis.  While  at  the  present  time  we  are 
not  in  a  position  to  give  it  a  definite  pathology,  it  seems  to  be  associated 
with  a  general  derangement  of  nutrition  which  is  in  some  way  connected 
with  formation  and  excretion  of  uric  acid.  It  is  not  certain  that  all 
these  cases  have  the  same  origin. 

The  disease  is  characterized  by  periodical  attacks  of  vomiting,  recur- 
ring at  intervals  of  weeks  or  months  without  any  adequate  exciting  cause. 
The  vomiting  is  severe  and  uncontrollable,  and  usually  lasts  from  twelve 
hours  to  three  days.  It  is  attended  with  symptoms  of  general  prostration 
which  may  be  alarming.  The  children  who  are  subjects  of  it  may  show 
in  the  interval  nearly  all  the  signs  of  perfect  health.  The  clinical  picture 
presented  by  these  cases  is  unique,  and  is  well  illustrated  by  the  history 
of  the  following  case,  which  is  the  most  characteristic  one  that  has  come 
under  my  observation  : 

The  patient  was  a  well-nourished  boy  of  six  years  when  he  first  came 
under  treatment.  He  belonged  to  a  neurotic  family,  and  the  attacks  dated 
back  to  infancy.  From  this  time  they  had  recurred  usually  at  intervals  of 
a  few  months;  occasionally  five  or  six  months  would  pass  without  one. 
The  symptoms  in  all  the  attacks  were  similar  in  kind,  differing  only  in 
degree.  I  observed  three  of  them.  They  were  preceded  by  a  prodromal 
period  lasting  from  twelve  to  twenty-four  hours,  marked  by  languor,  dul- 
ness,  dark  rings  under  the  eyes,  loss  of  appetite,  and  a  general  sense  of 
discomfort  in  the  epigastrium.  At  this  time  the  temperature  was  gener- 
ally but  not  always  elevated,  sometimes  to  103°  F.  The  vomiting  then 
began  suddenly.  It  was  attended  with  great  retching  and  distress;  it 
was  forcible,  and  often  repeated  every  half  hour  or  hour  for  two  days.  On 
20 


288  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 

one  occasion  it  occurred  seventeen  times  in  a  single  night.  Vomiting  was 
immediately  excited  by  the  taking  of  any  food  or  drink,  but  it  occurred 
when  nothing  was  taken.  The  vomited  matters  consisted  of  frothy  mucus 
and  serum,  frequently  streaked  with  blood,  apparently  from  the  violence 
of  the  emesis.  The  reaction  was  very  strongly  acid  ;  sometiTues  there  was 
bilious  vomiting.  The  temperature  usually  fell  to  about  100°  F.  when  the 
vomiting  began,  and  continued  at  or  below  this  point  throughout  the 
attack.  By  the  end  of  the  second  day  the  exhaustion  was  very  marked — 
so  severe,  in  fact,  as  apparently  to  threaten  life.  The  child  lay  in  a  semi- 
stupor,  with  eyes  half  open,  lips  and  tongue  dry,  rousing  at  times  to  beg 
for  water.  The  pulse  was  rapid  and  weak,  and  sometimes  slightly  irregu- 
lar. There  was  no  distention  of  the  abdomen;  it  was  usually  flattened. 
By  the  third  day  the  vomiting  became  less  frequent  and  then  ceased 
entirely.  Convalescence  was  rapid,  and  by  the  end  of  the  week  the 
boy  was  as  well  as  usual.  After  these  attacks  he  was  frequently  better 
than  for  some  time  previously.  Several  other  cases  have  come  under 
my  observation,  all  closely  resembling  this  one,  but,  with  two  exceptions, 
the  symptoms  were  not  so  severe.  In  one  of  these  children  the  attacks 
lasted  regularly  five  days. 

A  verv  similar  case  to  the  one  whose  history  is  given  above,  has  been 
reported  by  Snow  *  (Buffalo).  Gee  f  has  published  a  series  of  nine  cases 
of  cyclic  vomiting,  two  of  which  were  of  the  type  described,  but  much 
less  severe. 

Judging  from  these  limited  observations,  cases  may  be  seen  at  any 
period  of  childhood,  and  more  frequently  in  girls  than  in  boys.  They  are 
often  seen  in  neurotic  or  gouty  families.  The  general  health  and  nutri- 
tion of  the  patients  may  appear  excellent.  The  attacks  are  rarely  trace- 
able to  the  taking  of  indigestible  food,  and  they  have  little  in  common 
with  an  ordinary  severe  attack  of  acute  indigestion.  Exhaustion  or  fatigue 
may  bring  on  an  attack,  and  one  has  been  excited  by  some  minor  illness 
such  as  tonsillitis.  The  prodromal  symptoms  are  lassitude,  frequently 
headache,  a  sense  of  gastric  discomfort,  and  very  often  fever,  which,  how- 
ever, does  not  continue  through  the  illness.  In  some  of  the  cases,  for 
some  days  before  the  attack,  the  stools  are  noticed  to  be  almost  white. 
Constipation  is  not  marked,  and  is  often  absent.  Severe  epigastric  pain  is 
rare.  The  attacks  seem  to  be  self-limited,  and  they  are  but  little  affected 
by  treatment. 

Cyclic  vomiting  is  certainly  a  nervous  and  not  a  gastric  condition.  It 
has  many  points  of  resemblance  to  an  attack  of  migraine.  The  following 
observations  made  by  Dr.  C.  A.  Herter  upon  the  urine  of  the  case  whose 
history  I  have  given,  strengthens  this  hypothesis,  since  the  result  is  almost 

*  Archives  of  Paediatrics,  1893. 

f  St.  Bartholomew's  Hospital  Reports,  1883. 


CYCLIC   VOMITING. 


289 


identical  with  what  is  found  in  migraine.     All  the  following  observations 
were  made  upon  the  twenty-four-hours'  urine : 


Time  taken. 


Ijefore  the  attack  (uoniial) .  , 

First  (lay 

Second  day 

Third  day  (convalescent).  .  . 
Several  weeks  after  (normal) 


Urea, 

Uric  acid,  , 

Ratio  of  uric 

grammes. 

grammes. 

acid  to  urea. 

13-606 

0-251 

1  to  54 

17-249 

0-110 

1  to  157 

12-023 

0-0912 

1  to  132 

11-713 

0-234 

1  to  50 

15-040 

0-283 

1  to  53 

Observations  made  upon  the  urine  in  a  second  attack,  three  months 
later,  gave  results  which  w-ere  practically  identical  with  the  above.  A 
second  case  of  a  somewhat  similar  type,  but  less  severe,  showed  a  ratio  of 
uric  acid  to  urea  1  to  83  during  the  vomiting,  while  in  the  same  individual 
in  health  it  was  1  to  42.  Further  observations  are  necessary  before  the 
full  significance  of  these  changes  can  be  appreciated.  The  frequency 
with  which  the  attacks  are  preceded  by  light  gray  stools,  indicates  that 
disturbance  of  the  functions  of  the  liver  has  a  very  close  connection  with 
the  symj^toms. 

The  prostration  from  the  attacks  is  usually  of  short  duration.  The 
paroxysms  are  apt  to  recur  unless  a  proper  treatment  of  the  case  in  the 
interval  can  be  carried  out.  There  seems  btit  little  tendency  to  spontane- 
ous recovery.  In  most  of  the  cases  reported  they  have  extended  over  a 
period  of  several  years. 

Diagnosis. — Organic  disease  of  the  brain  and  kidneys  must  first  be 
excluded,  the  latter  only  by  careful  and  repeated  examination  of  the  urine. 
The  first  attack  witnessed  may  strongly  suggest  the  onset  of  meningitis, 
but  the  course  of  the  symptoms  soon  shows  that  this  is  not  present.  Usu- 
ally a  history  of  many  previous  attacks  may  be  obtained.  From  acute 
indigestion,  cyclic  vomiting  is  differentiated  by  the  fact  that  attacks  are 
not  brought  on  by  indigestible  food  and  also  by  the  persistence  of  the 
vomiting.  It  is  distinguished  from  gastritis  by  its  severity,  the  shorter 
duration  of  its  symptoms,  and  its  self-limited  course. 

Treatment. — When  the  premonitory  symptoms  appear,  free  purgation 
by  calomel  offers  the  best  prospect  of  aborting  an  attack.  If  the  vomit- 
ing has  once  begun,  notliing  seems  to  have  the  slightest  influence  in  con- 
trolling it.  It  is  usually  increased  by  the  taking  of  food  or  drink  or  by  any 
medication  by  the  mouth,  and  all  should  be  withheld.  Ice  may  be  held 
in  the  mouth  to  allay  thirst.  "When  the  vomiting  has  ceased  for  several 
hours  it  is  not  likely  to  recur  if  food  be  very  judiciously  administered  and 
in  small  quantities.  Broth,  whey,  kumyss,  or  small  quantities  of  iced  milk 
and  limewater  in  equal  proportions  may  then  be  given.  Acting  upon  the 
theory  that  the  symptoms  were  analogous  to  those  of  migraine,  the  treat- 
ment I  have  adopted  in  the  interval  has  been  purely  dietetic,  consisting 


290  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

in  the  exclusion  of  all  sugar  and  sweets,  and  in  carefully  limiting  the 
amount  of  starchy  foods.  The  diet  prescribed  has  consisted  of  meat,  green 
vegetables,  milk,  sour  fruits,  and  stale  bread.  This  diet  has  been  followed 
in  the  case  above  reported,  with  the  result  that  instead  of  having  four  or 
five  attacks  every  year  there  had  been  at  the  last  report  but  one  attack  in 
three  years.  In  addition  to  careful  regulatio7i  of  the  diet  the  general  nu- 
trition should  be  considered,  and  the  patient's  life  so  regulated  that  ex- 
treme fatigue  and  exhaustion  should  be  prevented. 

GASTRALGIA. 

This  term  is  applied  to  sudden,  severe  attacks  of  gastric  pain.  Gas- 
tralgia  occurs  as  a  symptom  in  most  of  the  severe  attacks  of  acute  gastric 
indigestion  ;  in  such  cases  it  is  more  marked  in  older  children  than  in 
infancy.  The  pain  of  diaphragmatic  pleurisy  is  often  referred  to  the  epi- 
gastrium, and  may  be  so  severe  as  to  lead  one  to  think  that  the  stomach  is 
the  seat  of  disease.  In  vertebral  caries  of  the  dorsal  region  epigastric 
pain  is  a  very  frequent,  early  symptom.  It  is  also  common  in  children 
who  suffer  from  malaria,  at  the  onset  of  acute  attacks,  and  it  may  be  severe 
when  the  febrile  symptoms  are  not  well  marked.  In  other  cases  pain  in 
the  stomach  is  of  the  nature  of  a  true  neuralgia,  which  may  be  excited  by 
exposure  to  cold,  by  wetting  the  feet,  by  drinking  ice-water,  and  by  many 
other  causes.  Children  who  are  predisposed  to  it  often  have  attacks  of 
considerable  severity  from  comparatively  slight  causes. 

In  mild  cases  there  is  an  intermittent  pain,  and  usually  no  other  symp- 
toms. In  severe  cases  the  pain  may  be  so  great  as  to  cause  pallor,  faint- 
ness,  cold  perspiration,  and  \'ery  marked  prostration.  When  the  origin  of 
the  pain  is  in  the  stomach  the  epigastrium  may  be  hard  and  sometimes 
retracted,  the  stomach  appearing  to  be  in  a  state  of  spasm. 

Treatment. — During  the  attacks  the  patient  should  be  put  to  bed,  and 
counter-irritation  used  over  the  stomach,  best  by  means  of  a  turpentine 
stupe  or  a  mustard  paste  ;  sometimes  a  hot-water  bag  will  suffice.  Inter- 
nally there  should  be  given  hot  water  containing  brandy  or  gin  and 
five  drops  of  spirits  of  chloroform ;  all  food  should  be  withheld.  Hot 
bottles  should  be  applied  to  the  feet  if  they  are  cold.  In  the  interval 
between  the  attacks  the  treatment  should  be  directed  to  the  patient's  gen- 
eral condition  ;  especially  should  the  cause  be  discovered.  In  cases  of 
recurring  pain  of  a  neuralgic  character  the  prolonged  use  of  arsenic  in  the 
form  of  Fowler's  solution,  two  or  three  drops  three  times  a  day,  may 
prove  of  great  benefit.  In  all  cases  attention  should  be  directed  to  the 
diet,  as  in  chronic  indigestion. 

ACUTE    GASTRIC   INDIGESTION. 

This  occurs  whenever  the  stomach  is  unequal  to  the  task  imposed  upon 
it.     It  may  be  either  because  the  task  is  too  great  or  because  the  capacity 


ACUTE   GASTRIC   INDIGESTION.  091 

of  the  stomach  for  work  is  diminished.  Under  these  two  heads  we  may- 
group  the  principal  causes  of  acute  indigestion. 

Under  the  first  head  the  most  important  thing  is  the  giving  of  im- 
proper food.  In  infants  this  is  most  frequently  the  use  of  cow's  milk 
which  contains  too  much  casein  because  not  sufficiently  diluted.  Other 
common  causes  are  sudden  weaning  or  any  other  abrupt  change  in  diet, 
the  too  early  use  of  solid  food,  and  overloading  of  the  stomach.  In  older 
children  the  usual  causes  are  the  use  of  indigestible  articles,  such  as  unripe 
fruits,  pastry,  etc.,  overloading  the  stomach,  and  swallowing  food  without 
sufficiently  masticating  it.  Conditions  which  may  diminish  for  the  time 
the  capacity  of  the  stomach  for  work  are  fatigue,  depression  induced  by 
atmospheric  heat,  chilling  of  the  surface,  especially  the  extremities,  denti- 
tion, and  the  nervous  impression  caused  by  the  onset  of  any  acute  disease. 
The  effect  is  seen  both  on  the  glandular  and  muscular  apparatus  of  the 
stomach.  The  secretions  are  diminished  or  altered  in  character,  and  the 
motor  activity  of  the  organ  is  arrested. 

Symptoms. — One  of  the  first  consequences  of  arrested  gastric  digestion 
is  that  the  food  remains  long  in  the  stomach.  Instead  of  being  empty  in 
two  or  two  and  a  half  hours  after  feeding,  as  is  normal  in  infancy,  the 
food  may  remain  in  the  stomach  five  or  six  hours,  or  even  longer.  The 
irritation  from  this  undigested  mass  excites  vomiting,  which  usually  ceases 
after  the  stomach  has  been  emptied.  The  vomiting  may  be  preceded  by 
nausea,  pain,  and  constitutional  depression  which  varies  with  the  age  and 
susceptibility  of  the  child  ;  in  infants  it  may  be  very  alarming. 

It  seems  probable  that,  as  a  consequence  of  arrested  gastric  digestion, 
the  proteids  are  not  converted  into  peptones,  but  remain  in  the  form  of 
albumoses.  These  products  have  been  shown  by  experiments  on  animals 
to  be  toxic,  producing  stupor  and  circulatory  disturbances.  They  are 
diffusible  and  are  undoubtedly  absorbed  with  great  rapidity,  and  may  be 
the  cause  of  nervous  symptoms  of  a  striking  character.  There  may  be 
dulness,  stupor,  and  sometimes  contracted  pupils,  so  as  to  suggest  opium 
narcosis,  or  there  may  be  restlessness,  excitement,  and  even  convulsions. 
There  is  also  marked  prostration,  weak  pulse,  and  fever.  The  tempera- 
ture in  most  cases  of  acute  indigestion  is  from  100°  to  102°  F. ;  not  infre- 
quently it  rises  to  104°  or  105°  F.  The  tongue  is  coated  and  the  appetite 
entirely  lost.  In  infants  these  symptoms  are  usually  associated  with  more 
or  less  evidence  of  intestinal  disturbance — generally  diarrhoea,  with  undi- 
gested food  in  the  stools.  Epigastric  distention  may  be  present.  Usually 
the  vomiting  ceases  in  from  six  to  twelve  hours,  and  after  the  stomach 
has  been  thoroughly  emptied  the  temperature  falls.  Provided  rest  to  the 
organ  can  be  secured,  and  the  exciting  cause  is  one  that  can  be  removed, 
the  patient  may  be  quite  well  in  two  or  three  days.  Relapses  are,  how- 
ever, easily  excited.  It  is  surprising  to  see  in  a  susceptible  patient  how 
trivial  a  cause  may  excite  a  relapse. 


292  DISEASES   OP   THE   DIGESTIVE   SYSTEM. 

The  diagnosis  between  a  simple  attack  of  acute  indigestion  and  one  of 
gastritis  can  not  be  made  at  the  outset.  The  former  is  much  more  fre- 
quent, and  may  be  quite  as  severe,  but  is  of  shorter  duration.  The  con- 
tinuance of  the  severe  symptoms,  especially  pain,  thirst,  fever,  and  vomit- 
ing of  mucus  tinged  with  blood,  justify  the  inference  that  inflammatory 
changes  exist.  The  prognosis  in  these  cases  is  good,  except  in  very  young 
or  very  delicate  infants.  In  such  patients  an  attack  of  acute  indigestion 
is  not  infrequently  fatal. 

Treatment. — The  indications  are,  to  empty  the  stomach  as  completely 
as  possible  and  then  to  secure  to  it  absolute  rest.  If  proper  treatment  is 
employed  at  the  outset,  the  majority  of  such  attacks  can  be  cut  short. 
Nothing  is  so  efficient  in  infants  as  stomach-washing.  (See  page  GO). 
A  single  washing  usually  suffices.  If  for  any  reason  this  can  not  be  em- 
ployed, the  child  may  take  from  its  bottle  a  large  amount  of  lukewarm 
water.  The  free  vomiting  which  this  usually  produces  may  be  sufficient 
to  cleanse  the  stomach  fairly  well,  but  by  no  means  so  easily  as  stomach- 
washing.  Persistent  vomiting  is  sometimes  arrested  by  giving  small  quan- 
tities of  quite  hot  water. 

The  subsequent  treatment  is  chiefly  dietetic.  Nothing  whatever  is  to 
be  given  for  three  or  four  hours,  and  then  albumin  water*  or  ice-cold 
whey  (page  152),  frequently,  and  in  small  quantities— e.  g.,  half  an  ounce 
to  one  ounce  every  hour.  After  twenty-four  hours  barley  water,  raw  beef 
juice  or  broth  may  be  tried,  but  no  milk  for  at  least  three  days.  When 
begun,  it  should  be  peptonized  and  diluted  with  five  or  six  parts  of 
water.  In  a  nursing  child,  the  breast  should  be  withheld  altogether  for 
twenty-four  hours,  and  then  nursing  allowed  for  two  minutes  every  three 
hours,  the  time  of  nursing  being  gradually  increased  to  three,  five,  and  ten 
minutes  as  improvement  occurs.  The  great  mistake  made  in  these  cases 
is  to  begin  food  too  early  and  to  give  too  much,  especially  of  cow's  milk. 

Drugs  are  relatively  of  little  value.  If  the  measures  mentioned  have 
been  used  promptly  they  will  not  often  be  required.  In  many  cases  inju- 
dicious medication  aggravates  the  symptoms  and  prolongs  tlie  attack. 
Unless  the  Ijowels  have  acted  freely,  calomel  (gr.  yV  every  hour)  may  be 
given  until  this  effect  is  obtained.  Where  there  is  continuous  vomiting 
of  very  acid  mucus  and  serum,  alkalies  are  indicated — limewater,  chalk 
mixture,  or  the  subcarbonate  of  bismuth.  It  is  important  to  keep  the 
child  as  quiet  as  possible.  Local  applications  to  the  epigastrium  are  very 
often  useful.  Either  dry  heat  may  be  applied  by  means  of  a  hot-water 
bao-  or  hot  flannels,  or  more  active  counter-irritation  bv  mustard.  In 
older  children  the  stomach  is  to  be  emptied  by  an  emetic,  such  as  ipecac, 
accompanied  by  large  draughts  of  warm  water.     After  this  it  should  bo 

*  Albumin-water :  The  white  of  one  fresh  egg,  one  half  pint  cold  water,  previously 
boiled,  a  little  salt,  one  teaspoonful  of  brandy  ;  shake  thoroughly,  and  feed  cold. 


ACUTE   GASTRITIS.  293 

kept  entirely  at  rest  for  half  a  day,  only  carbonated  waters  or  barley  water 
being  allowed  in  small  quantities  to  allay  thirst.  Later,  broth  or  boff 
juice  may  be  given,  then  milk  diluted  with  two  parts  of  limewater.  The 
patient  should  be  kept  upon  a  very  low  diet  for  four  or  five  days. 

ACUTE  GASTRITIS. 

In  comparison  with  the  frequency  of  inflammatory  diseases  of  the 
intestine,  those  of  the  stomach  are  rare,  particularly  so  in  infancy.  Gas- 
tritis seldom  exists  alone,  but  is  usually  associated  with  enteritis  or  colitis. 

Etiology. — The  causes  of  gastritis  are,  in  the  main,  those  of  acute 
gastric  indigestion — improper  food  or  feeding.  Besides,  it  may  be  caused 
by  the  introduction  of  irritants,  which  may  either  be  accidentally  swal- 
lowed or  given  as  drugs.  The  mucous  membrane  of  the  stomach  has 
much  more  resistance  to  infection  than  has  that  of  the  intestines ;  but  in 
certain  forms  of  inflammation,  especially  the  membranous,  infection  is 
clearly  the  cause. 

Lesions. — The  mucous  membrane  of  the  stomach  may  be  the  seat  of 
acute  catarrhal,  follicular,  or  membranous  inflammation,  all  forms  except 
the  catarrhal  being  very  rare.  There  is  also  seen  a  mixed  form,  from  its 
cause  usually  designated  as  "  corrosive  "  gastritis. 

Catarrhal  gastritis. — This  is  characterized  by  hypergemia  of  the  mu- 
cous membrane,  exudation  of  cells  into  the  mucosa,  a  great  increase 
in  the  secretion  of  the  mucous  glands,  and  changes  in  the  epithelium. 
About  the  only  change  which  can  be  recognised  by  the  naked  eye  is 
congestion  and  swelling  of  the  mucous  membrane.  These  are  usually 
more  marked  toward  the  pyloric  end  and  along  the  greater  curvature. 
There  may  be  small  extravasations  of  blood  into  the  mucosa.  The  stom- 
ach contains  undigested  food  and  mucus,  which  may  be  thick  and  tena- 
cious, adhering  very  closely  to  the  mucous  membrane.  The  mucus  may 
be  stained  brown  from  the  capillary  hemorrhages.  The  stomach  may  be 
either  distended  or  contracted.  Under  the  microscope  the  changes  are 
seen  to  be  almost  entirely  in  the  mucosa.  In  places  there  is  loss  of  the 
superficial  epithelium,  in  others  only  degenerative  changes  in  it  are  seen. 
The  mucosa  is  infiltrated  with  round  cells,  this  process  being  rarely  diffuse, 
but  generally  occurring  in  patches.  The  blood-vessels  are  distended  and 
many  small  extravasations  are  seen.  Sometimes  there  is  a  moderate  infil- 
tration of  the  submucosa.  Acute  catarrlial  gastritis  alone  is  rarely  severe 
enough  to  cause  death.  It  is  usually  seen  in  cases  which  prove  fatal 
from  other  causes,  particularly  diseases  of  the  intestine. 

Gastric  softening  [gastromalacia)  is  a  condition  dependent  i;pon  post- 
mortem changes — probably  self-digestion  of  the  stomach.  It  is  found 
both  where  gastric  symptoms  have  been  present  and  where  they  were  ab- 
sent. It  is  situated  nearly  always  in  the  posterior  wall,  and  usually  covers 
a  considerable  area,  about  one  third  or  one  fourth  of  this  wall.     It  is 


294  DISEASES   OF   THE   DIGESTIVE   SYSTExM. 

recognised  by  the  gelatinous,  translucent  appearance  of  the  walls  of  the 
stomach,  which  are  so  softened  that  the  finger  may  be  pushed  through 
them  without  force,  sometimes  so  that  the  stomach  ruptures  while  it  is 
being  removed.  This  condition  is  rarely  seen  when  the  stomach  is  empty. 
It  can  scarcely  be  mistaken  for  a  pathological  condition,  if  its  occurrence 
is  borne  in  mind. 

Follicular  gastritis. — This  is  usually  seen  in  connection  with  catarrhal 
inflammation,  but  it  may  form  the  most  important  feature  of  the  lesion. 
The  cases  are  quite  rare.  I  have  met  with  one  marked  example  in  an 
infant  three  weeks  old.  The  others  I  have  seen  were  associated  with  ileo- 
colitis. The  characteristic  feature  is  inflammation  of  the  solitary  lymph 
nodules  of  the  stomach,  which,  like  those  in  the  colon,  undergo  swelling, 
softening,  and  ulceration.  The  lesion  can  not  be  recognised  by  the  naked 
eye,  unless  ulcers  are  present.  These  appear  rather  thinly  scattered  over 
the  mucous  membrane  of  the  stomach,  about  a  line  in  diameter.  They 
are  seldom  closely  set  as  in  the  intestine.  Large  follicular  ulcers  I  have 
never  seen.  Under  the  microscope  the  ulcers  are  seen  to  be  in  all  respects 
similar  to  those  found  in  the  colon,  except  that  they  are  smaller  and  more 
superficially  situated,  generally  being  entirely  in  the  mucosa. 

Membranous  gastritis. — This  is  even  more  rare  than  the  varieties  pre- 
viously mentioned.  I  have  met  with  it  but  four  times.  One  case  was 
associated  with  a  membranous  colitis ;  a  second  case  with  pseudo-diph- 
theria of  the  fauces  and  larynx  in  an  infant  but  six  weeks  old.  The 
oesophagus  was  not  involved  in  this  case;  and  indeed  it  often  escapes. 
No  Loeffler  bacilli  could  be  found  either  in  cover-slip  preparations  or  by 
culture.  Both  these  cases  have  been  very  fully  reported  by  Dr.  ]\Iartha 
Wollstein.*  To  the  naked  eye  the  membrane  appears  as  of  a  grayish- 
green  colour;  it  is  adherent,  but  can  be  detached  in  quite  large  patches. 
Only  a  portion  of  the  stomach  was  covered  in  any  of  the  cases ;  in  two 
the  principal  disease  was  about  the  p3dorus ;  in  another  along  the  greater 
curvature.  In  Fenwick's  case  the  entire  surface  of  the  stomach  was 
lined  with  membrane.  The  microscopical  appearances  resemble  those  of 
membranous  colitis.  There  is  a  pseudo-membrane  composed  of  fibrin, 
granular  matter,  epithelial  cells,  and  bacteria.  The  mucosa  shows  a  mod- 
erately dense  infiltration  with  round  cells,  and  in  places  superficial  ulcera- 
tion. There  is  also  infiltration  of  the  submucosa,  and  in  some  places  even 
the  muscular  coat  is  involved. 

Membranous  gastritis  occurring  in  patients  dying  of  diphtheria  has 
been  described  by  Smirnow,  Andral,  Eilliet  and  Barthez,  Cahn,  Fenwick, 
and  others,  but  I  have  not  been  able  to  find  any  case  in  which  the  diag- 
nosis of  true  diphtheria  of  the  stomach  was  confirmed  by  cultures. 

*  Archives  of  Paediatrics,  July,  1892.  Here  will  be  found  an  excellent  summary  of 
the  literature  of  membranous  gastritis. 


ACUTE   GASTRITIS.  295 

Corrosive  gastritis  [toxic  rjastritis). — This  form  of  inflammation  is 
excited  by  various  irritating  and  caustic  substances,  which  are  usually 
taken  by  accident,  sometimes  for  the  purpose  of  producing  emesis.  The 
most  frequent  substances  are  carbolic  acid,  caustic  alkalies,  mineral  acids, 
arsenic,  salts  of  copper,  zinc,  or  antimony,  croton  oil,  and  corrosive  sub- 
limate. 

The  lesions  in  the  stomach  depend  upon  the  amount  of  the  substance 
swallowed,  the  degree  of  concentration,  and  whether  the  stomach  was 
full  or  empty  at  the  time.  Strong  caustics,  whether  acids  or  alkalies, 
usually  act  more  deeply  and  extensively  in  the  pharynx  and  oesophagus, 
for,  owing  to  the  spasmodic  contraction  of  the  muscles  of  these  parts, 
often  but  a  small  amount  of  the  substance  reaches  the  stomach.  Concen- 
trated irritant  poisons  produce  in  the  stomach  irregular  ulcers,  especially 
along  the  greater  curvature,  which  may  be  so  deep  as  to  cause  perforation, 
or  they  may  affect  the  mucous  membrane  only.  In  severe  cases  death 
takes  place  early,  often  in  a  few  hours.  Dark,  ragged  ulcers  are  found  in 
the  stomach,  the  surrounding  mucous  membrane  is  the  seat  of  intense 
congestion,  and  in  places  there  are  extravasations  of  blood.  If  death  is 
later  there  are  evidences  of  intense  inflammation,  sometimes  with  the  pro- 
duction of  pseudo- membrane.  If  the  amount  of  poison  is  not  sufficient 
to  cause  death,  and  if  the  patient  recovers  from  the  consecutive  gastritis, 
a  cicatricial  condition  of  the  stomach  results,  which  may  later  lead  to 
stenosis  of  the  pylorus  or  other  deformity  of  the  organ. 

Symptoms. — Catarrhal  gastritis  can  not  be  distinguished  in  its  begin- 
ning from  an  attack  of  acute  indigestion.  There  are  fever,  pain,  vomiting, 
thirst,  loss  of  appetite,  coated  tongue,  and  prostration.  The  presence  of 
inflammatory  changes  is  indicated  by  the  continuance  of  these  symptoms, 
particularly  the  pain,  vomiting,  fever,  and  thirst.  With  the  pain  there 
may  be  epigastric  tenderness.  All  food  or  liquids  are  immediately  re- 
jected, and  even  when  nothing  is  taken  the  retching  and  vomiting  may 
continue,  nothing  but  frothy  mucus  or  serum  being  brought  up,  some- 
times streaked  with  blood.  The  vomited  matters  are  usually  very  sour ; 
they  may  be  bilious.  The  temperature  is  high  only  at  the  outset.  After 
the  first  or  second  day  it  usually  ranges  between  100°  and  101-5°  F. 
Thirst  is  intense,  and  all  liquids  are  taken  with  avidity,  especially  if  cold, 
even  though  they  are  immediately  vomited.  The  tongue  is  thickly  coated 
with  a  white  fur,  and  the  breath  may  be  foul.  The  constitutional  symp- 
toms are  generally  most  severe  at  the  outset.  The  usual  duration  of  such 
attacks  is  four  to  seven  days,  but  with  improper  management,  especially 
injudicious  feeding,  the  disease  may  be  much  prolonged.  One  attack  may 
follow  another  until  a  chronic  condition  is  established.  In  most  of  the  cases 
there  is  some  disturbance  of  the  intestines,  usually  a  sharp  attack  of  diar- 
rhoea. Sometimes  the  gastric  symptoms  subside  after  a  few  days  and  those 
of  the  intestine  become  the  predominant  ones.      The  symptoms  above 


296  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

given  are  those  of  infancy.  In  older  children  there  is  less  of  fever,  pros- 
tration, and  djarrhoia,  but  pain  and  vomiting  are  prominent.  The  attacks 
are  usually  shorter  and  altogether  less  severe. 

The  rare  cases  of  follicular  gadritis  have  nothing  by  which  they  can 
be  distinguished  from  the  form  described,  except  a  more  prolonged  course 
and  a  greater  liability  to  haemorrhage,  blood  sometimes  being  vomited  in 
quite  large  amounts. 

Membranous  gastritis  also  presents  no  peculiar  symptoms.  In  fact, 
in  the  cases  I  have  personally  seen,  the  gastric  symptoms  were  insignifi- 
cant, and  the  condition  not  suspected  during  life. 

In  corrosive  gastritis  the  effects  of  the  caustic  may  be  seen  in  the 
mouth  and  pharynx,  the  mucous  membrane  being  of  a  gray  or  whitish 
colour.  There  are  felt  pain  and  a  sense  of  constriction  in  the  oesophagus 
and  stomach,  with  great  thirst.  Vomiting  follows  almost  immediately, 
and  the  matters  vomited  are  usually  bloody.  The  subsequent  course  in 
most  of  the  cases  is  the  rapid  development  of  collapse,  and  death  in  a  few 
hours  from  shock.  The  younger  the  child  the  sooner  does  the  case  ter- 
minate. In  irritant  poisoning  not  severe  enough  to  produce  death,  the 
symptoms  of  acute  gastritis  follow,  usually  accompanied  by  more  or  less 
enteritis  owing  to  the  passage  of  the  irritant  into  the  intestine.  There  is 
seen  a  continuance  of  the  vomiting,  pain  and  epigastric  distention,  and 
diarrhoea,  and  from  these  symptoms  death  may  result  in  two  or  three 
davs.  It  is  extremely  rare  in  infancy  for  the  jDatient  to  survive  both  the 
stage  of  shock  and  that  of  acute  inflammation,  so  that  the  deformities  of 
the  stomach  and  the  chronic  conditions  mentioned,  are  practically  never 
met  with  excepting  in  older  children. 

Treatment. — Cases  of  acute  catarrhal  gastritis  are  to  be  managed  very 
much  like  those  of  acute  gastric  indigestion.  Thirst  may  be  relieved  by 
swallowing  bits  of  ice.  Where  there  is  continuous  vomiting  of  acid 
mucus,  relief  is  sometimes  afforded  by  repeating  the  stomach-washing 
once  in  twelve  hours  with  a  1-per-cent  solution  of  bicarbonate  of  soda, 
xised  at  110°  F.  In  older  children,  beneficial  results  sometimes  follow  the 
use  of  bismuth  subcarbonate  (gr.  x  every  two  hours)  ;  but  in  infants  I 
must  confess  to  have  seen  but  little  effect  from  any  form  of  medication, 
the  reliance  being  upon  rest,  careful  feeding,  and  stomach-washing. 

Cases  of  corrosive  gastritis  require  special  treatment.  The  first  indica- 
tion is  to  administer  the  proper  chemical  antidote  to  the  substance  swal- 
lowed, and  the  next  to  use  bland  mucilaginous  or  oily  fluids,  such  as 
milk,  albumin-water,  oils  in  large  quantities,  etc.  Especially  should  stom- 
ach-washing be  avoided.  Opium  is  always  required,  on  account  of  pain, 
and  should  be  given  hypodermically.  The  general  symptoms  are  to  be 
treated  according  to  the  indications  of  the  individual  case. 


GASTRO-DUODENITIS.  297 

GASTRO-DUODENITIS. 

This  is  a  catarrhal  inflammation  of  the  stomach  and  duodenum. 
Sometimes  only  the  duodenum  is  involved.  The  inflammation  commonly 
extends  from  the  intestine  to  the  common  bile  duct,  the  swelling  of  which 
causes  jaundice.  The  term  gastro-duodenitis  is  sometimes  used  synony- 
mously with  catarrhal  jaundice.  The  condition  is  a  rare  one  in  young 
children,  and  especially  so  in  infancy.  I  have  never  seen  it  in  a  child 
under  two  years. 

The  causes  are  for  the  most  part  obscure.  It  occasionally  complicates 
malarial  fever.  I  have  twice  seen  it  with  influenza,  and  it  may  occur  with 
any  of  tlie  infectious  diseases,  llehn  has  described  a  form  which  occurred 
epidemically. 

The  symptoms  of  the  disease  are  quite  uniform.  When  primary,  the 
onset  is  like  an  ordinary  attack  of  indigestion,  with  vomiting,  pain,  slight 
fever,  and  a  moderate  amount  of  prostration.  The  vomiting  in  some  of 
the  cases  is  repeated  for  several  days.  The  pain  may  be  quite  severe,  and 
localized  in  the  region  of  the  duodenum.  It  may  be  associated  with 
tenderness  in  this  region.  The  bowels  are  usually  constipated.  After 
three  or  four  days,  icterus,  which  is  the  only  diagnostic  symptom,  appears. 
It  is  first  seen  in  the  conjunctiva,  afterward  in  the  skin,  varying  in  degree 
according  to  the  severity  of  the  attack,  but  in  most  cases  not  being  very 
intense.  It  is  accompanied  by  the  regular  symptoms  of  obstructive  jaun- 
dice. The  stools  are  gray,  sometimes  white;  there  is  a  marked  amount 
of  intestinal  flatulence.  The  urine  is  very  dark,  of  a  yellowish-green  or 
bronze  hue,  and  stains  the  clothing.  There  is  complete  anorexia ;  the 
tongue  is  thickly  coated  with  a  white  fur.  There  are  headache,  dulness, 
and  languor,  and  the  patient  feels  generally  wretched.  The  slow  pulse 
and  the  itching  skin  are  uncommon  symptoms  in  children.  The  liver  is 
usually  found,  upon  examination,  slightly  enlarged,  and  sometimes  tender 
on  pressure.  The  duration  of  the  disease  is  about  two  weeks,  the  general 
symptoms  disapjiearing  before  the  icterus. 

The  diagnosis  rarely  presents  any  difficulty,  and  the  prognosis  is  inva- 
riably good. 

Treatment. — In  the  diet,  fats  and  starches  should  be  reduced  to  a  low 
point  or  be  entirely  prohibited.  Patients  usually  do  much  better  upon  a 
diet  of  rare  meat,  fruit,  and  a  moderate  amount  of  milk.  If  there  is  very 
much  vomiting,  the  milk  should  be  largely  diluted  with  limewater  or 
partially  peptonized.  The  amount  of  food  given  should  be  small,  but  water 
should  be  allowed  freely,  particularly  the  mineral  waters.  The  bowels 
should  be  opened  every  other  day  by  calomel,  followed  by  a  saline  purga- 
tive. In  most  of  the  cases  no  other  treatment  is  necessary.  When  the 
pain  is  severe  it  may  be  relieved  by  counter-irritation  by  mustard,  tur- 
pentine, or  even  cantharides.     The  gastric  symptoms  should  be  managed 


298  DISEASES   OF  THE   DIGESTIVE  SYSTEM. 

like  those  of  ordinary  acute  gastritis.     The  restricted  diet  should  in  all 
cases  be  continued  for  at  least  a  week  after  the  jaundice  has  disappeared. 

CHRONIC   GASTRIC   INDIGESTION— CHRONIC   GASTRITIS— GASTRIC 

CATARRH. 

Although  from  a  pathological  point  of  view  these  conditions  are  not 
identical,  from  a  clinical  standpoint  there  is  no  advantage  in  attempting 
to  separate  them.  Nothing  distinguishes  chronic  indigestion  from  chronic 
gastritis  except  that  in  the  latter,  in  addition  to  continued  derangement 
of  function,  there  is  a  great  increase  in  the  production  of  gastric  mucus. 
Chronic  indigestion  seldom  exists  long  without  the  production  of  a  slight 
amount  of  catarrhal  inflammation.  This  is  usually  of  a  very  low  grade. 
This  condition  in  the  stomach  seldom,  if  ever,  exists  without  more  or  less 
involvement  of  the  intestine,  and  in  the  majority  of  cases  the  intestinal 
condition  is  the  more  important.  In  some,  however,  the  gastric  symp- 
toms predominate,  and  it  is  only  those  which  are  here  considered. 

Etiology. — Chronic  gastric  indigestion  may  follow  acute  attacks,  or 
it  may  be  chronic  from  the  outset.  If  the  latter,  it  depends  in  infancy 
upon  the  continued  use  of  improper  food  or  bad  habits  of  feeding.  It 
also  complicates  most  of  the  constitutional  diseases  of  infancy,  esi^ecially 
rickets,  syphilis,  tuberculosis,  malnutrition,  and  marasmus.  It  may  follow 
any  of  the  acute  infectious  diseases.  In  older  children  it  is  chiefly  due  to 
the  use  of  improper  food,  sometimes  to  the  habit  of  rapid  eating  and 
insufficient  mastication.  It  is  associated  with  constitutional  diseases  as 
in  infancy,  and  may  complicate  valvular  disease  of  the  heart. 

Lesions. — The  changes  found  in  chronic  gastritis  are  usually  confined 
to  the  mucosa.  In  the  mild  form  there  are  degenerative  changes  of  the 
epithelium  of  the  tubules,  with  increased  production  of  mucus ;  there 
may  be  a  slight  infiltration  of  the  mucosa  with  round  cells.  The  more 
severe  form,  with  marked  cell  infiltration  and  the  production  of  new  con- 
nective tissue,  is  extremely  rare.  The  submucous  coat  may  be  thickened 
and  the  muscular  coat  attenuated.  The  lesion  can  not  be  recognised  by 
the  naked  eye.  The  stomach  is  apt  to  appear  more  or  less  dilated,  and 
its  surface  is  coated  with  thick  and  very  adherent  mucus.  This  lesion 
rarely  exists  alone,  practically  never  in  infancy,  but  is-  associated  with 
similar  lesions  in  the  intestines,  the  latter  being  more  severe. 

Symptoms. — In  infants.— Fov  our  knowledge  of  the  conditions  exist- 
ing in  the  stomach  in  chronic  indigestion  we  are  indebted  to  the  work 
chiefly  of  Cassel,  Leo,  Troitzky,  and  Wohlmann.  Tiiere  is  in  most  cases 
an  excessive  production  of  mucus  which  is  tough  and  adherent,  and  may 
interfere  with  digestion,  even  though  secretions  are  normal.  Mucus  is 
especially  abundant  in  young  infants.  The  reaction  of  the  stomach  is 
almost  invariably  acid.  The  rennet  ferment  is  always  present.  Pepsin  is 
found  in  nearly  all  if  not  in  all  the  cases.     Hydrochloric  acid  is  generally 


CHRONIC   GASTRIC   IXDIGESTIOX.  299 

very  scanty;  but  is  increased  by  irrigating  the  stomach.  Fermentation 
takes  place,  particularly  in  the  fats  and  in  the  gastric  mucus.  The  results 
of  fermentation  are  the  production  of  lactic,  acetic,  butyric  and  other 
volatile  fatty  acids.  New  products  are  also  formed  from  the  decomposi- 
tion of  albumin,  and  gases  are  always  present.  Food  remains  long  in  the 
stomach  because  of  motor  inactivity,  which  is  partly  the  cause  and  partly 
the  result  of  the  disease.  It  often  continues  after  all  other  symptoms 
have  disappeared. 

The  most  constant  symptom  is  vomiting.  This  is  rarely  absent,  and 
it  may  take  place  at  any  time  after  feeding.  Some  infants  vomit  regu- 
larly within  half  an  hour  or  an  hour  after  feeding,  some  only  occasionally 
and  at  longer  intervals.  The  vomited  matters  consist  of  food,  often  that 
which  has  been  given  six  or  eight  hours  before,  and  mucus,  which  may  be 
in  large  quantities,  as  much  as  an  ounce  at  a  time.  The  food  remains 
long  in  the  stomach.  This  is  best  ascertained  by  stomach-washing.  In- 
stead of  being  empty  in  two  or  three  hours,  as  the  stomach  should  be, 
food  is  almost  invariably  found  four  or  five  hours,  and  in  some  cases  six 
or  eight  hours,  after  feeding.  This  is  one  of  the  most  constant  and 
conclusive  signs  of  gastric  indigestion. 

Undigested  food,  especially  casein,  appears  in  the  stools.  The  appetite 
maybe  good  or  it  may  be  very  poor.  As  a  rule,  children  take  less  food 
than  in  health.  The  tongue  is  usually  coated ;  there  are  signs  of  general 
malnutrition ;  there  are  seen  fretfulness  and  irregular  or  disturbed  sleep ; 
most  children  cry  a  great  deal,  but  some  are  unnaturally  quiet ;  the 
weight  is  stationary,  or  there  is  steady  loss ;  there  is  also  anaemia,  and 
the  child's  development  is  arrested.  There  is  always  some  derange- 
ment of  the  bowels,  occasionally  constipation  with  the  constant  presence 
of  masses  of  undigested  food  in  the  stools,  but  more  frequently  there  is 
diarrhoea.  There  may  be  dilatation  of  the  stomach.  This  is  especially 
liable  to  occur  in  rachitic  children  where  overfeeding  has  long  been 
practised. 

The  course  of  these  symptoms  is  indefinite.  There  is  little  tendency 
to  spontaneous  recovery,  and  they  often  go  on  for  several  months,  until 
some  intercurrent  disease  develops  which  proves  fatal. 

The  prognosis  depends  upon  the  age  of  the  patient,  the  duration  of 
the  disease,  the  surroundings,  and  upon  how  well  treatment  can  be  carried 
out.  In  infants  under  three  months  the  prognosis  as  to  life  is  often  bad. 
If  children  live  to  the  age  of  seven  or  eight  months,  they  may  recover  with 
proper  treatment.  These  patients  do  much  better  in  private  practice  than 
in  institutions.  Much  depends  upon  the  co-operation  of  an  intelligent 
mother  or  nurse.  Chronic  gastric  indigestion  is  not  dangerous  to  life 
except  in  very  young  infants.  Its  principal  danger  consists  in  the  pre- 
disposition it  gives  to  acute  diarrhoeal  diseases  in  summer.  Such  patients 
are  almost  certain  to  be  attacked,  and  are  verv  likelv  to  succumb.     It  may 


300  DISEASES   OP   THE   DIGESTIVE  SYSTEM. 

also  lead  to  the  development  of  marasmus.  Chronic  indigestion  increases 
very  much  the  danger  from  all  acute  diseases. 

Ill  older  children. — In  all  cases  the  most  constant  symptom  is  vomit- 
ing, which  may  occur  regularly  after  meals,  or  only  in  the  morning 
before  breakfast.  If  the  latter,  the  vomited  matters  consist  chiefly  of 
mucus.  In  addition  to  these  regular  attacks  there  may  be  the  frequent 
regurgitation  of  small  quantities  of  food.  There  are  gastric  flatulence 
and  pain,  due  to  hyperacidity  or  to  acid  fermentation.  The  appetite  is 
variable — sometimes  inordinate,  sometimes  entirely  lost ;  it  may  be  capri- 
cious, there  being  usually  a  craving  for  highly  seasoned  food.  The  tongue 
is  constantly  furred,  and  the  breath  usually  disagreeable.  These  symp- 
toms are  seen  in  all  degrees  of  severity.  Intestinal  disturbances  are  not 
so  frequent  as  in  infancy.  Constipation  is  more  common  than  diarrhoea. 
The  general  symptoms  are  those  of  malnutrition.  There  are  anaemia, 
wasting,  constant  fretfulness,  disturbed  sleep,  and  various  other  nervous 
disorders.  These  symptoms,  as  in  the  case  of  infants,  may  continue  in- 
definitely; there  is  little  tendency  to  spontaneous  recovery,  but  under 
favourable  circumstances,  with  constant  care,  much  may  be  done  for  all 
these  patients  and  many  of  them  may  be  completely  cured. 

Treatment. — Infants. — The  general  treatment  is  too  apt  to  be  ignored, 
but  it  is  just  as  important  as  measures  directed  more  specifically  to  the 
stomach.  A  large,  roomy  nursery,  and  plenty  of  fresh  air  by  night  and 
by  day,  are  very  important ;  sometimes  under  the  influence  of  these  alone 
improvement  begins.  General  friction  of  the  body  with  cocoa-butter  is 
useful  in  delicate  children  with  poor  circulation.  Infants  must  be  prop- 
erly covered,  and  it  is  of  the  utmost  importance  that  the  feet  be  kept 
warm.  Of  the  measures  directed  to  the  stomach,  only  two  are  to  be  de- 
pended upon — stomach-wasiiing  and  diet. 

Stomach-washing  (page  GO)  is  useful,  first,  in  removing  the  mucus 
which  is  so  abundant  in  most  of  these  cases;  secondly,  in  cleansing  the 
organ  thoroughly  at  least  once  a  day,  this  of  itself  is  a  most  important 
result;  thirdly,  as  a  stimulant  to  the  gastric  secretions,  especially  hydro- 
chloric acid.  Plain  boiled  water,  or  a  weak  alkaline  solution — sodium 
bicarbonate,  one  drachm  to  the  pint — may  be  employed.  In  the  early 
part  of  the  treatment  the  washing  should  be*  done  daily ;  later,  every 
second  or  third  day.  The  time  selected  is  not  very  important,  but  it  is 
better  to  make  this  about  three  hours  after  feeding.  The  mother  or  nurse 
may  easily  be  taught  to  wash  the  stomach,  so  that  it  may  be  done  as  fre- 
quently and  for  as  long  a  period  as  circumstances  require. 

In  the  matter  of  diet,  the  general  purpose  should  be  to  give  the  stom- 
ach as  little  to  do  as  possible,  throwing  for  the  time  the  burden  of  the 
work  of  digestion  upon  the  intestine.  As  the  greatest  diflficulty  is  in  the 
digestion  of  casein,  it  is  usually  better,  in  the  case  of  a  young  infant — i.  e., 
one  under  six  months — to  secure  a  wet-nurse.     But  this  may  not  succeed 


CHRONIC   GASTRIC  INDIGESTION.  301 

as  well  as  artificial  feeding,  as  it  is  in  our  power  to  modify  the  food  only 
to  a  limited  extent.  Where  a  good  wet-nurse  can  not  be  oljtained,  or 
where  even  breast  milk  is  not  tolerated,  cow's  milk  should  be  tried.  In 
modifying  cow's  milk,  it  should  not  be  forgotten  that  the  fat  as  well  as 
the  casein  may  be  a  source  of  trouble.  With  the  milk  sugar  there  is 
usually  no  difficulty.  The  b^^st  results  are  obtained  by  beginning  witli 
such  formulae  as  XVII  or  XVIII  (page  17(5),  obtained  by  diluting  plain 
milk  with  a  sugar  solution.  In  these,  both  the  proteids  and  fat  are  very 
low  and  the  sugar  relatively  higli.  The  ])roportions  of  the  first  two  in- 
gredients may  be  gradually  increased  as  the  case  improves.  If  this  plan 
fails,  the  milk  may  be  completely  peptonized  (page  148)  before  it  is  di- 
luted. Partially  pejitonizing  is  frequently  no  better  than  the  above  modi- 
fication used  alone.  In  very  obstinate  cases  whey  (page  152)  may  be  tried, 
and  may  be  retained  when  even  the  small  proportion  of  fat  and  casein 
in  the  forniula3  mentioned,  causes  disturbance.  Often  where  no  casein 
can  be  tolerated,  raw  beef  juice  or  some  of  the  beef  peptones,  such  as 
Mosquera's  beef  jelly,  are  assimilated  witliout  difficulty,  and  may  be  used 
exclusively  for  days  at  a  time.  In  infants  over  six  mouths  old  some  fari- 
naceous food,  such  as  a  thin  gruel  of  barley  or  arrowroot,  may  be  given 
alternately  with  the  beef  preparations;  or  one  of  the  malted  foods  may  be 
used  in  the  same  way.  Other  suggestions  regarding  diet  will  be  found 
111  the  chapter  on  Feeding  of  Difficult  Cases  during  the  First  Year  (page 
ISU). 

The  quantity  of  food  given  at  one  time  and  the  frequency  of  feeding 
are  also  important.  Under  no  circumstances  should  an  infant  with 
clironic  indigestion  be  fed  oftener  than  once  in  three  hours,  and  in  many 
cases  the  interval  for  children  over  three  months  of  age  should  be  four 
hours.  The  bottle  should  always  be  taken  away  in  twenty  minutes  after 
the  meal  has  begun.  The  number  of  meals  in  a  day  should  bo  the  same 
as  for  healthy  infants.  The  amount  of  food  should  always  be  rather  less 
than  that  required  by  a  healthy  infant  of  the  same  age.  It  is  wise  to 
begin  with  about  half  the  quantity,  gradually  increasing  as  the  child's 
powers  of  digestion  improve.  Gavage  is  sometimes  useful  where  vomit- 
ing is  frequent  and  can  not  be  controlled.  Food  administered  in  this 
way  may  be  retained,  when  it  is  immediately  vomited  if  given  from  the 
bottle  or  the  spoon. 

Drugs  have  a  very  limited  application  in  these  cases.  Usually  they  are 
too  much  employed.  The  majority  of  patients  do  better  when  they  are 
withheld  entirely.  They  may  be  useful  for  particular  symptoms.  Alka- 
lies may  temporarily  relieve  cases  with  excessive  acid  fermentation.  Small 
doses  of  strychnine  or  nux  vomica  may  stimulate  the  motor  activity  of  the 
muscular  walls  of  the  stomach.  Hydrochloric  acid  at  times  may  decidedly 
improve  the  digestion  where  it  is  given  well  diluted  after  meals;  often, 
however,  it  causes  vomiting.     Almost  all  the  indications  mentioned  are 


302  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

more  promptly  and  efficiently  met  by  stomach-washing  than  by  the  other 
means  referred  to. 

The  management  of  these  cases  in  older  children  must  be  conducted 
along  the  lines  laid  down  for  infants.  In  them,  stomach-washing  can  not 
be  employed,  and  other  means  must  be  used  to  clear  the  stomach  of 
mucus.  The  best  is  undoubtedly  the  use  of  large  draughts  of  water, 
as  hot  as  can  be  borne,  an  hour  before  eating.  From  six  to  eight  ounces 
should  be  taken,  preferably  slowly  by  sipping.  To  this  may  be  advan- 
tageously added,  in  many  cases,  fifteen  or  twenty  grains  of  bicarbonate 
of  soda. 

The  diet  should  consist  of  milk  diluted  at  least  three  times,  kumyss  or 
matzoon,  beef  juice,  raw  meat,  beef  peptones,  and  a  moderate  amount  of 
starchy  food,  preferably  dried  bread  or  zwieback.  Sweet  fruits,  and  in 
many  cases  all  fruits,  must  be  avoided.  The  amount  of  water  taken  at 
mealtime  should  be  carefully  restricted.  Beneficial  results  are  obtained 
in  most  of  these  cases  by  the  use  of  nux  vomica  or  simple  bitters  before 
meals,  and  the  regular  administration  of  hydrochloric  acid  (gtt.  v  to  viii 
of  the  dilute  acid)  shortly  after  meals.  All  pastry,  sweets,  nuts,  and  can- 
dies must  be  absolutely  prohibited.  With  improvement  in  the  symptoms 
green  vegetables  may  be  added  to  the  diet,  and  the  amount  of  starchy 
food  increased.  The  general  treatment  must  not  be  neglected.  The 
patient  should  lead  an  out-of-door  life  as  much  as  possible,  and  regular 
but  very  moderate  exercise  allowed.  Great  caution  is  necessary  against 
overfatigue.  Iron  may  be  given  in  most  cases  daring  convalescence;  but 
cod-liver  oil  should  be  carefully  avoided  until  the  gastric  symptoms  have 
quite  disappeared.  Kelapses  are  easily  excited,  and  the  most  constant  care 
regarding  the  food  must  be  maintained  for  months,  or  even  years. 

DILATATION  OF  THE  STOMACH. 

Moderate  dilatation  of  the  stomach  is  quite  a  frequent  condition,  al- 
though it  is  not  so  large  a  factor  in  the  disorders  of  digestion  in  infancy 
and  childhood,  as  many  who  have  written  upon  the  subject  would  lead  us 
to  believe.  A  very  marked  degree  of  dilatation  is  rare,  but  in  these  cases 
its  recognition  is  important  and  its  treatment  difficult. 

Dilatation  is  almost  invariably  regular  or  cylindrical ;  it  is  usually  most 
marked  at  the  cardiac  extremity  (Fig.  48).  Cases  of  irregular  or  saccular 
dilatation,  except  when  associated  with  cicatricial  conditions,  are  of  some- 
what doubtful  occurrence.  The  irregular  shapes  of  the  stomach  found  at 
autopsy,  dependent  upon  the  contraction  of  the  muscular  coats,  may  be 
easily  mistaken  for  hour-glass  contraction  or  saccular  dilatation.  The 
degree  of  dilatation  may  be  very  great;  thus,  the  stomach  of  a  child  three 
months  old  measured  at  autopsy  nine  ounces;  another,  four  and  a  half 
months  old,  ten  ounces ;  and  in  one  extreme  case,  the  stomach  of  a  two- 
weeks  old  baby  was  dilated  to  the  capacity  of  seventeen  ounces.     The 


DILATATION   OF   THE  STOMACH.  3(j3 

greatest  dilatation  I  have  measured  during  life  was  in  a  child  four  months 
old,  where  the  stomach  held  twelve  ounces. 

In  very  rare  instances  dilatation  may  result  from  congenital  stenosis 
of  the  pylorus.  The  most  important  predisposing  cause,  however,  is  the 
muscular  atony  which  accompanies  rickets.  It  is  found  to  a  slight  degree 
in  almost  all  severe  cases  of  rickets.  The  principal  exciting  causes  are 
continued  distention  from  overfeeding  and  chronic  indigestion. 

In  most  cases  the  only  symptoms  are  those  of  the  chronic  indigestion 
which  almost  invariably  accompanies  dilatation.  If  there  is  pyloric  steno- 
sis, vomiting  is  present.  In  young  infants  the  pressure  symptoms  may  be 
very  serious.  This  is  particularly  true  in  infants  with  acute  bronchitis  or 
broncho-pneumonia,  or  in  those  with  atelectasis.  In  these  patients  I  have 
seen  very  grave  symptoms  accompany  the  rapid  distention  of  a  dilated 


Fig.  48.— A,  dilated  stomach  from  rachitic  child  of  six  months;  B,  stomach  of  healthy  child 
ot  same  age.     (Outlines  reduced  from  photographs.) 

stomach,  and  in  one  very  delicate  infant  of  three  months  this  was  appar- 
ently the  cause  of  death.  A  positive  diagnosis  of  dilatation  is  only 
made  by  the  physical  signs.  There  are  epigastric  fulness  and  distention, 
and  in  some  very  thin  patients  the  outline  of  the  stomach  can  be  distinctly 
seen.  Dilatation  of  the  transverse  colon,  however,  may  be  mistaken  for 
dilatation  of  the  stomach.  In  the  latter,  the  lower  outline  is  convex,  while 
in  the  former  it  is  usually  slightly  concave.  The  most  satisfactory  means 
of  diagnosis  is  by  percussion.  The  examination  should  be  made  three  or 
four  hours  after  feeding,  at  which  time  the  whole  abdomen  is  apt  to  be 
tympanitic.  The  stomach  should  then  be  filled  with  water;  the  lower 
limit  of  the  area  of  flatness  will  be  the  lower  border  of  the  stomach.  This 
is  much  more  satisfactory  than  determining  the  outline  after  the  genera- 
tion of  gas  in  the  stomach.  If  the  lower  border  comes  nearly  to  the 
umbilicus  the  stomach  is  dilated  ;  if  it  is  below  the  umbilicus,  it  is  much 
dilated.  In  many  cases  the  capacity  of  the  stomach  can  be  measured  by 
simply  seeing  how  much  water  can  be  easily  introduced  into  it  by  means 
of  the  funnel  and  stomach  tube. 
21 


304  DISEASES   OF  TDE   DIGESTIVE   SYSTEM. 

The  prognosis  in  dilatation  of  the  stomach  is  good  except  when  it  is 
due  to  pyloric  stenosis.  If  the  infant  has  any  acute  or  chronic  pulmo- 
nary disease,  dilatation  of  the  stomach  may  add  to  the  discomfort  and 
even  the  danger  from  that  condition. 

In  the  management  of  these  cases  the  first  point  is  to  reduce  the  size 
of  the  meals,  and  to  regulate  the  diet  in  accordance  with  the  general  plan 
outlined  in  the  chapter  on  Chronic  Indigestion.  If  the  dilatation  is 
marked,  the  stomach  should  be  washed  once  a  day.  The  general  condition 
of  the  patient  usually  requires  tonics,  the  best  of  which  is  strychnine ;  and 
rickets,  if  present,  should  receive  its  appropriate  constitutional  treatment. 

ULCER  OF  THE  STOMACH. 

Ulceration  of  the  stomach  may  be  found  in  connection  with  several 
pathological  processes  which  are  quite  distinct  from  one  another  : 

1.  Ulcers  in  the  newly  born.  These  have  already  been  referred  to  in 
the  chapter  on  Hemorrhages  of  the  Newly  Born  (page  101).  The  only 
characteristic  symptom  is  haemorrhage. 

2.  Ulcers  resulting  from  follicular  gastritis.  These  also  are  not  fre- 
quent. As  a  rule  they  give  no  symptom  except  those  of  gastritis,  although 
in  several  cases  I  have  known  severe  haBmorrhage  to  result  from  them. 
These  cases  will  be  considered  in  the  next  chapter. 

3.  Tuberculous  ulcers.  These  are  quite  rare.  I  have  met  with  gastric 
ulcers  but  five  times  in  one  hundred  and  nineteen  autopsies  on  tubercu- 
lous cases ;  however,  the  evidence  was  not  conclusive  in  all  of  them  that 
the  ulcers  were  tuberculous.  Usually  there  were  many  small  ulcers ;  in 
one  case  but  two  were  present,  the  larger  one  being  nearly  three  fourths  of 
an  inch  in  diameter,  and  situated  on  the  posterior  wall  near  the  middle  of 
the  greater  curvature.  All  but  one  of  these  cases  were  in  infants,  one 
child  being  only  ten  months  old.  The  ulcers  gave  no  symptoms  during 
life,  and  death  took  place  from  general  tuberculosis.  This  is  the  history 
of  nearly  all  the  few  cases  on  record.  In  one,  however,  reported  by  Casin, 
a  tuberculous  ulcer  perforated  the  stomach  and  caused  death  from  peri- 
tonitis. Active  symptoms — bloody  vomiting  and  bloody  stools — were  ex- 
cited by  the  use  of  an  emetic. 

4.  Eound  perforating  ulcers.  These  are  in  their  pathology  essentially 
the  same  as  similar  ulcers  in  the  adult.  I  have  found  but  three  cases  on 
record  in  non-tuberculous  patients.  Two  were  in  young  children.  Eei- 
mer's  *  case,  three  and  a  half  years  old,  had  bloody  vomiting  and  stools 
for  several  days  before  death  took  place  as  a  result  of  perforation. 
Colganf  has  recently  added  another  case  in  a  child  two  and  a  half  years 
old,  where  no  symptoms  were  present  until  twelve  hours  before  death, 

*  Jahrb.  fiir  Kinderh.,  x,  p.  289. 

f  Medical  News.  Philadelphia,  October,  1892. 


n^MORRHAGE  FROM  THE  STOMACn.  305 

when  perforation  occurred.  The  characteristic  symptoms  of  ulcer  before 
perforation,  are  gastric  pain  and  tenderness,  vomiting  of  blood,  and  often 
bloody  stools.  Perforation  is  accompanied  by  collapse,  sometimes  by  high 
temperature,  the  rapid  development  of  tympanites,  and  death  from  shock 
or  from  peritonitis. 

The  prognosis  is  bad  in  all  forms  of  nicer  of  the  stomach,  except  the 
small  follicular  variety.  In  this,  however,  the  diagnosis  can  not  positively 
be  made  excepting  by  gastric  haemorrhage,  and  it  is  only  this  which  makes 
these  cases  serious. 

Treatment. — The  treatment  is  absolute  rest,  ico,  small  doses  of  opium, 
rectal  feeding,  stimulants;  later,  bismuth,  arsenic,  or  nitrate  of  silver. 

HEMORRHAGE    FROM   THE   STOMACH  (HEMATEMESIS). 

The  most  frequent  variety  of  haemorrhage  from  the  stomach,  that  met 
with  in  the  newly  born,  has  already  been  considered.     (See  page  103.) 

I  have  met  with,  three  fatal  cases  in  young  infants,  the  eldest  being 
fifteen  months  old.  In  the  first  case  there  were  symptoms  of  ordinarv 
gastro-enteritis.  On  the  seventh  day  the  vomiting  of  blood  began,  and 
was  repeated  about  ten  or  twelve  times  during  the  next  twenty-four  hours, 
when  death  took  place.  The  blood  was  quite  abundant,  as  much  as  a 
drachm  of  red  blood  being  discharged  at  once.  At  autopsy  there  were 
found  in  the  stomach  about  two  ounces  of  dark-brown  fluid,  but  no  gross 
lesion  was  discovered,  and  no  explanation  of  the  bleeding.  This  haemor- 
rhage was  apparently  capillary.  In  the  second  case  there  were  symptoms 
of  acute  gastro-enteritis  of  thirty-six  hours'  duration.  After  this  time 
there  was  marked  abdominal  distention  with  symptoms  of  collapse;  then 
a  profuse  haemorrhage  from  the  stomach,  the  child  dying  while  vomiting 
blood.  At  least  half  a  pint  was  discharged.  The  stomach  contained  a't 
autopsy  two  ounces  of  dark  fluid  blood,  and  the  mucous  membrane  was 
filled  with  minute  ulcers  extending  quite  through  the  mucosa.  In  the 
third  case  there  was  no  vomiting  of  blood,  but  the  patient  died  with  symp- 
toms of  internal  hemorrhage.  There  was  blood  in  the  up})er  part  of  the 
intestine,  and  the  stomach  was  filled  with  blood;  it  contained  many  small 
follicular  ulcers  resembling  those  found  in  the  previous  case. 

Hemorrhage  from  the  stomach  may  occur  in  purpura,  haemophilia, 
scurvy,  and  rarely  in  malaria.  In  young  girls  about  puberty  it  may  be  a 
form  of  vicarious  menstruation.  Occasionally  blood  may  be  vomited  in 
cases  of  hemorrhagic  measles.  Two  cases  are  reported  in  wiiicli  fatal 
hemorrhage  followed  the  swallowing  of  a  foreign  body.  In  both,  vomiting 
of  blood  occurred  long  after  the  original  accident.  In  one  case  two  and 
a  half  years  had  elapsed.  The  autopsy  in  this  case  showed  impaction 
of  the  foreign  body  and  ulceration  into  the  arch  of  the  aorta.  Spurious 
hemorrhages  may  occur  where  blood  has  been  swallowed  and  then  vomited. 
The  source  of  this  is  most  frequently  the  nose  or  pharynx.     It  may  hap- 


306  DISEASES  OP   THE   DIGESTIVE  SYSTEM. 

pen  in  infants  at  the  breast,  where  the  blood  is  drawn  during  nursing  from 
a  fissure  or  ulcer  in  the  nipple.  The  amount  of  blood  vomited  under 
these  circumstances  may  be  large  enough  to  be  quite  alarming.  It  may 
be  recognised  by  the  child's  general  condition  being  normal,  and  by  the 
presence  of  fissures  or  ulcers  upon  the  nipple.  It  may  sometimes  be 
noticed  that  the  vomiting  of  blood  follows  nursing  from  one  breast  and 
not  from  the  other. 

Symptoms. — There  may  be  no  symptoms  except  those  of  internal  hsem- 
orrhage,  but  this  is  rare.  Usually  there  is  vomiting  of  blood,  and  blood 
appears  in  the  stools.  If  the  haemorrhage  is  rapid  and  vomiting  speedily 
occurs,  the  blood  may  be  of  a  bright-red  colour.  If  it  has  been  long  in  the 
stomach  it  is  of  a  dark-brown  or  black  colour  resembling  cofCee-grounds. 
The  stools  containing  blood  from  the  stomach  are  black  and  tarry  in 
appearance.  The  general  symptoms  will  depend  upon  the  amount  of 
blood  lost. 

In  a  case  where  blood  is  vomited,  the  first  point  is  to  distinguish  spu- 
rious from  true  gastric  haemorrhage.  The  nose  and  pharynx,  especially  its 
posterior  wall,  must  be  carefully  examined.  If  the  child  is  at  the  breast, 
the  nipples  should  be  scrutinized.  In  older  children  it  is  important  to 
distinguish  vomiting  of  blood  from  haemoptysis.  This  distinction  is  to 
be  made  in  accordance  with  the  rules  laid  down  in  text-books  on  adult 
medicine.  The  prognosis  is  bad  if  the  haemorrhage  is  due  to  ulcer,  if  it  is 
very  profuse,  or  if  it  occurs  in  young  infants.  When  it  occurs  in  connec- 
tion with  constitutional  diseases  the  prognosis  depends  upon  the  original 
disease. 

Treatment. — The  patient  should  be  kept  quiet,  preferably  upon  the 
back,  and  Monsel's  solution  administered  in  small  doses,  largely  diluted. 
Should  the  patient  show  signs  of  collapse,  stimulants  may  be  given  hy- 
podermically  or  by  the  rectum.  No  food  should  be  given  by  the  stomach 
until  some  time  after  the  haemorrhage  has  ceased. 


CHAPTER  VI. 

DISEASES  OF  THE  INTESTINES. 

MALFORMATIONS  AND  MALPOSITIONS. 

Malformations  are  not  very  frequent,  but  are  of  great  variety.  With 
the  exception  of  those  situated  at  the  lower  end  of  the  intestine  they  are 
not  of  much  practical  importance,  for  the  condition  is  such  ordinarily  as 
to  be  incompatible  with  life.  They  may  be  met  with  at  any  point  in  the 
canal,  but  most  frequently  they  are  in  the  rectum  and  anus.     Aside  from 


MALFORMATIONS   OF   THE   INTESTINES. 


307 


Fig.  49. — Malformationrt  of  the  rectum. 
K,  rectum. 


R 


A 

A, anus ; 


these,  malformations  of  the  large  intestine  are  much  less  common  than 
those  of  the  small  intestine. 

Malformations  of  the  Rectum. — In  Fig.  49  are  shown  the  usual  varieties 
of  malformation  of  the  rectum.  The  most  frequent  is  atresia  ani  (1). 
In  this  the  cutaneous  septum  has  not  been  absorbed,  but  the  intestine  is 
normal  to  its  lower  extreinity.  This  form  is  readily  curable  by  a  surgical 
operation.  In  the  next  variety  (2)  the  cutaneous  orifice  and  the  lower 
part  of  the  rectum  are  nor- 
mal,-but  a  membrane  sepa-  1 
rates  this  portion  from  tlie 
upper  part  of  the  gat.  This 
is  usually  situated  within  two 
or  three  inches  of  the  anus. 
The  bulging  of  the  lower  part 
of  the  distended  intestine  can 
usually  be  felt  by  the  finger 
in  the  rectum,  and  a  simple 
division  of  the  membrane  by 
a  guarded  bistoury  may  relieve 

the  condition.  The  third  form  (3)  is  more  serious.  Here  the  rectum 
terminates  in  a  blind  pouch  at  a  variable  distance  from  the  anus,  and  is 
represented  below  by  an  impervious  fibrous  cord.  The  diagnosis  of  this 
condition  can  not  positively  be  made  without  opening  the  abdominal 
cavity.  The  bulging  of  the  intestine  appreciable  by  the  finger  in  the 
rectum,  is  the  only  point  which  differentiates  the  preceding  variety  from 
this  one.  Instead  of  atresia  of  the  rectum  there  may  be  stenosis  of  varying 
degrees,  which  may  give  rise  to  the  usual  symptoms  of  stricture.  This 
is  often  curable  by  dilatation. 

Malformations  of  the  Small  Intestine. — There  may  be  stenosis  or 
atresia  at  any  point,  often  at  many  points.  Obstruction  is  much  more 
frequently  in  the  upper  than  in  the  lower  part  of  the  small  intestine,  the 
most  common  seat  being  the  duodenum.  Atresia  is  more  often  seen  than 
stenosis.  There  may  be  a  single  point  of  obstruction,  or  the  lumen  of 
the  intestine  may  be  obliterated  for  a  considerable  distance,  the  intestine 
being  represented  only  by  a  fibrous  cord  which  connects  the  two  open  por- 
tions, or  there  may  be  no  connection  between  them.  In  all  cases  the  in- 
testine above  is  found  very  greatly  distended,  and  that  below  empty  and 
usually  atrophied.  The  causes  of  these  multiple  deformities  are  mainly 
two — f(x>tal  peritonitis  and  volvulus.*  In  foetal  peritonitis  there  are 
usually  found  bands  of  adhesions  between  the  intestinal  coils,  and  between 


*Silbermann  (.Tahrb.  fiir  Kindorh..  Bd.  xviii,  p.  420)  makes  peritonitis  the  princi- 
pal oause,  while  (xaertner  (Jahrb.  fiir  Kinderh.,  Bd.  xx,  p.  403)  attril)ntcs  most  of  these 
deformities  to  volvulus. 


308  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

the  intestine  and  the  solid  viscera.  Syphilis  has  been  assigned  as  a  cause 
in  many  cases.  Volvulus,  or  a  twisting  of  the  intestine  during  its  devel- 
opment, is  a  more  satisfactory  explanation  for  the  majority  of  the  cases, 
especially  where  there  are  multiple  points  of  atresia.  All  these  conditions 
are  beyond  the  reach  of  surgical  treatment.  The  symptoms  appear  soon 
after  birth  and  are  those  of  intestinal  obstruction.  (See  page  115.)  The 
higher  the  point  of  obstruction  the  shorter  the  duration  of  life;  it  is 
rarely  more  than  a  week  in  any  case  of  atresia ;  in  stenosis  it  may  be  two 
or  three  months. 

MeckeVs  diverticulum. — This  is  the  remains  of  the  omphalo-mesenteric 
duct,  which  in  foetal  life  forms  a  communication  between  the  intestine 
and  the  umbilical  vesicle.  It  is  given  off  from  the  ileum,  usually  about  a 
foot  above  the  ileo-csecal  valve.  Most  frequently  this  exists  as  a  blind 
pouch  from  one  half  to  two  or  three  inches  long,  communicating  with  the 
intestine.  At  the  extremity  of  this  there  may  be  a  fibrous  cord,  which 
may  be  free  in  the  abdomiual  cavity  or  attached  to  the  umbilicus.  In 
other  cases  the  duct  may  remain  pervious  to  the  umbilicus,  so  that  there 
is  a  ffBcal  fistula.  Prolapse  of  the  mucous  membrane  of  the  duct  may 
lead  to  an  umbilical  tumour.  (See  page  113.)  Meckel's  diverticulum, 
especially  when  present  as  a  cord  connecting  the  ileum  to  the  umbilicus, 
may  compress  a  coil  of  intestine,  leading  to  obstruction  or  even  strangula- 
tion.    This  may  occur  in  infancy  or  later  in  life. 

Malpositions. — The  ascending  colon  may  be  found  upon  the  left  side. 
There  may  be  a  complete  transposition  of  the  abdominal  viscera.  In  cases 
of  congenital  umbilical  hernia  a  large  part  of  the  intestines  may  be  found 
in  the  tumour,  and  in  diajDhragmatic  hernia  they  may  be  in  the  thoracic 

cavitv. 

DIARRHCEA. 

The  term  diarrhoea  is  used  to  cover  all  conditions  attended  by  frequent 
loose  evacuations  from  the  bowels.  These  depend  upon  an  increase  in 
peristalsis  and  in  the  intestinal  secretions.  There  are  certain  etiological 
factors  which  are  common  to  all  forms  of  diarrhoea. 

Aye. — A  peculiar  susceptibility  exists  in  very  young  children.  This  is 
well  brought  out  by  the  following  statistics.  My  associate,  Dr.  Crandall, 
has  tabulated  three  thousand  cases  of  diarrhoea,  including  those  treated 
by  both  of  us  in  private  and  dispensary  practice,  and  others  from  the 
records  of  two  large  dispensaries  in  New  York.  The  ages  of  those  apply- 
ing for  treatment  were  :  under  six  months,  14  per  cent ;  six  to  twelve 
months,  29  per  cent ;  twelve  to  eighteen  months,  24  per  cent ;  eighteen  to 
twenty-four  months,  17  per  cent ;  over  two  years,  16  per  cent.  It  will  be 
noted  that  the  greatest  susceptibility  is  between  six  and  eighteen  months, 
and  that  over  four  fifths  of  all  the  cases  occurred  during  the  first  two  years. 

Season. — The  next  striking  fact  about  diarrhoeal  diseases  is  their  prev- 
alence during  the  summer  season.     This  is  graphically  shown  in  Figs. 


DIARRHOEA. 


309 


50  and  51,  where  are  given  by  months  the  cases  treated  in  a  large  Xew 
York  dispensary  for  ten  years,  and  the  mortuary  records  for  the  entire 
city  during  the  same  period.     The  enormous  increase  in  the  number  of 


F. 

C. 

Jan. 

Feh. 

Mar. 

Apr. 

May. 

.III 

ne. 

.Ill 

y. 

A  up. 

Sept. 

o 

■t. 

N' 

0-7. 

H 

77* 

25° 
20^ 
15° 
10° 
5° 
0° 

] 

I 

j 

1 

1 

1 

1 

! 

1 

1 

1 

i 

1 

68" 

/•f"^ 

1 

i-«. 

1 

'  •' 

\  * 

1 

fifl° 

( 

\ 

••• 

\ 

, 

^ 

^ 

,♦' 

L_ 

*.  1 

V 

*• 

RO'' 

;  / 

\ 

s^ 

b 

V 

-* 

1 

. 

\ 

\ 

1 

> 

_> 

41° 

; 

• 

s 

\     \    \      \ 

—  1 

1 

_' 

/ 

s^ 

%    1 

••>. 

1 

.'• 

tL 

^h... 

*A 

1 

' 

_• 

V- 

'- 

•- 

; 

*««, 

_j 

— 

— t— 

1 

■■^ 

32'' 

I 

• 

_ 

1 

1 

_i 

1 

._. 

• 

1 

315   289   3o9   403   660  4103  12,468  6205  3641   1723  648   324 

Fig.  50. — Mortality  from  diarrhoeal  diseases  in  New  York  for  ten  years  in  children  under  five; 

compared   with    the   mean   temperature  for  the  same  period.     ,  mortality ; \ 

nieau  temperature.     (iSeibert.) 

cases  occurring  in  the  summer  months  does  not  have  reference  to  any 
single  form  of  diarrhcea,  but  to  all  forms.  The  significance  of  these  facts 
will  be  considered  later. 

Surroundings. — While  diarrhoeal  diseases  are  especially  frequent  in 
cities  and  among  the  poor,  still  they  are  not  essentially  diseases  of  the 
city  nor  of  poverty.  Severe  and  even  fatal  cases  are  constantly  met  with 
among  all  classes  and  in  all  j^laces.     Sufficient  evidence  has  not  yet  accu- 


F. 

C. 

Ja 

n. 

Feb. 

M 

ir. 

.Apr. 

Mn 

v. 

.Til 

le. 

.III 

ly. 

Aug. 

Sept. 

Oct. 

N 

av. 

Dee. 

85° 
20° 
15° 
10° 
5° 
0° 

' 

it 

A 

f\ 

/  \ 

fiR° 

/   ' 

/ ' 

V 

• 

\" 

r-' 

\ 

* 

59° 

J 

1 

I 

*i 

1 

\, 

/ 

1 

/ 

\ 

L 

MT 

\ 

V 

' 

I 

^ 

— 

^ 

\ 

r- 

41° 

' 

i 

\ 

— < 
^1 

.' 

/ 

V 

«<» 

i 

\ 

^* 

*^»'— 

' 

^ 

»- 

T 

•— 

—4 

32^ 

. 

_ 

_ 

1 

_ 



_ 





_^ 

__ 

1    . 

_J 

168   116   167   177   245   1011   2443   1524  1053   716  .  215    121 

Fig.  51. — Cases  of  diarrhceal  disease  treated  in  the  German  Dispensary  (New  York)  in  ten 
years  iu  children  under  five;  compared  with  the  mean  temperature  fur  the  same  period. 
,  cases  of  diarrhcjca ; ,  mean  temperature.     (Seibert.) 

mulated  to  establish  a  direct  connection  between  a  polluted  atmosphere  and 
the  prevalence  of  diarrha'al  diseases.  They  are  not  essentially  filth-diseases ; 
yet  their  frequency  and  severity  are  both  increased  by  want  of  cleanliness  in 
apartments,  in  the  persons  and  clothing  of  infants,  especially  the  napkins. 


310  DISEASES  OF   THE   DIGESTIVE   SYSTEM. 

chiefly,  it  appears,  as  these  lead  to  a  contamination  of  the  food.  Vacher 
has  shown  that  the  mortality  from  diarrhoia  in  the  large  English  towns 
had  no  constant  relation  to  the  density  of  population.  Poverty,  neglect, 
and  bad  surroundings,  predispose  to  diarrhoea  in  summer,  just  as  they  do 
to  other  forms  of  acute  disease  in  the  cold  season. 

Constitution. — Everything  which  lowers  the  general  vitality  increases 
the  liability  to  diarrhcBal  diseases.  Children  suffering  from  marasmus, 
malnutrition,  syphilis,  rickets,  or  tuberculosis  are  especially  prone  to  be 
affected,  and  these  make  up  the  bulk  of  the  fatal  cases  in  cities. 

Dentition. — There  are  -cases  in  which  diarrhoea  and  dentition  are 
closely  associated,  for  the  bowels  quickly  become  normal  when  the  teeth 
have  pierced  the  gum.  These,  although  rare,  do  occur.  Too  much,  how- 
ever, can  not  be  said  in  contradiction  of  the  wide-spread  belief  among  the 
laity  that  diarrhoea  accompanying  dentition  is  normal  or  even  beneficial. 
The  infrequency  of  diarrhoea  during  dentition  in  the  cold  season,  is  the 
best  argument  against  its  importance  as  an  etiological  factor. 

Food  and  feeding. — Of  1,943  fatal  cases  which  I  have  collected,  only 
three  per  cent  had  the  breast  exclusively.  In  my  own  experience  fatal 
cases  of  diarrhoeal  disease  in  nursing  infants  are  extremely  rare.  These 
are  significant  facts.  They  show  that  the  manner  of  feeding  is  one  of 
the  most  important  factors  in  the  production  of  diarrhoea.  This  is  to  be 
connected  with  the  statistics  with  reference  to  age.  The  poor  in  New 
York  are  wont  to  nurse  their  infants  exclusively  for  about  six  months.  If 
nursing  is  continued  longer,  it  is  usually  with  the  addition  of  other  food, 
often  of  the  most  indigestible  kind.  Children  among  the  poor  in  tene- 
ments enjoy  immunity  from  intestinal  disease  just  in  proportion  as  they 
are  breast-fed,  and  just  so  long  as  they  are  so ;  but  as  soon  as  artificial 
feeding  is  begun,  diarrhoeal  diseases  are  prevalent.  There  are  many  rea- 
sons for  this.  In  most  cases,  however,  it  is  not  artificial  feeding  2^er  se, 
but  artificial  feeding  ignorantly  and  improperly  done,  which  is  to  be 
blamed.  If  cow's  milk  is  employed  as  a  substitute  for  breast-milk,  the 
differences  in  composition  are  either  not  appreciated  or  else  ignored,  so 
that  many  artificially-fed  children  suffer  from  malnutrition.  The  com- 
parative safety  of  cow's  milk  in  winter  and  in  the  country,  however,  shows 
that  the  difference  in  chemical  composition  is  not  the  most  important  one. 
A  common  and  very  serious  mistake  is  that  of  over-feeding.  Artificial- 
ly-fed children  are  almost  always  over-fed.  The  common  practice  of  feed- 
ing an  infant  every  time  it  cries,  or  of  keeping  the  bottle  at  its  mouth  the 
greater  part  of  the  time,  is  productive  of  untold  harm. 

The  feeding  of  impure  or  contaminated  milk  is  Hn  important  cause  of 
diarrhoea,  especially  among  the  poor  in  cities  during  the  summer.  The 
condition  of  the  milk  may  be  due  to  disease  in  the  cow,  to  adulteration  or 
pollution  at  the  dairy,  during  transportation,  or  in  the  homes.  It  may 
come  from  dirty  vessels  in  which  the  milk  is  kept,  or  dirty  bottles  from 


DIARRUCEA.  311 

wliich  it  is  fed.  In  some  cases  the  milk  may  be  the  vehicle  of  specific  in- 
fection. In  others,  its  condition  is  owing  to  the  ordinary  fermentation 
changes  due  to  the  age  of  the  milk — it  being  often  two  and  sometimes 
three  days  old  before  it  is  consumed,  and  very  often  kept  with  little  or 
no  ice.  It  is  surprising  to  see  how  quickly  diarrhoea  is  excited  by  impure 
milk.  I  once  saw  in  the  New  York  Infant  Asylum  every  one  of  the 
twenty-three  healthy  children,  all  over  two  years  old  and  occupying  one 
ward,  attacked  in  a  single  day  with  diarrhea  which  w^as  traced  to  this 
cause.  Articles  of  food  totally  unsuited  to  the  child's  digestion  are  often 
given.  Among  the  poor  it  is  a  commo^n  practice  to  give  all  kinds  of  solid 
food  to  children  from  twelve  to  eighteen  months  old,  while  those  of  two 
years  often  get  only  the  regular  diet  of  the  family.  The  great  majority  of 
the  attacks  of  diarrhoea  in  children  over  two  years  old  can  be  traced  di- 
rectly to  improper  food. 

The  factors  mentioned — over-feeding,  too  frequent  feeding,  and  the 
habitual  use  of  improper  food — all  combine  to  produce  a  chronic  indiges- 
tion which  is  probably  the  most  important  predisposing  cause  of  diar- 
rhoeal  diseases. 

The  Different  Varieties  of  Acute  Diarrhoea. — Mechanical  diarrhwa. — 
This  includes  cases  in  which  diarrhoea  is  produced  by  foreign  bodies,  or 
substances  taken  as  food  which  virtually  act  as  foreign  bodies :  such  are 
partly-cooked  rice  or  other  cereals,  dried  fruits,  or  fresh  fruits  containing 
seeds;  green  corn,  radishes,  celery,  cabbage,  or  other  vegetables  ;  nuts  and 
unripe  fruits.  The  irritation  caused  by  such  substances  may  produce  only 
increased  secretion  and  peristalsis  by  which  the  offending  articles  are  re- 
moved, or,  if  sufficiently  severe  and  continued,  it  may  lead  to  actual  in- 
flammation of  the  mucous  membrane  of  the  intestine. 

The  indications  for  treatment  are  first  to  give  an  active  cathartic — 
castor  oil,  calomel,  or  a  saline — and,  after  thorough  evacuation  of  the 
bowel  has  taken  place,  to  quiet  the  excessive  irritation  by  opium.  The 
particular  preparation  used  is  not  important.  For  two  or  three  days 
after  such  an  attack  the  diet  should  be  very  light,  and  of  such  a  character 
as  to  leave  but  little  residue — e.  g.,  for  infants,  broth,  beef  juice,  white  of 
egg ;  and  for  older  children,  diluted  milk  or  kumyss.  The  patient  should 
be  kept  quiet,  preferably  in  bed,  until  the  stools  are  quite  normal.  The 
neglect  of  such  mild  attacks  is  a  frequent  cause  of  more  severe  ones. 

Diarrhoea  from  drugs. — In  susceptible  infants  any  of  the  ordinary 
cathartic  drugs  may  cause  an  attack  of  diarrhoea,  because  the  physiological 
effects  have  been  either  exaggerated  or  prolonged.  It  is  doubtful  whether 
such  attacks  are  often  produced  in  nursing  infants  by  cathartics  taken  by 
the  nurse.  The  organic  acids  contained  in  fruits  may  operate  in  the  same 
way  as  cathartic  drugs.  In  cases  like  these  the  diarrlupa  is  readily  con- 
trolled by  opium,  usually  by  small  doses,  which  should  be  repeated  after 
each  action  of  the  bowels. 


312  DISEASES   OF  THE   DIGESTIVE  SYSTEM. 

Diarrlima  from  nervous  influences. — Certain  nervous  impressions  seem 
to  be  able  to  produce  diarrhoea  Avhere  no  other  factors  are  present.  Some- 
times these  act  in  conjunction  with  other  causes.  The  most  important 
are  chilling  of  the  surface,  depression  caused  by  atmospheric  heat,  fatigue, 
exhaustion,  fright,  and  dentition.  Diarrha?a  may  be  seen  in  older  chil- 
dren with  anaemia,  chorea,  and  general  malnutrition.  It  is  a  characteristic 
of  many  of  these  cases,  that  the  taking  of  food  into  the  stomach  immedi- 
ately excites  a  movement  of  the  bowels.  The  stools  usually  contain  undi- 
gested food,  because  the  intestinal  contents  are  so  rapidly  hurried  forward. 
The  chief  abnormal  condition  in  such  cases  is  exaggerated  peristalsis. 
This  is  best  controlled  by  rest  and  opium ;  small  doses  only  are  usually 
required. 

Eliminative  diarrlma. — This  term  has  been  applied  to  cases  in  which 
diarrhoea  is  evidently  an  effort  on  the  part  of  Nature  to  rid  the  blood  of 
some  irritant  or  toxic  element.  The  best-known  examjDle  is  the  diarrhoea 
of  uraemia.  It  is,  however,  very  probable  that  the  diarrhoea  of  many  acute 
infectious  diseases  belongs  in  this  category.  The  danger  of  suddenly  ar- 
resting such  a  discharge  is  a  real  one.  It  should  be  closely  watched,  and 
not  allowed  to  become  in  itself  a  drain  upon  the  patient,  but  checked 
only  when  excessive. 

Acute  intestinal  indigestion. — Diarrhoea  is  a  constant  symptom  of  this 
condition,  which  is  of  such  importance  that  it  will  be  considered  at 
length.  The  exciting  cause  of  the  diarrhoea  may  be  either  the  mechanical 
irritation  of  particles  of  undigested  food,  or  the  various  putrefactive  prod- 
ucts which  take  place  from  the  decomposition  of  such  food.  This  form 
is  especially  severe  in  infancy,  and  is  usually  accompanied  by  high  fever 
and  other  marked  constitutional  symptoms.  Gastric  symptoms  are  jores- 
ent  in  most  of  the  cases. 

In  the  forms  of  diarrhoea  above  enumerated  there  are  no  lesions,  and 
the  bacteria  found  in  the  stools  are  the  ordinary  bacteria  of  the  intestines. 
All  other  forms  of  acute  diarrhoea  are  to  be  regarded  as  infectious,  the 
infection  starting  from  the  intestinal  contents.  All  of  them  also  are  as- 
sociated with  lesions,  the  severity  of  which  depends  upon  the  nature  and 
degree  of  the  infection,  and  the  duration  of  the  process.  In  the  mildest 
cases  and  in  those  of  short  duration,  the  lesions  involve  only  the  suj^erficial 
epithelium.  In  these  the  symptoms  are  due  not  so  much  to  the  anatom- 
ical changes,  as  to  functional  derangement  and  the  presence  of  toxic  ma- 
terials in  the  intestine  ;  some  of  these  act  locally  and  others  produce  con- 
stitutional symptoms  by  absorption  into  the  general  circulation.  These 
have  been  classed  as  cases  of  acute  gastro-enteric  infection. 

In  the  more  severe  forms,  and  in  those  of  longer  duration,  the  lesions 
may  involve  the  entire  mucosa,  or  they  may  extend  into  the  submucosa 
quite  to  the  muscular  coat.  They  vary  greatly  in  character  as  well  as  in 
degree.      The  lesions  are  very  important,  as  modifying  the  symptoms, 


ACUTE   INTESTINAL   INDIGESTION.  o;^3 

course,  and  termination  of  these  cases.  For  this  reason  they  are  some- 
times classed  as  cases  of  inflammatory  diarrhoea  ;  here,  from  the  position 
of  the  lesions,  they  are  grouped  under  the  term  ileo-colitis. 

According  to  Booker's  observations,  the  bacteria  usually  associated 
with  the  superficial  lesions  are  bacilli;  those  with  the  deeper  lesions, 
streptococci. 

The  pathological  relation  existing  between  the  different  forms  of  diar- 
rhoeal  disease  is  a  very  close  one.  The  same  case  may  pass  successively 
through  the  stages  of  acute  indigestion,  gastro-enteric  infection,  and  ileo- 
colitis. This  transition  may  be  very  slow,  or  it  may  be  so  rapid  that  the 
different  stages  can  not  be  distinguished.  Instead  of  passing  through  the 
entire  series,  the  process  may  stop  at  any  stage  and  the  case  recover,  or  it 
may  at  any  stage  prove  fatal. 

ACUTE  INTESTINAL   INDIGESTION. 

In  infants,  acute  indigestion  is  seldom  limited  either  to  the  stomach  or 
to  the  intestine,  although  in  one  ease  the  disturbance  of  the  stomach  is 
slight  and  that  of  the  intestine  serious,  and  in  another  the  reverse  may  be 
observed.  In  these  little  patients  the  intestinal  symptoms  are  much  more 
frequent,  and  as  a  rule  they  are  more  severe  than  those  referable  to  the 
stomach.  There  will  be  considered  in  this  connection  only  the  intestinal 
symptoms  of  acute  indigestion ;  the  gastric  symptoms  have  been  described 
on  page  291.  It  should  be  I'emembered  that  these  may  be  seen  in  all  possi- 
ble combinations.  In  older  children  it  is  not  uncommon  to  see  the  intes- 
tinal symptoms  alone. 

Etiology. — The  causes  are  essentially  the  same  as  those  mentioned 
under  Gastric  Indigestion — the  use  of  improper  food,  over-feeding,  sudden 
change  of  food  as  in  weaning,  and  various  conditions  affecting  the  nerv- 
ous system,  such  as  heat,  cold,  fatigue,  or  the  onset  of  any  acute  disease. 
A  predisposition  to  such  attacks  is  furnished  by  summer  weather,  a  deli- 
cate constitution,  and  especially  by  a  feeble  digestion.  This  predisposition 
is  greatly  increased  by  previous  attacks  of  acute  or  chronic  indigestion  or 
intestinal  inflammation.  In  susceptible  children,  both  infants  and  those 
who  are  older,  the  slightest  error  in  feeding  may  induce  an  attack. 

Symptoms. — In  infants,  if  the  attack  develops  suddenly,  gastric  symp- 
toms are  usually  present ;  if  more  gradually,  they  are  usually  absent.  The 
local  symptoms  are  colicky  pain,  tympanites,  and  diarrhoea.  The  impor- 
tant constitutional  symptoms  are  fever,  prostration,  and  various  nervous 
disturbances.  In  older  children  the  pain  generally  precedes  the  diarrhoea 
by  some  hours,  and  is  referred  to  the  region  of  the  umbilicus.  In  infants, 
pain  is  indicated  by  the  sharp,  piercing  cry,  great  restlessness,  and  drawing 
up  of  the  legs.     Tympanites  is  rarely  very  marked,  and  may  be  wanting. 

The  stools  are  always  increased  in  number  and  are  from  four  to  twelve 
a  day.     If  more  frequent  they  are  very  small.     The  first  stools  are  more  or 


314  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

less  faecal,  but  this  character  is  soon  lost.  In  infancy  the  colour  is  first 
yellow,  then  yellowish-green,  and  finally  often  grass-green.  Wegscheider 
has  shown  that  this  colour  is  due  to  biliverdin.  The  exact  nature  of  the 
process  in  the  intestine,  in  consequence  of  which  biliverdin  takes  the  place 
of  bilirubin  as  the  colouring  matter  of  the  stools,  is  still  a  disputed  point, 
but  in  infancy  this  change  in  colour  is  nearly  constant.  The  reaction  of 
the  stools  is  almost  invariably  acid.  The  odour  may  be  sour,  or  it  may  be 
very  foul.  The  stools  are  thinner  than  normal,  and  after  a  few  hours 
usually  become  almost  fluid.  Blood  is  not  present,  nor  is  mucus  seen, 
unless  the  symptoms  have  lasted  several  days.  Undigested  food  is  always 
present ;  in  infants  upon  a  milk  diet,  this  is  seen  as  fat  or  lumps  of  casein. 
Fat  may  appear  as  small,  yellowish- white  masses  resembling  casein,  but 
distinguished  by  their  solubility  in  equal  parts  of  alcohol  and  ether. 
Casein  masses  are  more  numerous,  larger,  and  whiter.  Unchanged  starch 
may  be  recognised  by  the  iodine  reaction.  The  microscope  shows,  in  ad- 
dition to  food-remains,  mucus,  epithelial  cells,  and  bacteria.  Epithelial 
cells,  usually  of  the  cylindrical  variety,  are  numerous  in  proportion  to  the 
severity  and  duration  of  the  attack.  The  bacteria  are  the  ordinary  forms 
found  in  the  fgeces  (Booker). 

In  the  cases  with  sudden  onset  the  temperature  is  invariably  elevated. 
In  infants  it  ranges  from  102°  to  105°  F. ;  in  older  children  from  100°  to 
103°  F.  The  high  temperature  does  not  continue.  Usually  after  twelve 
or  twenty-four  hours  it  falls  nearly  or  quite  to  normal.  In  the  cases  with 
a  more  gradual  onset,  or  those  of  a  less  severe  character,  the  temperature 
does  not  often  go  above  101°  F.  The  general  j^rostration,  like  the  tem- 
perature, is  greatest  in  infants  and  in  the  cases  beginning  abruptly.  It 
is  sometimes  so  severe  as  to  threaten  life.  There  are  rapid  pulse,  pallor, 
drawn  features,  and  general  muscular  weakness.  There  may  be  restless- 
ness, due  to  pain  and  the  general  discomfort,  or  there  may  be  dulness, 
apathy,  or  convulsions. 

The  course  and  termination  of  the  disease  depend  upon  the  previous 
condition  of  the  patient,  the  nature  of  the  exciting  cause,  and  the  treat- 
ment employed.  In  a  previously  healthy  child,  if  the  cause  is  at  once  re- 
moved and  proper  treatment  instituted,  the  severe  symptoms  rarely  last 
more  than  a  day  or  two,  and  in  four  or  five  days  the  patient  may  be  quite 
well.  In  delicate  infants,  a  severe  attack  of  acute  intestinal  indigestion  in 
the  hot  season,  is  likely  to  prove  the  first  stage  of  a  pathological  process 
which  may  continue  until  serious  organic  changes  in  the  intestine  have 
taken  place.  This  result  may  not  follow  the  first  attack,  but  one  is  often 
succeeded  by  others  until  it  occurs.  If  circumstances  are  such  that  proper 
dietetic  treatment  and  general  hj^gienic  measures  can  not  be  carried  out, 
this  termination  is  very  common. 

Diagnosis. — It  is  impossible  to  recognise  an  attack  of  acute  intestinal 
indigestion  until  the  diarrhoea  begins  ;  the  previous  symptoms  of  fever, 


ACUTE   INTESTINAL   INDIGESTION.  315 

prostration,  etc.,  are  seen  in  many  infantile  diseases.  From  the  other 
forms  of  diarrhcea,  this  is  distinguished  by  its  brief  duration,  although  its 
symptoms  may  be  very  threatening.  The  nervous  symptoms  are  usually 
less  marked  than  in  gastro-outeric  infection,  and  vomiting  is  not  so  fre- 
quent. 

Prognosis. — Such  attacks  do  not  endanger  life  except  in  very  young 
or  very  delicate  infants,  in  whom  they  may  be  fatal.  The  worst  feature  of 
most  cases  is  that  such  attacks  predispose  to  more  serious  intestinal  dis- 
eases, many  of  which  have  their  origin  in  acute  indigestion  which  has 
been  either  neglected  or  badly  managed. 

Treatment. — The  same  general  plan  is  to  be  followed  as  in  cases  of 
gastric  indigestion— viz.,  first,  to  empty  the  bowels  as  completely  as  pos- 
sible of  all  decomposing  or  irritating  masses  of  food ;  secondly,  to  secure 
to  the  patient,  and  especially  to  the  digestive  organs,  as  complete  rest  as 
possible.  For  the  first  indication  nothing  is  better  than  calomel,  which 
may  be  given  iu  one-fourth-grain  doses,  and  repeated  every  hour  until 
the  full  effect  is  seen.  Any  other  active  purge,  such  as  castor  oil  or 
syrup  of  rhubarb,  may  be  substituted.  Thirst  is  always  great  on  account 
of  the  fever  and  the  loss  of  fluid  by  the  stools,  but  digestion  even  in  the 
stomach  is  feeble,  and  often  arrested  altogether.  For  the  first  twenty-four 
hours  no  plan  succeeds  better  than  that  of  withholding  everything  in  the 
shape  of  food,  giving  only  such  articles  as  whey,  albumen-water,  mineral 
waters,  or  cold  boiled  water.  Small  quantities  must  be  given — i.  e.,  one  to 
four  teaspoonfuls — but  the  interval  may  be  as  short  as  ten  or  fifteen  min- 
utes. If  the  prostration  is  very  great,  stimulants  may  be  needed.  Brandy 
is  the  best  form  of  administration.  After  the  offending  materials  have  all 
been  swept  from  the  intestine,  but  never  before,  opium  may  be  given  in 
doses  large  enough  to  control  the  excessive  catharsis.  For  a  child  a  year 
old,  one  quarter  grain  of  Dover's  powder  after  each  stool  is  usually  suffi- 
cient, and  often  a  smaller  dose  may  answer  the  purpose. 

The  difficult  problem  is  to  feed  these  cases  during  the  latter  part  of 
the  attack.  In  nursing  infants,  the  breast  may  be  begun  after  twenty-four 
hours,  the  nursing  interval  being  six  hours,  and  the  time  of  one  nursing 
beinjT  not  longer  than  five  minutes.  Between  the  nursings  other  food 
may  be  given.  In  the  case  of  infants  past  the  nursing  age,  or  those  who 
are  being  artificially  fed,  cow's  milk  must  be  withheld  in  all  forms  for  at 
least  three  days,  and  then  given  greatly  diluted.  For  infants  under  six 
months,  not  more  than  one  part  of  milk  to  seven  of  water  should  be  em- 
ployed. Milk  sugar,  in  the  proportion  of  one  even  tablespoonful,  should 
be  added  to  each  eight  ounces  of  food.  Such  a  mixture  has  the  following 
composition  :  fat,  0-4  per  cent ;  sugar,  o'O  per  cent ;  proteids,  Go  per  cent. 
In  some  cases  it  is  necessary  to  use  even  so  great  a  dilution  as  one  part  of 
milk  to  twelve  of  water,  and  one  tablespoonful  of  the  milk  sugar  to  each 
ten  ounces  of  food.     This  contains  approximately :   fat,  O'^b  per  cent ; 


316  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

sugar,  4-0  per  cent ;  proteids,  0-3  per  cent.  "With  improvement,  the 
proportions  of  the  fat  and  proteids  must  be  very  gradually  increased, 
as  for  some  time  the  digestion  is  easily  disturbed.  In  some  cases  there 
is  an  advantage  in  using  partially  or  completely  peptonized  milk  (page 
148). 

The  diet  of  older  children  in  the  acute  stage  should  be  much  like  that 
of  infants.  Later  it  should  consist  of  meat,  broths,  eggs,  milk,  and  a 
small  quantity  of  dried  bread.  All  cereals,  vegetables,  and  especially  all 
fruits,  should  be  withheld  for  some  time,  and  when  given  should  be 
allowed  only  in  small  quantities,  and  the  effect  on  the  stools  watched. 
Kumyss  and  matzoon  are  frequently  better  borne  than  plain  milk. 

The  use  of  drugs  in  these  attacks,  except  those  already  referred  to  as 
indicated  during  the  early  stage,  seems  to  me  to  influence  the  disease  very 
little.  Sometimes  good  results  follow  the  giving  of  the  extractum  pan- 
creatis  half  an  hour  after  meals,  or  of  some  of  the  j)reparations  of  malt 
when  farinaceous  food  is  first  allowed.  If  the  diarrhcea  following  the  acute 
symptoms  is  prolonged  or  excessive,  it  usually  indicates  that  either  intes- 
tinal infection  or  inflammation  is  present,  and  the  case  should  be  treated 
accordingly.  General  measures,  such  as  rest,  frequent  bathing,  fresh  air, 
and  change  of  air,  are  very  important  in  the  management  of  all  these  cases, 
especially  when  they  occur  during  the  summer. 


CHAPTER  YII. 

DISEASES   OF   THE  INTESTINES.— {ConUnued.) 

ACUTE   GASTRO-EXTERIC  INFECTION. 

Synonyms:  Summer  diarrhoea,  gastro-intestinal  catarrh,  gastro-enteritis,  cholera 
infantum,  mycotic  diarrhoea. 

This  is  the  form  of  diarrhoea  which  is  so  prevalent  in  summer.  It 
occurs  regularly  each  season  as  an  epidemic  in  most  large  cities  of  the 
temperate  zone,  the  lesions  in  the  intestines  are  slight,  amounting  in  most 
cases  only  to  a  superficial  catarrhal  inflammation,  often  bearing  no  relation 
to  the  severity  of  the  symptoms  which  are  mainly  due  to  the  absorption 
of  toxic  materials,  the  result  of  the  putrefactive  changes  in  the  stomach 
and  intestine.  This  form  of  diarrhoea  may  follow  closely  upon  an  attack 
of  acute  indigestion,  in  which  it  very  often  has  its  beginning.  When  the 
infection  is  of  sufficient  intensity  and  duration,  it  leads  to  the  develop- 
ment of  marked  structural  changes  in  the  intestine,  especially  in  the  lower 
ileum  and  the  colon.  Acute  gastro-enteric  infection  thus  stands  midway 
between  acute  indigestion  and  ileo-colitis. 


ACUTE   GASTRO-ENTERIC   INFECTION.  317 

Etiology. — Among  the  causes  of  acute  gastro-enteric  infection  are  to 
be  mentioued,  first,  those  which  give  rise  to  acute  indigestion,  and,  sec- 
ondly, the  general  factors  mentioned  as  predisposing  to  all  forms  of  diar- 
rhoea] disease — age,  surroundings,  constitution,  food,  and  methods  of  feed- 
ing. (See  page  310.)  The  most  striking  thing  about  these  cases  is  their 
prevalence  during  hot  weather;  hence  this  feature  demands  a  closer  ex- 
amination. While  all  varieties  of  diarrhoea  are  more  frequent  in  summer, 
it  is  the  form  under  consideration  which  is  especially  prevalent.  Year 
after  year  are  repeated  in  New  York  the  conditions  which  are  graphically 
represented  in  the  charts  on  page  309 — viz.,  an  epidemic  which  begin- 
ning in  June  rapidly  increases  in  severity  reaching  its  height  in  July, 
from  which  time  it  diminishes  steadily  during  August  and  September, 
regularly  coming  to  an  end  in  October.  What  is  true  of  New  York  is  also 
true  of  Philadelphia,  Baltimore,  and  other  large  American  cities,  as  well 
as  of  Berlin  and  other  cities  of  central  Europe.  A  study  of  these  charts 
shows  that  while  the  mean  temperature  rises  gradually  during  April  and 
May,  it  is  not  until  June  is  reached  with  its  mean  temperature  of  Gl°  F., 
that  any  notable  increase  in  diarrhoeal  diseases  begins.  It  appears  then 
that  an  average  mean  temperature,  or,  according  to  Seibert,  an  average  mini- 
mum temperature,  of  about  60°  F.  is  needed  to  start  the  epidemic.  Not 
many  cases  are  seen  until  such  a  temperature  has  lasted  for  some  days, 
usually  about  a  week.  The  epidemic  then  begins  in  force  and  increases 
in  severity  through  July.  The  explanation  of  the  high  mortality  of  this 
month  appears  to  be,  not  the  4°  or  5°  F.  by  which  the  temperature  of  July 
exceeds  that  of  June  and  August,  but  that  the  majority  of  the  susceptible 
infants  are  unable  to  withstand  the  first  very  hot  month.  Humidity  and 
rainfall,  according  to  the  careful  investigations  of  both  Seibert  in  New 
York  and  Baginsky  in  Berlin,  do  not  influence  either  the  prevalence  of 
summer  diarrhoea  or  its  mortality. 

The  action  of  heat  in  producing  diarrhoea  was  formerly  regarded  as  a 
direct  one.  The  worst  cases  were  looked  upon  as  examples  of  heat-stroke 
or  thermic  fever.  There  is  no  doubt  that  the  constitutional  depression 
produced  by  high  atmospheric  temperature  may  seriously  interfere  with 
digestion,  and  that  sometimes  the  thirst  which  excessive  perspiration 
produces  may  lead  to  the  giving  of  too  much  food,  which  also  may  be 
a  cause  of  indigestion.  While  this  exjilauation  may  be  satisfactory  for  a 
small  proportion  of  the  cases,  it  is  not  adequate  for  the  great  majority. 
The  view  almost  universally  held  at  the  present  time  regarding  summer 
diarrhoea  is  that  it  is  of  infectious  origin.  The  grounds  for  this  opinion 
are  briefly  as  follows :  A  certain  temperature  is  required,  which  is  the 
same  as  that  at  which  the  growth  of  bacteria  begins  to  bo  very  active. 
This  disease  prevails  to  the  extent  to  which  other  food  than  breast-milk 
is  given  to  infants.  Thus  it  affects  infants  after  weaning,  and  those 
younger  who  are  partly  or  entirely  fed  upon  cow's  milk,  or  at  least  who 


318  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

are  'not  nursed.  Cow's  milk,  as  ordinarily  handled,  contains  in  summer 
an  enormous  number  of  bacteria  (page  144),  which  increase  directly  with 
the  age  of  the  milk  and  the  height  of  the  temperature  at  which  it  is  kept. 
It  has  been  shown  by  Vaughan  and  others  that  certain  substances  may  be 
produced  in  milk  which  are  capable  of  exciting  in  animals  all  the  symp- 
toms of  severe  cases  of  cholera  infantum.  In  the  milk  which  children 
had  been  taking  when  such  symptoms  developed,  the  same  toxic  substances 
were  found.  The  two  diseases  to  which  summer  diarrhoea  has  the  closest 
analogy — typhoid  fever  and  cholera — are  both  due  to  a  specific  infection. 

During  the  past  few  years  extended  bacteriological  studies  of  the 
intestinal  discharges  in  these  cases  have  been  made,  particularly  by 
Booker  (Baltimore)  and  Baginsky  (Berlin).  The  results  thus  far  ob- 
tained have  failed  to  establish  the  connection  between  any  single  form 
of  bacteria  and  any  variety  of  diarrhoea.  The  forms  most  frequently 
associated  with  cases  of  the  cholera-infantum  type  belong  to  the  proteus 
group.  The  varieties  found  in  the  other  cases  have  been  chiefly  the 
ordinary  saprophytic  bacteria,  prominent  among  which  is  the  hay-bacillus 
(Fliigge).  These  germs  gain  entrance  to  the  body,  in  the  great  majority 
of  cases,  through  milk,  although  it  is  possible  that  water  may  sometimes 
be  the  vehicle.  Whether  they  may  be  taken  in  with  the  inspired  air  is  very 
questionable.  In  most  of  the  cases  it  is  probably  the  living  bacteria  which 
enter  the  body,  while  in  others  the  symptoms  are  produced  by  taking  food 
in  which  poisonous  products  have  already  been  formed  by  the  action  of 
bacteria.  The  latter  seems  to  be  the  explanation  of  some  of  the  cases  in 
which  symptoms  come  on  almost  immediately  after  the  ingestion  of  con- 
taminated milk. 

The  acceptance  of  the  view  of  the  infectious  character  of  summer  diar- 
rhcBa,  brings  up  the  interesting  question  of  direct  contagion.  With  our 
present  knowledge  we  can  not  believe  that  this  is  often,  if  it  is  ever,  the 
way  in  which  this  disease  is  spread.  When  occurring  in  institutions  or 
in  families,  it  usually  happens  that  a  number  of  cases  are  attacked  simul- 
taneously rather  than  successively,  this  indicating  a  common  cause,  usually 
to  be  found  in  the  food,  for  all.  However,  we  know  enough  about  the 
spread  of  typhoid  fever  and  cholera  from  fsecal  discharges,  to  appreciate 
the  importance  of  careful  disinfection  of  all  stools  and  napkins,  particu- 
larly in  institutions. 

Relation  of  the  different  etiological  factors. — The  predisposition  to 
attacks  of  summer  diarrhoea  is  partly  general  and  partly  local.  The  gen- 
eral influences  are  age  (under  two  years),  feeble  constitution,  unh)'gienic 
surroundings,  and  a  condition  of  general  malnutrition  dependent  upon 
improper  food  or  feeding.  The  most  important  of  the  local  causes  is  a 
chronic  derangement  of  digestion,  usually  the  result  of  improper  feeding. 
In  addition  there  may  be  present  a  low  grade  of  catarrhal  inflammation. 
The  exciting  cause  of  an  attack  may  be  acute  indigestion.      In  conse- 


.    ACUTE   GASTKO-EXTERIC  INFECTION.  3I9 

quence  of  an  arrest  of  digestion,  there  is  left  in  the  stomacH  and  intestines 
food  which  readily  undergoes  decomposition  ;  and  at  the  same  time  there 
are  furnished  conditions  in  which  bacteria  may  develop,  which,  though 
previously  present,  were  unable  to  gain  a  foothold ;  or  bacteria  may  be 
introduced  in  such  numbers  and  of  such  virulence  as  to  overpower  the  di- 
gestive organs ;  or,  finally,  bacterial  products  may  be  ingested  with  the 
food,  .requiring  only  absorption  to  produce  their  effects. 

Lesions. — The  statements  which  follow  are  based  upon  a  study  of  forty 
autopsies,  in  twenty-two  of  which  microscopical  examinations  were  made. 
The  lesion  may  be  briefly  described  as  a  superficial  catarrhal  inflammation 
affecting  the  entire  gastro-enteric  tract,  although  it  varies  much  in  severity 
in  the  different  regions  and  in  the  different  cases.  The  colon,  the  lower 
ileum,  and  the  stomach,  are  apt  to  suffer  most,  the  duodenum  and  the 
jejunum  least. 

Tlie  gj-oss  ajjpearances. — These  are  usually  disappointing,  .and  may 
often  show  but  little  that  is  abnormal.  The  stomach  is  distended  with 
gas,  and  contains  undigested  food.  Its  walls  may  be  coated  with  mucus. 
The  ujoper  part  of  the  small  intestine  is  empty.  The  lower  portion  con- 
tains particles  of  food,  and  yellow,  gray,  or  green  materials,  often  offensive, 
resembling  the  stools  passed  during  life.  The  transverse  colon,  the  cscum, 
and  sigmoid  flexure  are  apt  to  be  distended  with  gas,  and  contain  materials 
similar  to  those  mentioned,  while  the  rest  of  the  large  intestine  is  usually 
empty  and  its  walls  contracted.  It  may  be  coated  with  mucus.  The 
mucous  membrane  of  the  stomach  may  show  intense  congestion,  gener- 
ally in  patches,  or  it  may  be  pale.  The  mucous  membrane  of  the  small 
■intestine  may  be  pale  throughout ;  there  are  often  irregular  areas  of  con- 
gestion, or  a  very  intense  congestion  of  a  large  part  of  its  surface,  par- 
ticularly in  the  ileum.  With  this  there  may  be  redness  and  swelling  of 
Peyer's  jDatches  and  the  lymph  nodules  (solitary  follicles).  In  the  colon 
the  mucous  membrane  is  congested,  especially  upon  the  rugre.  This  con- 
gestion may  be  general  or  in  patches.  The  lymph  nodules  are  usually 
swollen;'  but  this  may  be  due  to  an  antecedent  process,  and  not  to  the  final 
attack.  There  is  no  thickening  of  the  intestinal  walls.  The  changes  de- 
scribed  are  not  at  all  uniform,  and  do  not  differ  very  greatly  from  the 
appearances  often  seen  in  the  intestines  when  patients  have  died  of  other 
diseases. 

In  the  cases  classed  clinically  as  cholera  infantum,  the  patliological 
changes  are  more  characteristic.  The  greater  part  of  the  small  intestine, 
and  sometimes  the  entire  colon,  are  distended  with  gas,  and  contain  ma- 
terials of  a  grayish-white  colour  about  the  consistency  of  a  thin  gruel.  It 
has  a  mawkish  odour,  but  usually  not  a  very  offensive  one.  The.  mucous 
membrane  of  the  entire  intestinal  tract  has  in  most  cases  a  pale,  "  washed- 
out"  appearance.     Sometimes  this  is  seen   only  in  the  small  intestine, 

while  there  are  areas  of  congestion  in  the  colon.     If  cholera  infantum  has 
22 


320 


DISEASES  OP  THE   DIGESTIVE  SYSTEM. 


been  ingrafted  upon  some  other  pathological  process  in  the  intestines,  as 
is  not  infrequent,  there  is  found  post-mortem  evidence  of  this  in  the 
form  of  severe  catarrhal  inflammation,  sometimes  old  ulcerations.  In 
some  cases,  where  the  symptoms  have  been  those  of  choleriform  diarrhoea, 
there  are  found  evidences  of  an  intense  diffuse  gastro-enteritis,  as  shown 
by  congestion  of  the  stomach  and  almost  the  entire  intestinal  tract,  with 
swelling  of  the  mucous  membrane,  and  especially  of  Peyer's  patches. 

The  microscopical  appearances*— Vuless  autopsies  are  made  very  soon 
after  death— at  least  within  four  hours— it  is  not  safe,  in  most  of  the  cases, 
to  draw  conclusions  from  the  conditions  found ;  as  post-mortem  changes 
take  place  so  readily  in  the  intestines,  and  these  changes  are  so  like  those 
of  the  disease  under  consideration.  This  applies  particularly  to  the  con- 
dition of  the  epithelium.  One  should  also  be  cautious  in  interpreting  the 
appearances  of  portions  of  the  intestine  which  have  been  greatly  distended 
with  gas.  The  essential  lesions  of  this  disease  are  found  in  the  superficial 
epithelium  of  the  stomach  and  intestine.  In  places  this  has  disappeared. 
In  other  places  the  cells  are  in  position,  but  both  the  cell  protoplasm  and 
the  nuclei  are  so  changed  that  they  do  not  stain  normally.  Bacteria, 
usually  bacilli  (Booker),  are  found  in  the  epithelial  layer  and  in  the  pockets 
of  the  follicles.  They  are  not,  as  a  rule,  found  in  the  deeper  parts  of  the 
intestinal  wall,  nor  in  the  lymph  nodes  of  the  mesentery.  The  changes 
in  and  about  the  blood-vessels  are  variable.  The  small  vessels  may  be 
distended,  and  there  may  be  haemorrhages  or  an  exudation  of  leucocytes 
in  their  neighbourhood.  These  appearances  are  seen  either  in  the  mucous 
or  submucous  layer.  The  exudation  from  the  blood-vessels  is  usually 
slight,  and  in  many  cases  is  wanting.  Peyer's  patches  and  the  lymph  nod- 
ules may  be  enlarged  from  cell-proliferation.  Pathologically  no  sharp 
line  can  be  drawn  between  these  lesions  and  those  of  the  early  stage  of 
ileo-colitis ;  the  latter  affect  the  lower  ileum  and  colon  chiefly,  often  ex- 
clusively, and  the  lesions  are  more  advanced  and  involve  the  deeper  parts 
of  the  intestinal  wall. 

Clinically,  there  are  two  quite  distinct  forms  of  gastro-enteric  infection, 
which  will  be  separately  considered — (1)  the  simple  form  and  (2)  true 
cholera  infantum. 

Simple  Gastro-Enteric  Infection. — There  are  seen  in  infants  mild 
cases  with  a  gradual  onset,  little  or  no  fever,  and  no  gastric  disturbance, 
and  severe  cases  with  a  sudden  onset,  usually  attended  by  high  tempera- 
ture and  by  vomiting.  In  the  mild  form,  there  may  be  for  the  first  few 
days  no  symptoms  except  the  diarrhoeal  discharges,  or  the  children  may 
be  peevish  and  fretful — especially  at  night — and  may  seem  generally  out 
of  sorts.     From  the  fact  that  the  general  symptoms  are  so  few,  such  cases 

*  For  fuller  description,  see  article  by  the  author  in  Keating's  Cyclopaedia,  vol.  iii, 


ACUTE   G  ASTRO-ENTERIC   INFECTION.  321 

are  often  allowed  to  go  on  for  several  days,  under  the  impression  that  the 
children  are  "  only  teething."  The  stools  gradually  become  more  frequent ; 
they  are  thin,  green,  yellow,  or  brown,  and  always  contain  undigested  food. 
After  a  time  the  odour  becomes  offensive,  and  mucus  is  present.  The  ap- 
petite may  be  normal,  but  is  usually  impaired,  and  may  be  almost  lost. 
The  tongue  is  coated,  the  mucous  membrane  of  the  mouth  congested,  and 
in  very  young  infants  often  covered  with  thrush.  The  general  health  may 
not  be  noticeably  affected  for  several  days  ;  but  more  often  the  infants 
become  pale,  their  limbs  grow  soft  and  flabby,  they  lose  their  spirits,  they 
are  fretful,  they  sleep  badly,  and  the  scales  show  a  loss  of  one  or  two 
pounds  in  a  week. 

With  proper  treatment,  there  is  noticed  in  favourable  cases  an  im- 
provement in  the  character  and  frequency  of  the  stools ;  the  appetite 
returns ;  the  strength  and  spirits  improve  ;  and  the  children  recover  after 
an  illness  of  from  one  to  three  weeks.  Occasionally  the  condition  may 
last  a  much  longer  time.  Relapses  are  very  easily  brought  on  by  errors 
in  diet,  especially  by  overfeeding.  In  other  cases  severe  symptoms  may 
supervene  at  any  time,  and  the  case  may  become  one  of  the  cholera-infan- 
tum  type.  This  often  takes  place  with  great  suddenness,  and  is  frequently 
coincident  Avith  a  few  days  of  very  hot  weather,  or  follows  some  gross 
dietetic  error.  In  still  others  the  symptoms  may  continue  with  the  grad- 
ual formation  of  follicular  ulcers,  the  case  becoming  one  of  ileo-colitis. 
A  termination,  not  so  common  as  either  of  the  preceding,  is  a  continu- 
ance of  the  mild  symptoms  with  exacerbations  and  remissions,  until  the 
cool  weather  of  autumn  comes. 

In  the  cases  developing  suddenly,  the  clinical  picture  is  quite  a  differ- 
ent one.  The  attack  may  begin  abruptly  in  a  child  previously  healthy, 
or  there  may  have  been  for  some  days  a  slight  intestinal  derangement.  If 
an  infant,  it  is  restless,  cries  much,  sleeps  but  a  few  minutes  at  a  time,  and 
seems  in  distress.  The  skin  is  hot  and  dry,  the  temperature  rises  rapidly 
to  102°  or  103°  F.,  often  to  lOS"",  and  all  the  symptoms  indicate  the  onset 
of  some  serious  illness.  The  infant  may  lie  in  a  dull  stupor,  with  eyes 
sunken,  weak  pulse,  and  general  relaxation,  or  there  may  be  restlessness, 
excitement,  even  convulsions.  There  is  great  thirst,  so  that  everything 
offered  is  eagerly  taken,  or  everything  maybe  refused.  Usually,  in  the 
course  of  from  four  to  six  hours  after  the  onset,  vomiting  begins ;  it  is 
first  of  undigested  food  taken  many  hours  before.  If  this  was  milk,  it 
comes  up  in  hard  curds  and  very  sour.  Even  after  the  stomach  has  been 
apparently  emptied,  mucus,  serum,  and  sometimes  bilious  matters,  are 
ejected  in  small  quantities  after  much  retching.  Vomiting  is  easily  ex- 
cited by  the  giving  of  food  or  drink. 

Diarrhoea  soon  follows — first  fffical  stools,  then  great  bursts  of  flatus, 
with  the  expulsion  of  a  thin  yellow  material  with  an  offensive  odour.  Four 
or  five  such  discharges  may  occur  in  as  many  hours.     In  other  cases  the 


322  DISEASES  OP  THE   DIGESTIVE  SYSTEM. 

stools  are  gray,  green,  or  greenish-yellow,  sometimes  brown.  They  often 
do  not  differ  at  first  from  those  of  an  ordinary  attack  of  acute  intestinal 
indigestion.  The  most  characteristic  features  are  the  amount  of  the  gas 
expelled,  the  colicky  pains  preceding  the  discharges,  and  the  foul  odour. 
After  the  first  day  the  stools  may  be  almost  entirely  fluid,  varying  in  num- 
ber from  six  to  twenty  a  day,  and  often  large  even  then.  Their  offensive 
character  usually  continues.  After  two  or  three  days  mucus  may  appear. 
The  microscoi^ical  examination  of  the  stools  shows,  besides  the  things 
mentioned  in  the  stools  of  acute  indigestion,  great  numbers  of  separate 
epithelial  cells,  and  sometimes  groups  of  cells  attached  to  a  basement 
membrane.  In  addition  there  may  be  round  cells  and  some  red  blood- 
corpuscles.  The  bacteriological  examination  shows  that  the  normal  varie- 
ties are  usually  diminished  in  number,  while  many  new  forms  are  present, 
chiefly  putrefactive  bacteria. 

In  many  cases  the  free  evacuation  of  the  bowels  is  followed  by  a  drop  in 
the  temperature  and  subsidence  of  the  nervous  symptoms,  and  the  child 
may  fall  asleep,  to  be  awakened  for  an  occasional  stool  after  a  few  hours. 
The  prostration,  though  often  great  in  the  beginning,  is  not  usually  of 
lono-  duration.  Under  the  most  favourable  circumstances,  after  one  or 
two  days  of  severe  symptoms,  the  case  goes  on  to  a  rapid  convalescence. 
The  stools  continue  abnormally  frequent  for  five  or  six  days,  but  gradu- 
ally assume  their  normal  character,  and  a  prompt  recovery  occurs.  The 
chief  features  contributing  to  such  favourable  results,  are  a  good  constitu- 
tion on  the  part  of  the  child  and  one's  ability  to  regulate  the  feeding  after- 
ward. 

If  the  circumstances  are  not  so  favourable,  if  the  infant  is  very  young, 
delicate,  or  cachectic,  there  may  be  no  reaction  from  the  first  storm  of 
symptoms,  and  the  attack  may  terminate  fatally.  In  such  cases  the  tem- 
perature continues  elevated  from  100°  to  103*  F.,  sometimes  higher.  The 
stomach  is  irritable  and  rejects  everything.  The  stools  continue  thin, 
green,  and  are  often  irritating  to  the  anus  and  skin.  There  is  steadily 
increasing  prostration,  and  death  may  take  place  from  exhaustion  in 
semi-stupor  or  in  convulsions.  In  other  cases  the  vomiting  ceases,  the 
temperature  falls,  the  stools  become  less  frequent  and  perhaps  less  offen- 
sive, but  contain-  more  mucus  and  occasionally  traces  of  blood.  There  is 
also  some  reaction  from  the  early  nervous  depression,  but  the  children  be- 
come pale,  worn,  and  waste  steadily.  The  temperature  ranges  between  99° 
and  102°  F.,  and  all  the  symptoms  belonging  to  ileo-colitis  gradually  de- 
velop. Sometimes  there  may  be  a  series  of  such  acute  attacks  separated 
by  a  week  or  ten  days,  the  stools  never  becoming  quite  normal  between 
them,  but  all  other  symptoms  being  absent.  It  may  not  be  until  the 
third  or  fourth  attack  that  ileo-colitis  is  finally  established. 

In  children  over  two  years  old  there  are  seen  some  features  which 
differ  from  the  cases  described  above  as  occurring  in  infants.     Vomiting 


ACUTE  GASTRO-ENTERIC   INFECTION.  323 

does  not  come  on  so  readily  as  in  infants,  pain  is  a  more  prominent  symp- 
tom, and  the  temperature,  as  a  rule,  is  lower.  Such  cases,  although  be- 
ginning with  severe  symptoms,  usually  make  good  recoveries ;  there  is 
much  less  likelihood  of  their  going  on  to  the  development  of  ileo-colitis 
than  in  the  case  of  infants. 

Diagnosis. — The  diagnostic  points  about  these  attacks  are  their  sudden 
onset,  severe  symptoms,  comparatively  brief  duration,  and  usually  favour- 
able termination.  Attacks  of  acute  gastro-enteric  infection  can  not  always 
be  distinguished  from  acute  indigestion,  but  as  a  rule  they  are  character- 
ized by  a  higher  temperature,  greater  disturbance  of  the  nervous  system, 
very  offensive  fluid  stools,  and  by  occurring  epidemically  in  summer.  To 
differentiate  these  cases  from  those  of  ileo-colitis,  may  be  impossible  for 
the  first  two  or  three  days.  The  onset  may  be  identical  in  both  cases. 
The  continuance  of  high  temperature  beyond  the  second  day  points  to  in- 
flammatory changes ;  so  also  do  the  appearance  of  blood  and  of  much 
mucus  in  the  stools,  and  the  existence  of  continuous  pain. 

Almost  any  acute  disease  in  infants  may  be  ushered  in  with  gastro- 
enteric symptoms,  especially  in  summer.  This  is  particularly  true  of 
scarlet  fever,  pneumonia,  tonsillitis,  and  malaria.  Each  one  of  these  is  to 
be  recognised  by  its  peculiar  symptoms :  pneumonia,  by  its  rapid  respira- 
tion and  physical  signs ;  tonsillitis,  by  the  appearance  of  the  throat ;  scar- 
let fever,  by  the  appearance  of  the  throat  and  the  eruption;  malaria,  by 
the  enlarged  spleen  and  remittent  temperature.  One  should  look  for 
some  other  disease  whenever  there  is  seen  very  manifest  improvement  in 
the  gastro-enteric  symptoms,  with  a  continuance  of  the  high  temperature 
and  general  prostration. 

Prognosis. — Simple  cases  of  gastro-enteric  infection  do  not  often  prove 
fatal,  except  in  infants  under  three  months  old  or  those  already  suffering 
from  marasmus.  Such  patients  are  often  overcome  in  the  first  stage  of 
intoxication.  It  is  surprising  to  see  with  how  few  symptoms  they  suc- 
cumb. Even  an  apparently  mild  attack  may  prove  fatal,  and  a  guarded 
prognosis  must  always  be  given. 

In  other  cases  the  prognosis  resolves  itself  into  this  question :  What 
are  the  probabilities  that  the  existing  attack  will  go  on  to  the  develop- 
ment of  serious  intestinal  lesions?  If  the  child  has  been  delicate,  badly 
fed,  has  suffered  from  frequent  attacks  of  indigestion  and  diarrhoea,  if  its 
surroundings  are  bad,  if  the  case  has  been  neglected  for  two  or  three 
days,  and  if  proper  dietetic  and  hygienic  treatment  can  not  be  carried  out, 
it  is  probable  that  the  process  will  continue  until  structural  changes  in 
the  intestine  have  taken  place.  The  degree  of  probability  is  in  propor- 
tion to  the  number  of  these  factors  present.  Manifestly,  all  the  condi- 
tions are  worse  in  hot  weather.  Much  depends  upon  early  treatment 
and  upon  our  ability  to  remove  the  exciting  causes.  If  the  patient  was 
previously  suffering  from  any  other  disease,  such  as  rickets  or  pertussis, 


324  DISEASES  OF   THE   DIGESTIVE  SYSTEM. 

the  prognosis  is  much  worse  both  as  to  life  and  to  the  duration  of  the 
attack. 

Prophylaxis. — So  long  as  dentition  and  atmospheric  heat  per  se  were 
regarded  as  the  great  causative  factors,  the  field  of  prophylaxis  was  limited  ; 
but  a  better  understanding  of  the  etiology  brings  with  it  great  possibili- 
ties in  the  prevention  of  this  disease. 

Prophylaxis  must  have  regard,  first,  to  the  hygienic  surroundings  of 
children,  and  to  all  sanitary  conditions  in  the  cities — cleaner  streets  and 
more  parks.  In  the  tenement  homes  and  all  institutions  for  infants,  there 
should  be  more  air  and  sunlight,  less  crowding,  greater  cleanliness  about 
the  persons  of  children,  frequent  bathing,  and  proper  care  of  napkins.  In 
summer,  napkins  should  either  be  washed  immediately  or  thrown  into  a 
disinfectant  solution.  In  case  infants  are  suffering  from  diarrhoea  this 
latter  plan  should  invariably  be  followed.  City  children  should  be  sent  to 
the  country,  wherever  it  is  possible,  for  the  months  of  July  and  August. 
Part  of  the  benefit  here  is  derived  from  the  change  of  air,  and  a  larger 
part  from  the  pure  milk,  which  is  almost  out  of  the  question  for  the  poor 
in  the  city.  Where  a  long  stay  is  impossible,  day  excursions  do  much  good. 
The  fresh-air  funds  and  seaside  homes  have  done  more  in  New  York  to 
diminish  the  mortality  from  diarrhoeal  diseases  in  summer  than  all  medi- 
cinal treatment ;  their  importance  and  value  can  not  be  overestimated. 

The  second  part  of  prophylaxis  relates  to  foods  and  feeding.  Maternal 
nursing  should  be  encouraged  by  every  possible  means.  No  weaning  should 
be  done,  if  it  can  be  avoided,  during  summer.  Nothing  is  better  estab- 
lished than  the  close  relation  existing  between  artificial  feeding  and  diar- 
rhoeal diseases.  I  have  elsewhere  stated  my  belief  that  in  the  great  ma- 
jority of  the  cases  it  is  ignorant  and  improper  artificial  feeding  which  is 
the  real  cause.  The  general  rules  laid  down  elsewhere  on  the  subject  of 
artificial  feeding  must  be  carried  out,  as  to  the  quantity  of  food,  fre- 
quency of  feeding,  modification  of  cow's  milk,  and  all  matters  relating  to 
the  care,  transportation,  and  sterilization  of  milk.  Whatever  causes  in- 
digestion, whether  it  be  acute  or  chronic,  may  also  be  ranked  as  a  cause 
of  diarrhoeal  diseases.  The  important  dangers  to  be  emphasized  in  this 
connection  are  overfeeding,  too  frequent  feeding,  the  use  of  improper 
foods,  and  use  of  impure  foods,  especially  milk. 

Overfeeding  is  particularly  to  be  avoided  during  days  of  excessive  heat. 
It  is  at  such  times  an  excellent  rule  with  infants  to  diminish  each  meal 
by  at  least  one  third,  making  up  the  deficiency  with  water,  and  to  give 
water  very  freely  between  the  feedings.  All  water  given  to  infants 
or  young  children  should  first  be  boiled.  Children,  like  adults,  require 
less  food  in  very  hot  weather,  but  more  water.  Infants  cry  from  thirst 
and  heat,  and  even  those  at  the  breast  are  likely  to  be  given  too  much 
food.  Infants  should  never  be  fed  more  frequently  during  hot  weather, 
but  generally  less  so. 


ACUTE  GASTRO-ENTERIC   INFECTION.  325 

No  greater  work  of  philanthropy  can  be  done  among  the  poor  in  sum- 
mer, than  to  provide  means  whereby  pure,  clean  milk  for  young  children 
can  be  supplied  at  the  price  now  paid  for  an  inferior  article.* 

Early  and  prompt  attention  should  be  given  to  all  the  milder  derange- 
ments of  the  stomach  and  intestines.  The  larger  proportion  of  serious 
attacks  are  preceded  for  some  time  by  milder  symptoms,  which  are  often 
easily  managed  by  prompt  attention  at  the  outset.  Too  much  can  not  be 
said  in  condemnation  of  the  practice  of  allowing  a  diarrhcea  to  continue 
for  a  week  or  more,  simply  because  the  child  happens  to  be  teething.  Yet 
many  mothers  believe  such  a  condition  of  the  bowels  to  be,  not  only  not 
injurious,  but  positively  beneficial. 

In  brief,  prophylaxis  demands  (1)  sending  as  many  infants  out  of 
the  city  in  summer  as  possible ;  (2)  the  education  of  the  laity  up  to  the 
importance  of  regularity  in  feeding,  the  dangers  of  overfeeding,  and  as 
to  what  is  a  proper  diet  for  infants  just  weaned ;  (3)  proper  legal  restric- 
tions regarding  the  transportation  and  sale  of  milk ;  (4)  the  exclusion  of 
germs  or  their  destruction  in  all  foods  given,  but  especially  in  milk,  by 
careful  sterilization  in  summer,  and  by  scrupulous  cleanliness  in  bottles, 
nipples,  etc. ;  (5)  prompt  attention  to  all  mild  derangements;  (6)  cutting 
down  the  amount  of  food  and  increasing  the  amount  of  water  during  the 
days  of  excessive  summer  heat. 

Hygienic  Treatment.— If  the  attack  occurs  in  the  city  in  midsummer, 
and  does  not  yield  in  three  or  four  days  to  the  treatment  employed,  the 
child  should  be  sent  to  the  country,  if  possible.  In  the  case  of  an  infant 
under  a  year  this  is  imperative.  Usually  the  seashore  is  to  be  preferred 
to  the  mountains,  but  this  is  not  so  important  as  it  is  that  the  child  shall 
go  where  it  is  likely  to  have  the  best  food  and  the  best  surroundings. 
Children  must  not  only  be  sent  away ;  they  must  be  kept  away  until  quite 
recovered.  In  the  country  or  in  small  towns  a  change  is  not  so  necessary, 
and,  in  fact,  not  generally  required.  In  cases  which  have  become  some- 
what chronic,  more  can  sometimes  be  accomplished  by  a  change  of  air 
than  by  all  other  means. 

Fresh  air  is  of  the  utmost  importance  for  all  diarrheal  cases  in  sum- 
mer. No  matter  how  much  fever  or  prostration  there  may  be,  these  cases 
always  do  better  if  kept  out  of  doors  the  greater  part  of  the  day.  Nothing 
is  so  depressing  as  close,  stifling  apartments.  Children  should  be  kept 
quiet,  and  especially  should  not  be  allowed  to  walk,  even  if  they  are  old 
enough  and  strong  enough  to  do  so.  They  can  be  kept  out  in  carriages, 
in  perambulators,  or  in  hammocks. 

*  Something  of  this  has  ah-eady  been  done  in  Boston  by  the  milk  hihoratory,  and 
in  New  York  by  the  milk  dis{)ensary  in  connection  with  the  Good  Samaritan  Dispen- 
sary, which  has  been  organized  by  Koplik  to  furnish  "sterilized  "  milk  for  infants;  and 
also  by  the  Straus  milk  depots,  where  the  same  thing  is  done  on  a  much  larger  scale, 
this  charity  having  branches  in  half  a  dozen  districts  of  the  city. 


326  DISEASES  OF   THE   DIGESTIVE   SYSTEM. 

The  clothing  should  bo  very  light  flannel ;  a  single  loose  garment  is 
preferable.  Linen  or  cotton  may  be  put  next  the  skin  if  this  is  very 
sensitive  and  there  is  much  perspiration.  At  the  seashore  and  in  the 
mountains,  special  care  should  be  taken  that  sufficient  clothing  at  night 
is  supplied. 

Bathing  is  useful  to  allay  restlessness,  as  well  as  for  cleanliness  and  the 
reduction  of  temperature.  For  the  first  purpose  a  sponge  bath  of  alcohol 
and  water  or  vinegar  and  water,  is  sufficient.  For  the  reduction  of  tem- 
perature, only  the  tub  bath  is  to  be  relied  on.  If  the  temperature  con- 
tinues above  103°'  F.,  systematic  bathing  should  be  employed.  The 
temperature  of  the  bath  should  be  about.  100°  F.  when  the  child  is  put  in- 
to it,  and  should  then  be  gradually  reduced  to  80°  or  85°  F.  by  adding  ice. 
The  bath  should  be  continued  for  from  ten  to  twenty  minutes,  according 
to  the  requirements  of  the  case.  Thus  used,  it  has  generally  a  very  quiet- 
ing effect,  which  is  entirely  lost  by  the  terror  and  excitement  caused  by 
putting  a  young  child  suddenly  into  a  cold  bath. 

Scrupulous  cleanliness  should  be  secured  in  the  child's  person  and 
clothing.  Napkins,  as  soon  as  soiled,  should  be  removed  from  the  child 
and  from  the  room  and  placed  in  a  disinfectant  solution.  Excoriations  of 
the  buttocks  and  genitals  are  to  be  prevented  by  scrupulous  cleanliness 
and  the  free  use  of  some  absorbent  powder,  such  as  starch  and  boric  acid. 

Dietetic  Treatment. — It  is  of  the  first  importance  to  remember  that 
during  the  early  stage. of  the  acute  cases,  digestion  is  practically  arrested. 
To  give  food  at  this  time,  manifestly  can  only  do  harm. 

In  nursing  infants,  the  breast  must  be  withheld  so  long  as  a  disposition 
to  vomit  continues,  and  no  food  whatever  given  for  at  least  twelve  hours. 
Thirst  may  be  allayed  by  giving  frequently,  but  in  small  quantities,  cold 
whey,  barley  or  albumin  water.  Stimulants  may  be  added  to  these  if 
required.  If  they  are  refused  or  vomited,  absolute  rest  to  the. stomach 
will  do  more  than  anything  else  to  hasten  recovery.  After  the  stomach 
has  been  quiet  for  twenty-four  hours,  it  is  generally  safe  to  allow  the  child 
to  be  put  to  the  breast  tentatively.  The  intervals  of  nursing  should  not 
be  shorter  than  four  hours,  and  the  amount  allowed  at  one  feeding  should 
not  be  more  than  one  fourth  the  usual  quantity.  This  may  be  regulated 
by  allowing  an  infant  to  nurse  at  first  only  two  or  three  minutes.  Between 
the  nursings  may  be  alternated,  whey,  barley  water,  or  albumin  water, 
so  that  something  is  given  every  two  hours.  Nursing  may  be  gradually 
increased,  so  that  in  three  or  four  days  the  breast  may  be  taken  exclu- 
sively. If  there  is  any  reason  to  suspect  the  breast  milk,  such  as  menstru- 
ation, pregnancy,  or  some  special  nervous  disturbance,  it  may  be  necessary 
to  stop  the  nursing  temporarily  or  permanently,  according  to  circum- 
stances, and  secure  a  wet-nurse  or  begin  artificial  feeding.  In  infants 
just  weaned  the  same  plan  is  to  be  followed. 

In  infants  under  four  months  who  are  being  artificially  fed,  if  the 


ACUTE   GASTRO-ENTERIC  INFECTION.  327 

attack  be  a  severe  one  and  occur  in  summer,  a  wet-nurse  should  be  se- 
cured wherever  this  is  possible.  If  this  is  out  of  the  question,  we  have 
to  face  one  of  the  most  difficult  problems  in  artificial  feeding.  Cow's 
milk  must  always  be  withheld  entirely  during  the  stage  of  acute  symp- 
toms, and  for  several  days  longer.  When  it  is  begun,  both  the  casein  and 
tlie  fat  must  be  very  greatly  reduced  by  dilution,  and  in  many  cases  the 
casein  predigested.  For  young  infants,  milk  should  be  diluted  from  six 
to  ten  times,  and  preferably  with  a  sugar  solution.  (See  formulae  XVII 
and  XVIII,  page  176).  Instead  of  using  only  a  sugar  solution,  part  of 
the  dilution  may  be  with  barley  or  rice  water.  In  some  cases  it  may  be 
sufficient  to  peptonize  milk  for  ten  or  twenty  minutes ;  but  in  many  we 
must  do  more,  at  first  continuing  the  peptonizing  for  two  hours,  or  until 
the  digestion  of  the  casein  is  complete  (page  148).  Kumyss  and  matzoon 
are  sometimes  retained  when  cow's  milk  is  rejected.  These  should  be 
diluted  with  two  or  three  parts  of  water  and  given  cold.  They  may  some- 
times advantageously  be  continued  as  the  sole  diet  for  several  days.  Dur- 
ing the  period  of  acute  symptoms  we  must  rely  upon  the  substitutes  for 
milk — rice  or  barley  water,  wine  whey,  the  malted  foods,  albumin  water, 
fresh  beef  Juice,  animal  broths,  and  the  liquid  beef  peptonoids.* 

The  same  general  principles  of  feeding  must  be  applied  in  older  chil- 
dren. All  food  is  to  be  withheld  until  the  vomiting  ceases,  and  then 
broths  and  beef  juice  given ;  later,  kumyss  or  matzoon,  then  milk,  or  thin 
gruels  made  with  milk.  Solid  food  should  not  be  allowed  for  several  days 
after  the  stools  have  become  normal. 

General  princijjles  of  feeding. — All  food,  but  especially  cow's  milk, 
must  be  stopped  at  once.  No  food  whatever  is  to  be  given  upon  a  very 
irritable  stomach ;  but  thirst  must  always  be  relieved  by  bland  fluids  given 
frequently  in  small  quantities,  and  cold.  Articles  requiring  the  least  di- 
gestion and  leaving  the  smallest  residue  should  next  be  tried.  Food  pre- 
scriptions must  be  made  with  the  same  care  and  exactness  as  those  for 
drugs,  for  in  most  cases  they  are  more  important.  Quantity  and  fre- 
quency must  be  definitely  stated,  as  well  as  the  articles  ordered.  Direc- 
tions should  be  given  in  writing,  or  they  will  be  forgotten  before  the 
physician  is  out  of  the  house.  A  practical  acquaintance  with  the  proper 
appearance  and  taste  of  every  food  ordered,  is  absolutely  indispensable. 
It  is  a  common  mistake  to  give  too  much  at  a  time,  to  feed  too  frequently, 
to  try  too  many  articles  at  once,  and  to  change  before  a  thing  has  been 
fairly  tested.  For  a  single  feeding  the  quantity  allowed  will  vary  accord- 
ing to  the  tolerance  of  the  stomach,  but  it  should  always  be  much  less 
than  is  given  in  health,  usually  from  one  fourth  to  one  half  that  amount. 
It  is  very  rarely,  if  ever,  necessary  to  nurse  or  feed  a  sick  child  oftener 
than  every  two  hours.     In  cases  of  great  prostration,  stimulants  may  be 

*  These  foods  are  considered  at  length  on  pages  150-157. 


328  DISEASES  OF   THE   DIGESTIVE  SYSTEM. 

required  much  more  frequently.  We  have  only  to  imagine  how  an  adult 
suffering  from  nausea  would  feel  to  be  offered  something  in  the  shape  of 
food  every  five  or  ten  minutes,  in  order  to  appreciate  the  disgust  for  all 
food  which  soon  overtakes  an  infant  who  is  similarly  besieged. 

Still,  after  all  has  been  said,  it  is  a  difficult  problem  to  feed  these  chil- 
dren under  three  years  of  age,  capricious  as  they  are  by  nature  and  still 
more  by  education,  and  the  judgment  and  tact  of  the  physician  are  taxed 
to  their  utmost.  We  must  have  many  resources,  for  a  food  which  one 
child  takes  well  the  next  disdains  utterly.  The  best  plan  is  to  select  from 
a  list  of  articles  of  accepted  value,  such  as  circumstances  will  permit,  and 
such  as  are  most  likely  to  be  properly  prepared,  and  try  them  patiently, 
one  after  another,  until  one  is  found  which  the  child  under  treatment 
will  take,  and  one  which  agrees  with  him. 

Medicinal  and  Mechanical  Treatment. — It  must  be  borne  in  mind  that 
we  are  not  treating  an  inflammation  of  the  stomach  or  intestines,  although 
such  may  be  the  ultimate  result  of  the  process.  Our  therapeutic  meas- 
ures are  to  be  directed  against  the  acute  indigestion  and  the  active  putre- 
faction in  the  alimentary  tract. 

The  first  indication  is,  therefore,  to  evacuate  the  stomach  and  the  en- 
tire intestinal  tract  at  the  earliest  moment,  and  to  do  this  as  thoroughly 
as  possible.  Under  no  circumstances  should  the  treatment  be  begun  with 
the  use  of  measures  to  stop  the  discharges. 

To  empty  the  stomach  is  not  necessary  in  every  case,  since  the  initial 
vomiting  may  have  done  this  efficiently.  Whenever  vomiting  persists 
immediate  resort  should  be  had  to  stomach-washing  (page  60).  A  sin- 
gle washing  is  generally  sufficient,  and  if  employed  at  the  outset  may  do 
much  to  shorten  the  attack.  If  there  are  high  fever  and  great  thirst,  it  is 
often  advisable  to  leave  an  ounce  or  two  of  water  in  the  stomach.  If  the 
vomited  matters  have  been  very  sour,  ten  grains  of  bicarbonate  of  soda 
may  be  introduced  with  the  portion  which  is  to  be  left  behind.  To  older 
children  emetics  may  be  given,  but  to  infants  never.  As  a  substitute  for 
stomach-washing  in  children  over  two  years  old,  or  where  it  can  not  be 
employed,  copious  draughts  of  boiled  water  may  be  given.  This  is  taken 
readily,  and  as  it  is  usually  vomited  almost  at  once  it  may  cleanse  the 
stomach  thoroughly ;  but  it  is  inferior  to  stomach-washing. 

To  clear  out  the  small  intestine,  only  cathartics  are  available.  For  the 
colon,  we  may  in  addition  employ  irrigation.  Calomel  and  castor  oil  are 
greatly  superior  to  all  other  cathartics.  Calomel  has  the  advantage  of  ease 
of  administration,  of  a  favourable  effect  upon  vomiting,  and  of  an  anti- 
fermentative  as  well  as  purgative  action.  One  fourth  of  a  grain  should 
be  given  every  hour  up  to  eight  doses,  or  until  the  characteristic  green 
stools  are  seen.  When  the  stomach  is  not  disturbed,  I  prefer  castor  oil  in 
most  cases,  as  it  sweeps  the  whole  canal,  causes  little  griping,  is  very  cer-. 
tain,  and  its  after-effects  are  soothing.     It  is  important  that  a  full  dose  be 


ACUTE   GASTRO-ENTERIC   INFECTION.  329 

given — two  drachms  to  a  child  a  year  old,  and  half  an  ounce  to  one  of 
four  years. 

Irrigation  of  the  colon  (page  G3)  is  advisable  in  all  cases,  as  it  hastens 
the  effect  of  the  cathartic  and  removes  at  once  much  irritating  and  offen- 
sive material.  It  should  be  done  two  or  three  times  the  first  day,  but 
afterward  once  daily  is  sufficient.  A  saline  solution  (one  ounce  to  the 
gallon),  at  a  temperature  of  about  90°  F.,  is  to  be  preferred;  and  a  long 
rectal  tube  should  always  be  used.  The  initial  evacuation,  almost  com- 
j)lete  starvation  for  twenty-four  hours,  and  careful  feeding  after  that  time, 
are  all  the  treatment  that  is  necessary  in  a  large  number  of  cases. 

Other  drugs  are  of  secondary  importance.  Their  value  is  certainly 
very  much  overestimated.  This  statement  is  made  after  a  thorough  and 
honest  trial,  in  hospital  and  private  practice,  of  most  of  those  that  have 
been  recommended.  Since  the  recognition  of  the  fact  that  putrefactive 
processes  play  so  important  a  role  in  these  cases,  the  drift  of  opinion  and 
practice  has  been  toward  the  use  of  drugs  believed  to  act  in  the  alimen- 
tary tract  as  antiseptics.  In  using  drugs  the  conditions  usually  present 
are  to  be  kept  in  mind  :  the  digestive  process  in  the  stomach  and  upper 
small  intestine  is  feebly  carried  on,  and  there  is  very  active  decomposi- 
tion in  the  lower  part  of  the  small  intestine  and  in  the  colon.  In  com- 
parison with  the  intestinal  contents,  the  amount  of  any  drug  which  can 
be  administered  is  so  small,  the  conditions  in  the  intestine  are  so  com- 
plex, and  our  present  knowledge  of  the  exact  nature  of  the  processes  of 
fermentation  or  decomposition  which  we  wish  to  control  is  so  limited, 
that  it  is  extremely  doubtful  whether  such  a  thing  as  antiseptic  medica- 
tion of  the  gastro-enteric  tract  is  practicable  at  the  present  time.  It  is 
more  than  probable  that  a  very  large  number  of  the  drugs  given  to  influ- 
ence this  process,  never  reach  that  part  of  the  intestine  where  the  most 
active  decomposition  is  going  on.  Experience  has  shown  that  certain 
drugs  which  have  been  classed  as  antiseptics  are  valuable,  but  as  yet  we 
must  use  them  empirically.  Those  in  my  experience  which  have  been 
found  most  useful  are  bismuth,  calomel,  salol,  and  salicjlate  of  soda; 
although  the  list  might  be  very  much  extended. 

Bismuth  has  the  advantage  that  it  rarely  causes  vomiting,  and  that 
most  of  its  preparations  can  be  given  in  large  doses.  Of  the  newer  prepa- 
rations, the  salicylate,  subgallute  and  beta-naphthol  bismuth,  the  subgallate 
is  easily  superior  to  the  others.  This  may  be  given  in  doses  of  from  two 
to  four  grains  every  two  hours,  to  a  child  of  one  year.  Like  the  subnitrate 
it  is  insoluble  and  is  best  given  suspended  in  mucilage.  The  salicylate 
may  be  given  in  the  same  doses  as  the  salicylate  of  soda.  For  the  great 
majority  of  cases,  however,  I  think  the  subnitrate  is  still  to  be  preferred. 
To  be  efficient,  at  least  two  drachms  of  this  should  be  given  daily  to  a  child 
two  years  old.  It  usually  blackens  the  stools.  It  may  be  kept  up  through- 
out the  attack.     Calomel  mav  be  jriven  in  doses  of  one  twentieth  to  one 


330  DISEASES  OP   THE   DIGESTIVE  SYSTEM. 

tenth  grain  every  hour.  Its  best  effects  are  seen  where  it  is  used  early  in 
the  disease.  It  should  not  be  continued  for  more  than  twenty-four  or 
thirty-six  hours.  The  gray  powder  may  be  given  in  the  same  manner. 
Salicylate  of  soda  is  probably  decomposed  in  the  stomach,  setting  free 
salicylic  acid  ;  to  a  child  of  one  year,  two  grains  may  be  given,  dissolved  in 
water,  every  two  hours,  after  feeding.  This  is  not  to  be  used  if  the  stom- 
ach is  very  irritable,  as  it  may  excite  vomiting.  Its  best  effect  is  seen 
after  the  vomiting  has  stopped,  and  when  the  stools  are  fluid.  It  should 
be  given  alone.  Salol  is  decomposed  in  the  intestine  into  salicylic  and 
carbolic  acids.  To  a  child  of  two  years  one  grain  may  be  given  every  two 
hours  ;  sometimes  more  will  be  borne.  It  may  be  given  alone,  or  with  bis- 
muth. This  also  may  cause  vomiting.  Acids  have  been  recommended,  on 
the  ground  that  the  gastric  contents,  when  examined,  show  a  deficiency  of 
hydrochloric  acid,  and  from  the  experiments  of  Pfeiffer,  which  indicate  that 
green  stools  are  dependent  upon  an  alkaline  fermentation  in  the  intestine. 
The  acids  most  used  are  hydrochloric  and  lactic.  Of  the  former,  from 
one  half  to  three  drops  of  the  dilute  acid  may  be  given,  well  diluted  with 
water,  every  two  hours,  fifteen  minutes  after  feeding.  Of  the  latter, 
slightly  larger  doses  may  be  used.  They  are  not  indicated  in  the  most 
acute  cases  when  vomiting  is  present,  or  when  the  stomach  is  easily  dis- 
turbed. The  best  results  are  seen  from  them  in  the  later  stages  and  in 
the  subacute  cases.  Acids  are  best  given  alone.  Alkalies  are  of  value 
only  in  acute  cases,  especially  where  there  is  acid  fermentation  of  the 
stomach,  with  vomiting  and  eructations  of  gas.  Limewater,  bicarbonate 
of  soda,  magnesia,  or  chalk  mixture  may  be  employed.  My  own  experi- 
ence accords  with  that  of  most  recent  writers  in  attributing  to  astringents 
little  or  no  value.  They  often  do  positive  harm,  by  disturbing  the  stom- 
ach and  interfering  with  digestion. 

While  opium  in  some  form  or  quantity  is  required  in  many  cases,  as 
often  used  it  undoubtedly  does  more  harm  than  good.  The  chief  symp- 
toms indicating  opium  are  great  frequency  of  movements  and  severe  pain. 
It  is  contra-indicated  until  the  intestinal  tract  has  been  thoroughly  emp- 
tied by  cathartics  and  by  irrigation  ;  also  when  the  number  of  discharges 
is  small,  particularly  if  they  are  very  offensive;  it  is  especially  to  be 
avoided  when  cerebral  symptoms  and  high  temperature  coexist  with 
scanty  discharges.  Opium  is  admissible  in  the  early  part  of  the  disease 
after  the  tract  has  been  thoroughly  emptied ;  it  is  also  useful  sometimes 
during  convalescence,  when  the  administration  of  food  is  followed  imme- 
diately by  a  movement  of  the  bowels ;  and  when,  without  an  elevation  of 
temperature,  often  with  good  appetite,  the  stools  are  frequent  and  contain 
undigested  food,  because  peristalsis  is  so  active  that  the  intestinal  con- 
tents are  hurried  along  with  such  rapidity  that  there  is  not  time  for 
complete  intestinal  digestion  and  absorption.  Nothing  requires  nicer  dis- 
crimination than  the  use  of  opium  in  diarrhoea.     It  is  wise  to  administer 


ACUTE  GASTRO-ENTERIC  INFECTION.  331 

it  always  in  a  separate  prescription,  and  never  in  composite  diarrhoeal 
mixtures.  In  this  way  it  can  be  reguluted  according  to  the  effect  pro- 
duced upon  the  number  of  stools.  If,  following  tlie  administration  of 
opium,  the  stools,  though  diminishing  in  number,  do  not  improve  in  char- 
acter, and  the  temperature  rises,  the  dose  must  be  greatly  reduced  or  the 
drug  stopped  altogether.  There  is  no  great  choice  as  to  preparations. 
Dover's  powder,  the  deodorized  tincture,  and  paregoric  are  perhaps  the 
most  satisfactory.  As  to  dosage,  great  variations  are  required  in  the  dif- 
ferent cases.  Enough  is  to  be  given  to  produce  a  certain  effect — the 
diminution  of  pain  and  the  control  of  excessive  peristalsis — but  never 
enough  to  check  the  number  of  discharges  entirely,  or  to  cause  stupor. 
The  uncertainty  of  absorption  must  also  be  remembered ;  a  second  full 
dose  should  not  be  given  until  a  sufficient  time  has  elapsed  for  the  effect 
of  the  first  to  pass  away.  Better  results  are  commonly  obtained  by  the 
frequent  use  of  very  small  doses,  than  by  larger  ones  at  longer  intervals. 
For  an  average  child  of  one  year,  five  minims  of  paregoric,  one  fourth 
minim  of  the  deodorized  tincture,  or  one  fourth  grain  of  Dover's  powder, 
may  be  used  as  an  initial  dose,  to  be  repeated  every  one,  two,  or  four 
hours,  according  to  the  effect  produced.  In  some  cases  excellent  results 
are  obtained  by  the  use  of  morphine  hypodermically ;  to  a  child  of  one 
year  yi^  grain  may  be  given,  and  the  dose  repeated  in  an  hour  if  no 
effect  is  seen. 

Stimulants  are  required  in  the  majority  of  the  severe  cases.  The  pros- 
tration is  great  and  develops  rapidly ;  frequently  almost  no  food  can  be 
assimilated  for  twenty-four  or  thirty-six  hours,  while  the  drain  from  the 
discharges  continues.  The  general  condition  of  the  patient  is  the  best 
guide  as  to  the  time  for  stimulation  and  the  amount  given.  Usually 
stimulants  are  not  begun  early  enough.  Old  brandy  is  the  best  prepara- 
tion for  general  use,  champagne  possibly  being  preferred  for  older  chil- 
dren when  the  stomach  is  very  irritable.  An  infant  a  year  old  will,  under 
most  circumstances,  take  from  half  an  ounce  to  an  ounce  of  brandy  in 
.  twenty-four  hours.  Stimulants  should  always  be  diluted  with  at  least  six 
parts  of  water,  and  should  be  given  cold,  preferably  in  small  quantities, 
at  short  intervals.  If  they  are  not  retained  when  given  by  the  mouth, 
they  may  be  used  hypodermically. 

In  cases  of  extreme  prostration,  the  hot  bath,  mustard  to  the  extremi- 
ties, and  sometimes  the  mustard  pack,  are  beneficial.  Where  the  drain  is 
rapid  and  very  great,  and  in  all  cases  approaching  the  cholera-infantum 
type,  subcutaneous  saline  injections  should  be  used,  in  the  manner  de- 
scribed under  Cholera  Infantum. 

General  considerations   in  treatment. — (1)  All  severe  cases  must  be 

watched  very  closely,  especially  those  in  infants  under  six  months.     If  the 

temperature  is  rising  and  the  passages  are  very  fluid,  one  should  always 

•  be  apprehensive.     (2)  The  character  of  the  discharges  is  a  better  indica- 


332  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

tiou  than  is  their  number,  of  the  patient's  condition  and  of  the  effect  of  any 
plan  of  treatment.  (3)  Nothing  is  more  simple  than  to  give  opium  enough 
to  reduce  the  number  of  passages;  but  unless  there  is  some  other  sign  of 
improvement,  very  little  good,  and  probably  much  harm,  has  been  done. 
(4)  We  must  treat  the  patient,  and  not  direct  all  our  thought  to  acid  or 
alkaline  stools,  ptomaines,  or  bacteria.  The  value  of  every  therapeutic 
measure  is  to  be  estimated  by  its  effect  upon  the  patient's  general  condi- 
tion. (5)  No  matter  how  strongly  we  may  be  convinced  of  the  value  of 
anv  drug  or  combination  of  drugs,  if  they  continue  to  disturb  the  stom- 
ach they  are  worse  than  useless.  (6)  Both  the  mother  and  nurse  must  be 
impressed  by  the  fact  that  the  diet  is  an  important  part  of  the  treatment, 
and  that  foods  need  to  be  given  just  as  carefully  as  drugs.  (7)  In  the 
management  of  any  single  case  the  important  thing  is  prompt  and  thor- 
ough evacuation  of  the  stomach  and  bowels,  then  rest  for  these  organs 
for  from  twelve  to  twenty-four  hours,  or,  as  some  one  has  tersely  put  it, 
"  bold  starvation  " ;  but  it  is  necessary  in  all  cases  that  Avater  be  given 
freely.  No  cases  do  worse  than  those  in  which  the  mother  or  nurse  in 
charge  can  not  be  made  to  appreciate  the  value  of  starvation,  but  insists 
upon  giving  food,  especially  milk,  in  violation  of  the  rules  laid  down.  (8) 
Great  care  is  required  during  convalescence,  and  in  fact  during  the  re- 
mainder of  the  summer,  to  prevent  relapses ;  these  usually  occur  from 
errors  in  diet,  particularly  during  days  of  excessive  heat. 

Cholera  Infantum. — In  comparison  with  the  class  of  cases  just 
considered,  cholera  infantum  is  rare.  The  term  should  be  restricted  to 
cases  of  genuine  choleriform  diarrhcea.  Much  confusion  has  arisen  from 
adopting  this  as  a  generic  name  for  all  cases  of  summer  diarrhcea.  There 
is  no  other  form  of  diarrhoeal  disease  in  which  the  evidence  of  infec- 
tious origin  is  so  strong.  Its  resemblance  to  Asiatic  cholera  is  striking. 
Its  close  connection  with  the  feeding  of  impure  cow's  milk  is  well  estab- 
lished. The  symptoms  are  essentially  toxic,  and  are  due  to  the  effect  of  the 
poison  upon  the  heart,  the  nerve-centres,  and  the  vaso-motor  nerves  of  the 
intestine.     The  secondary  symptoms  depend  upon  the  abstraction  of  fluid. 

Cholera  infantum  may  occur  in  an  infant  previously  healthy,  but  this 
is  very  rare.  As  a  rule,  there  is  some  antecedent  intestinal  disorder.  It 
may  be  a  mild  diarrhoea  of  a  few  days'  or  even  weeks'  duration,  or  it  may 
supervene  in  the  course  of  a  subacute  ileo-colitis  with  such  severity  as  to 
carry  off  the  patient  in  a  few  hours.  The  development  of  the  choleriform 
symptoms  in  all  cases  is  very  rapid,  and  a  child,  who  perhaps  has  been 
regarded  as  scarcely  ill  enough  to  require  a  physician,  may  be  brought,  in 
the  course  of  five  or  six  hours,  to  death's  door. 

Usually  there  are  general  symptoms — prostration,  and  a  steadily  rising 
temperature — for  a  few  hours  before  the  vomiting  and  purging  begin, 
or  these  may  be  the  first  things  to  excite  alarm.  Vomiting  may  precede 
diarrhoea,  or  both  may  begin  simultaneously.     The  vomiting  is  very  fre- 


CHOLERA   INFANTUM. 


333 


qiient.  First,  whatever  food  is  in  the  stomach  is  vomited,  then  serum 
and  mucus,  and  finally  bilious  matter.  If  it  subsides  for  a  time,  it  is 
almost  sure  to  begin  anew  by  the  taking  of  food  or  drink.  The  stools 
are  frequent,  large,  and  fluid,  and  in  the  course  of  half  a  day,  twelve 
or  fifteen  may  occur.  If  less  frequent  they  are  proportionately  larger. 
They  are  of  a  pale  green,  yellow,  or  brownish  colour  in  the  beginning, 
but  as  they  become  more  frequent  they  often  lose  all  colour  and  are 
almost  entirely  serous.  The  sphincter  is  sometimes  so  relaxed  that  small 
evacuations  occur  every  few  minutes.  The  first  stools  are  usually  acid, 
later  they  are  neutral,  and  when  serous  they  may  be  alkaline.  In  most 
cases  they  are  odourless ;  in  rare  instances  they  are  exceedingly  offensive, 
at  times  the  odour  being  overpowering.  Microscopically  the  stools  show 
large  numbers  of  epithelial  cells,  some  round  cells,  and  immense  numbers 
of  bacteria. 

Loss  of  weight  is  more  rapid  than  in  any  other  pathological  condition 
in  childhood.  Baginsky  records  a  case  in  which  it  reached  three  pounds 
in  two  days.  The  fontanel  is  depressed,  and  in  rare  instances  there  may 
be  overlapping  of  the  cranial  bones.  The  general  prostration  is  great 
almost  from  the  outset.  The  face,  better,  perhaps,  than  any  single  symp- 
tom, indicates  what  a  profound  impression  has  been  made  upon  the  sys- 
tem. The  eyes  are  sunken,  the  features  sharpened,  the  angles  of  the 
mouth  drawn  down,  and  a  peculiar  pallor  with  an  expression  of  anxiety 
overspreads  the  whole  countenance.  In  the  early  stages  the  nervous  symp- 
toms are  those  of  irritation :  children  cry  loudly  or  moan,  and  throw  ■ 
themselves  fretfully  about  in  their  cribs,  the  excitement  sometimes  bor- 
dering upon  an  active  delirium.  Later,  these  symptoms  give  place  to  dul- 
ness,  stupor,  relaxation,  and  coma  or  convulsions. 

The  temperature,  in  my  experience,  has  been  invariably  elevated,  and 
usually  in  proportion  to  the  severity  of  the  attack.  In  cases  recovering, 
it  has  generally  been  from  102°  to  103°  F.,  while  in  fatal  cases  it  has  risen 
almost  at  once  to  104°  or  105°  F.,  and  often  shortly  before  death  it  has 
reached  106°  or  even  108°  F.  Such  a  rectal  temperature  often  occurs 
with  a  clammy  skin  and  cold  extremities,  and  is  discovered  only  by  the 
thermometer.  Many  writers  speak  of  subnormal  temperature  in  the  later 
stages,  but  such  has  not  been  my  experience.  The  pulse  is  always  rapid, 
and  very  soon  it  becomes  weak,  often  irregular,  and  finally  almost  imper- 
ceptible. The  respiration  is  irregular  and  frequent,  and  may  be  stertorous. 
The  tongue  is  generally  coated,  but  soon  becomes  dry  and  red,  and  is  often 
protruded.  The  abdomen  is  generally  soft  and  sunken.  There  is  almost 
insatiable  thirst.  Everything  in  the  shape  of  fluids,  especially  ice-water, 
is  drunk  with  avidity,  even  though  vomited  as  soon  as  it  is  swallowed. 
Very  little  urine  is  passed,  sometimes  none  at  all  for  twenty-four  hours ; 
yet  this  need  give  no  special  concern,  as  it  depends  upon  the  great  loss  of 
fluid  by  the  bowels. 


334  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

Symptoms  such  as  those  described  rarely  continue  more  than  one  day 
without  a  decided  change  either  for  better  or  worse.  In  the  fatal  cases 
there  are  hyperpyrexia,  cold,  clammy  skin,  absence  of  radial  pulse,  stu- 
por, coma  or  convulsions,  and  death.  The  diarrhoea  and  vomiting  may 
continue  until  the  end,  or  both  may  entirely  cease  for  some  hours 
before  it  occurs.  The  patients  may  pass  into  a  condition  resembling 
the  algid  stage  of  epidemic  cholera,  with  pinched,  sunken  features,  sub- 
normal temperature,  dyspnoea,  and  cool  breath,  and  may  die  in  col- 
lapse. In  other  cases,  after  the  first  day  of  very  severe  symptoms,  the  dis- 
charges diminish,  but  the  nervous  symptoms  become  specially  prominent. 
There  are  restlessness  and  irritability  or  apathy  and  stupor.  The  fontanel 
is  sunken ;  the  eyes  are  half  open  and  covered  with  a  mucous  film ;  respi- 
ration is  irregular  and  superficial,  sometimes  even  Cheyne-Stokes ;  the 
pulse  is  feeble,  irregular,  or  intermittent ;  the  extremities  are  cold ;  the 
muscles  of  the  neck  drawn  back ;  the  abdomen  retracted ;  no  desire  for 
food  is  shown,  the  patient  rousing  only  from  thirst.  The  temperature  is 
not  elevated,  but  normal  or  subnormal.  From  this  condition  recovery  may 
take  place  with  gradual  abatement  of  the  nervous  symptoms,  improved 
•  pulse  and  circulation,  the  stools  gradually  becoming  more  consistent  and 
having  more  colour;  or  the  symptoms  may  merge  into  those  of  ileo-colitis. 
]\Iuch  more  frequent  than  either  of  the  foregoing,  is  the  fatal  termination. 

These  nervous  symptoms  described  were  grouped  by  the  earlier  writers, 
first  by  Marshall  Hall,  under  the  term  sjjurious  hydrocephalus,  or  hi/- 
drencephaloid.  They  have  been  variously  explained  by  different  writers 
as  due  to  cerebral  ana?mia,  cerebral  hyperiBmia  (venous),  oedema  of  the 
meninges,  thrombosis  of  the  cerebral  sinuses,  and  uraemia.  In  but  a 
single  instance  have* I  met  with  post-mortem  changes  in  the  brain 
whicTi  bore  any  proper  relation  to  the  symptoms.*  Although  I  have 
examined  the  brain  in  almost  all  my  autopsies  upon  patients  dying  from 
diarrhoeal  diseases,  I  have  never  in  such  cases  seen  sinus  thrombosis,  and 
but  rarely  oedema.  Cerebral  hyperemia  was  often  met  with  in  cases  dying 
in  convulsions,  but  not  with  any  regularity  otherwise.  Nor  have  my  obser- 
vations upon  the  kidneys  confirmed  the  observations  of  Kjellberg,  whom 
most  of  the  writers  since  his  day  have  quoted,  as  to  the  great  frequency  of 
nephritis.  Albumin,  casts  and  renal  epithelium  in  the  urine  are  rare,  and 
■  blood  I  have  never  seen.  The  kidneys  at  autopsy  are  found  generally 
.paler  than  normal,  with  a  moderate  cloudy  swelling  of  the  cortex,  but  not 
more  than  in  other  febrile  disorders  of  infancy.  These  facts  forbid  our 
regarding  either  the  renal  or  the  cerebral  changes  as  an  explanation  of  the 

*  In  this  infant  the  cerebral  symptoms  were  so  marked  and  so  characteristic  that 
two  excellent  physicians  who  watched  the  case,  unhesitatingly  made  a  diagnosis  of 
meningitis.  The  intestinal  symptoms  were  considered  of  secondary  importance.  The 
autopsy  revealed  follicular  ulcers  of  the  ileum,  moderate  parenchymatous  nephritis, 
and  an  extreme  degree  of  cerebral  anaemia. 


CHOLERA  INFANTUM.  335 

nervous  symptoms  of  most  of  these  cases ;  they  seem  rather  to  depend 
upon  acute  inanition  and  intestinal  toxaemia. 

In  cases  going  on  to  recovery  the  vomiting  usually  ceases  first ;  then 
the  stools  become  less  frequent,  contain  more  solid  matter,  and  have  more 
colour.  Improvement  in  the  pulse,  a  fall  in  the  temperature,  and  subsi- 
dence of  the  nervous  symptoms  soon  follow.  The  disappearance  of  the 
nervous  symptoms  is  always  to  be  regarded  as  a  very  favourable  sign.  The 
discharges  gradually  assume  more  and  more  of  the  character  of  a  catarrhal 
diarrhoea,  which  continues  a  week  or  more.  Convalescence  is  never  very 
rapid.  Sometimes,  after  all  signs  of  improvement  have  continued  for  two 
or  three  days,  the  choleraic  discharges  return  with  great  severity,  and  the 
case  proves  fatal. 

An  infrequent  complication  of  cholera  infantuna  is  sclerema.  This 
condition  is  found  associated  with  muscular  contractions,  subnormal  tem- 
perature, and  other  signs  of  the  most  extreme  depression.  These  cases 
are  invariably  fatal. 

Diagnosis. — Cholera  infantum  can  scarcely  be  mistaken  for  any  other 
form  of  intestinal  disease  if  its  chief  symptoms  are  kept  in  mind — con- 
stant vomiting,  profuse  serous  stools,  great  thirst,  dry  tongue,  high  tem- 
perature, and  great  restlessness,  followed  by  rapidly  developing  collapse, 
sunken  fontanel,  pinched,  anxious  face,  cold  extremities,  weak  pulse, 
dyspnoea,  cyanosis,  stupor,  coma,  and  death. 

Prognosis. — The  prognosis  is  worse  in  a  very  young  infant,  in  one  who 
has  been  badly  fed  and  poorly  cared  for,  when  all  the  surroundings  are 
unfavourable,  when  the  patient  has  suffered  from  antecedent  disease,  and 
ia  midsummer.  Yet  fatal  cases  are  often  seen  in  infants  previously 
healthy  and  living  in  good  surroundings.  There  are  cases  in  which  it  is 
evident,  from  the  first  few  hours  of  the  attack,  that  death  Avill  be  the 
issue.  The  physician  is  never  warranted  in  telling  parents  that  the  result 
would  have  been  different  had  he  been  called  in  time.  Xo  matter 
what  treatment  is  employed,  tlie  vast  majority  of  the  very  severe  cases 
terminate  fatally.  Of  the  cases  of  true  cholera  infantum  which  have  come 
under  my  notice  during  the  last  ten  years,  fully  two  thirds  have  died. 
The  result  depends  more  upon  the  severity  of  the  attack  than  upon  any- 
thing else. 

Treatment. — Restricting  the  term  to  the  class  of  cases  described  above, 
all  who  have  seen  much  of  the  disease  must  admit  that  the  results  of 
treatment  are  extremely  unsatisfactory,  and  that  tlie  most  severe  cases 
pursue  their  course  but  little,  if  at  all,  influenced  by  the  treatment  era- 
ployed.  This  statement  is  made  after  persoiud  trial  of  almost  every 
method  of  treatment  which  has  been  advocated  by  writers  upon  the  subject. 

In  the  way  of  prophylaxis  much  can  be  done.  All  the  general  rules 
of  prevention  laid  down  in  the  previous  chapter  should  be  enforced  here. 
Special  emphasis,  however,  is  to  be  laid  upon  the  early  treatment  of  the 
23 


336  DISEASES  OP   THE   DIGESTIVE  SYSTEM. 

milder  iutestinal  derangements,  since  it  is  a  rule,  to  which  the  exceptions 
are  few,  that  such  symptoms  precede  for  some  days  the  occurrence  of  the 
choleriform  diarrhoea.  No  case  of  diarrhoea  in  summer  is  to  be  neglected 
on  the  score  of  existing  dentition.  It  is  also  important  in  convales- 
cence from  ileo-colitis  that  vigilance  should  never  be  relaxed  until  the 
stools  are  normal.  One  frequently  sees  cases  which,  so  far  as  it  is  pos- 
sible to  Judge,  had  been  progressing  steadily  toward  recovery,  cut  off  in 
a  day  by  the  development  of  cholera  infantum. 

The  best  view  of  the  treatment  will  be  gained  if  we  keep  in  mind  that 
we  ate  not  treating  intestinal  catarrh,  nor  intestinal  inflammation,  although 
this  may  ensue,  but  that  these  are  essentially  cases  of  poisoning;  that 
the  toxic  materials  act  by  causing  great  depression  of  the  heart  and  the 
system  generally  by  acting  on  the  nerve-centres,  and  by  paralysis  of  the 
vaso-motor  nerves  of  the  intestines. 

The  main  indications  are:  (1)  to  empty  the  stomach  and  intestine ; 
(2)  to  neutralize  the  effect  of  the  poison  upon  the  heart  and  nervous  sys- 
tem ;  (3)  to  supply  fluid  to  the  blood  to  make  up  for  the  very  great  drain 
of  the  discharges;  (4)  to  reduce  the  temperature;  (5)  to  treat  special 
symptoms  as  they  arise. 

For  the  first  indication  we  must  rely  upon  mechanical  means — stom- 
ach-washing and  intestinal  irrigation — for  there  is  no  time  to  wait  for  the 
action  of  cathartics.  For  the  second,  nothing  in  my  hands  has  proved  so 
useful  as  the  hypodermic  use  of  morphine  and  atropine.  I  believe  tliis 
to  be  more  efficient  than  any  other  means  of  treatment  we  possess.  Mor- 
phine is  contra-indicated  where  the  purging  has  ceased  or  is  slight,  and 
where  there  is  drowsiness,  stupor,  or  relaxation.  The  effects  of  the  dose 
should  always  be  carefully  watched ;  a  small  dose  repeated  is  better  than 
a  single  large  dose.  For  a  child  a  year  old,  not  more  than  gr.  y^  of 
morphine  and  gr.  -g^^  of  atropine  should  be  the  initial  dose.  It  may 
be  repeated  every  hour  until  the  desired  effects  are  produced  :  these  are, 
arrest  of  the  vomiting  and  purging  (or  at  least  their  diminution),  improve- 
ment in  the  heart's  action,  and  in  the  nervous  symptoms.  Here,  as  in 
shock,  we  find  morphine  our  most  reliable  heart  stimulant.  The  use  of 
opium  by  the  mouth  is  not  to  be  relied  upon,  owing  to  the  uncertainty  of 
absorption  and  the  liability  to  produce  vomiting. 

For  the  third  indication,  it  is  useless  to  give  fluids  by  the  mouth. 
The  only  thing  that  can  be  depended  upon  is  the  injection  into  the  cellu- 
lar tissue  of  a  saline  solution  (common  salt  forty-five  grains,  sterilized 
water  one  pint).  This  may  be  injected  into  the  cellular  tissue  of  the  ab- 
domen, buttocks,  thighs,  or  back.  To  be  efficient  at  least  half  a  pint 
should  be  given  in  the  course  of  every  twelve  hours.  A  very  much 
larger  quantity  can  often  be  used  with  advantage.  This  causes  no  irrita- 
tion, and  is  absorbed  with  surprising  rapidity.  A  simple  apparatus  for 
making  the  injection  has  been  devised  by  Dawbarn,  viz.,  to  attach  the 


ACUTE   ILEO-COLITIS.  337 

needle  of  a  hypodermic  syringe  by  a  few  inches  of  rubber  tubing,  to  the 
nozzle  of  a  bulb  (Davidson's)  syringe.  It  must  be  tied  securely.  Only  a 
sterilized  syringe  should  be  used,  and  care  must  be  taken  to  prevent  the 
entrance  of  air.  The  injection  is  made  slowly,  and  the  exact  amount 
introduced  at  each  time,  measured. 

Only  baths  are  to  be  relied  upon  for  the  reduction  of  temperature. 
The  graduated  bath  should  be  used,  as  described  on  page  48.  It  may 
be  continued  from  ten  to  thirty  minutes.  To  be  efficient,  it  must  be 
used  frequently — as  often  as  every  hour  if  symptoms  are  threatening.  Iced 
cloths  or  an  ice  cap  should  be  applied  to  the  head.  Ice-water  injections 
are  a  valuable  accessory  to  the  treatment  by  baths.  A  rectal  tube  should 
be  used,  and  the  injection  carried  high  up  into  the  colon,  the  water  being 
allowed  to  flow  in  and  out  freely.  Nothing  should  be  allowed  by  the 
mouth  except  ice  and  iced  champagne  or  brandy.  The  stimulants  must 
be  given  in  small  quantities  and  frequently.  When  stimulants  taken  by 
the  mouth  are  vomited,  they  should  be  given  hypodermically.  Brandy, 
ether,  or  camphor  may  be  employed,  and  used  freely.  During  the  stage 
of  most  acute  symptoms,  to  attempt  to  give  food  or  drugs  of  any  kind 
by  the  mouth  is  worse  than  useless.  After  the  stage  of  violent  symptoms 
has  subsided  and  reaction  is  established,  the  subsequent  management  in 
respect  to  feeding  and  medication  should  be  the  same  as  in  the  cases  con- 
sidered in  the  previous  chapter.  If  the  symptoms  described  as  hydren- 
cephaloid  are  present,  opium  is  to  be  avoided,  stimulants  by  the  mouth 
used  freely,  and,  if  these  are  not  retained,  they  should  be  given  hypo- 
dermically. For  cold  extremities  and  subnormal  temperature,  hot  mus- 
tard baths  should  be  used  to  establish  reaction,  mustard  paste  applied  all 
over  the  body,  and  hot- water  bags  and  bottles  placed  about  the  patient. 


CHAPTER  VIII. 
DISEASES  OF   THE  INTESTINES.— {Continued.) 

ACUTE   COLITIS  AND   ILEO-COLITIS. 

Synony.Tis:  Entero-colitis,  enteritis,  enteritis  foUicularis,  dysentery,  inflammatory 
diarrhoea. 

The  terms  colitis  and  iJco-colitis  are  general  ones,  embracing  those 
forms  of  intestinal  disease  in  which  there  are  found  more  serious  le- 
sions than  those  of  the  superficial  epithelium,  which  occur  in  acute  gas- 
tro-enteric  infection.  By  separating  these  two  groups  of  cases  it  is  not 
meant  to  imply  that  cases  of  ileo-colitis  are  not  infectious ;  but  in  gastro- 
enteric infection  recovery  or  death  takes  place  before  anything  more  than 
superficial  changes  have  occurred,  while  in  the  ileo-colitis  the  pathological 


338  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

process  continues  until  there  have  been  produced  marked  lesions,  often 
involving  all  the  walls  of  the  intestine.  Ileo-colitis  is  thus  to  be  regarded 
as  a  condition  in  which  any  case  of  gastro-enteric  infection  may  termi- 
nate. Sometimes  the  transition  is  so  gradual  that  it  is  impossible,  by 
symptoms,  to  draw  a  line  between  them.  This  is  especially  true  of  the 
cases  terminating  in  follicular  ulceration  of  the  colon.  In  some  of  the 
other  forms — acute  catarrhal  and  acute  membranous  colitis — the  evi- 
dences of  a  severe  intestinal  inflammation  are  often  manifest  from  the 
very  outset.  This  difference  is  probably  due  to  the  character  of  the  infec- 
tion and  its  virulence  in  the  two  classes  of  cases.  The  extent  of  the  le- 
sions depends  very  much  upon  the  duration  of  the  process.  It  has  seemed 
wise,  with  our  present  understanding  of  these  cases,  to  drop  the  term 
dysentery  as  a  generic  one,  grouping  them  all  under  the  general  head  of 
ileo-colitis  until  an  etiological  classification  shall  become  possible. 

Etiology. — Most  of  the  etiological  factors  discussed  in  the  previous 
chapter  apply  with  equal  force  to  the  cases  of  ileo-colitis.  It  may  be  sec- 
ondary to  any  of  the  infectious  diseases,  particularly  measles,  diphtheria, 
and  broncho-pneumonia.  Epidemics  of  ileo-colitis,  in  the  true  sense  of 
the  term,  I  have  never  seen.  As  to  contagion,  we  are  still  in  doubt  as  to 
the  degree  in  which  this  is  possible.  Infants  are  most  often  affected,  but 
the  disease  is  not  uncommon  up  to  the  fifth  year.  Attacks  are  more  fre- 
quent in  the  summer,  but  they  may  occur  at  any  season  of  the  year.  They 
are  often  seen  in  the  fall  months,  when  outbreaks  sometimes  seem  to  be 
very  closely  connected  with  marked  changes  in  the  temperature. 

But  little  is  as  yet  definitely  known  regarding  the  nature  of  the  infec- 
tion in  cases  of  ileo-colitis.  Booker  found  that  the  deeper  lesions  were 
almost  invariably  associated  with  the  presence  of  streptococci,  but  whether 
they  are  primary  or  secondary  is  not  easy  to  determine.  What  part  the 
amoeba  coli  plays  in  the  colitis  of  infancy  and  early  childhood  it  is  now 
impossible  to  say.  Amoebge  have  been  found  by  Cahen  and  others  in  the 
stools  of  typical  cases,  but  thus  far  too  few  observations  have  been  made 
to  admit  of  any  deductions. 

Lesions.— The  nature  of  the  lesions  in  ileo-colitis  differs  very  much  in 
the  different  groups  of  cases,  but  their  position  is  quite  constant :  they 
affect  the  lower  ileum  and  the  colon.  In  about  half  the  cases  only  the 
colon  is  affected.  The  lesions  of  the  ileum  are  frequently  limited  to  its 
lower  two  or  three  feet. 

The  frequency  with  which  the  different  varieties  of  ileo-colitis  were 
found  in  eighty-two  of  my  own  autopsies  was  as  follows : 

Follicular  ulceration 36 

Catarrhal  inflammation 26 

Catarrhal  ulceration 6 

Membranous  inflammation 14 

83 


ACUTE   ILEO-COLITIS.  339 

Acute  catarrhal  ileo-colitis. — la  the  milder  cases  there  are  changes  in 
the  epithelium  and  infiltration  of  the  mucosa.  In  the  severe  cases  the 
submucosa  is  involved,  and  the  infiltration  of  the  mucosa  may  be  so  great 
as  to  lead  to  necrosis  and  the  formation  of  catarrhal  ulcers. 

Gross  appearances. — While  the  lower  ileum  and  the  colon  are  most 
seriously  affected,  it  is  not  uncommon  to  find  quite  marked  changes  in  a 
considerable  portion  of  the  small  intestine,  and  even  in  the  stomach.  In 
the  cases  of  short  duration,  the  lesions  are  sometimes  more  marked  in  the 
small  intestine  than  in  the  colon.  The  stomach  contains  undigested  food, 
and  mucus  which  is  commonly  stained  a  dark-brown  colour.  It  may  be 
dilated  or  contracted.  The  mucous  membrane  is  pale  or  congested  ;  if 
the  latter,  it  is  usually  in  patches,  and  more  about  the  pyloric  orifice. 


A  ' h^yr^r^  ^^^mukm  :\  k  .# ""^fe 


Fio.  52. — Acute  catarrhal  inflammation  of  the  ileum. 

At  the  left  is  seen  the  edge  of  a  Peyer's  yiatch  ( P)  greatly  swollen.  The  most  striking 
feature  of  the  lesion  is  the  loss  of  the  superficial  epitlielium,  which  is  shown  in  all  parts  of  the 
specimen.  The  significance  of  this  depends  upon  the  fact  that  the  autopsy  was  maile  but  two 
liours  after  death.  '  At  several  points,  F,  F,  the  tubular  follicles  have  loosened  and  fallen  out. 
The  mucosa,  A,  is  slightly  infiltrated  with  cells,  especially  near  the  Peyer's  patch.  The  sub- 
mucosa, C,  and  muscular  coats,  I),  F,  are  normal.  \ ,  F,  are  small  veins.  HlMory. — Infant,  nine 
months  old,  previously  healthy;  sick  three  days  with  severe  intestinal  sym]>toms:  temperature. 
10.3°  to  105°  F.  Avtnpsy. — .\c'ute  catarrhal  inflammation  of  ileum  and  colon  :  Peyer's  patches 
red  and  swollen.  The  specimen  is  taken  from  the  lower  ileum.  The  supci-ficial  character  of 
the  lesion  is  chiefly  due  to  the  short  duration  of  the  process. 

The  intestinal  contents  are  generally  green  in  colour,  and  thin.  The 
mucous  membrane  is  often  coated  with  tenacious  mucus.  The  small  in- 
testine is  distended  with  gas,  the  large  intestine  nearly  empty,  except  the 
transverse  colon.  The  mucous  membrane  may  appear  somewhat  swollen. 
In  the  small  intestine  there  are  occasionally  seen  swelling  and  oedema  of 
the  villi,  so  that  they  project  abnormally  and  give  a  plush-like  appearance. 
Congestion  is  a  constant  feature,  and  it  may  be  simply  upon  the  folds  of  the 
mucous  membrane,  or  about  the  solitary  lymph  nodules ;  or  it  may  be  in- 
tense and  involve  the  whole  intestine  for  some  distance.  Small  ha^morrhagic 
areas  are  often  seen  here  and  there,  widely  scattered.  In  the  most  severe 
cases  there  are  m.arked  thickening  and  uniform  congestion,  and  the  appear- 
ance io  sometimes  much  like  that  seen  in  membranous  inflammation.    The 


340  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

lymph  nodules  (solitary  follicles)  througliout  the  colon  are  usually  swollen, 
projecting  above  the  mucous  membrane  about  the  size  of  a  pin's  head. 
Peyer's  patches  may  be  normal,  or  they  may  be  swollen  and  congested, 
with  other  evidences  of  catarrhal  inflammation  in  the  surrounding  mucous 
membrane,  or  more  rarely  they  may  be  involved  when  the  rest  of  the  mu- 
cosa appears  healthy.  The  same  is  true  of  the  lymph  nodules  of  the  small 
intestine.  The  lymph  nodes  of  the  mesentery  are  usually  swollen  and 
acutely  congested,  but  they  may  appear  normal. 

Microscojiical  appearances. — In  interpreting  the  changes  found  in  the 
mucosa,  the  same  precautions  must  be  observed  as  stated  on  page  320. 

There  is  usually  loss  of  the  superficial  epithelium  and  of  that  lining 
the  tubular  glands  at  their  orifices.     Upon  the  surface  of  the  mucosa  and 


i^ifttW^I^KS:;-.      '" 


^^f^'-s^g^; 


Fig.  53. — Acute  catarrhal  inflammation  of  the  ileum ;  severe  form. 

The  mucosa,  0,  is  everywhere  densely  infiltrated  with  round  cells,  compressing  the  tubular 
follicles,  and  in  places,  Z,  i.,  almost  etfacinor  them.  Upon  the  surface  of  the  mucosa  is  a  thick 
layer  of  cells  and  mucus.  Beneath  this  the  epithelial  arches,  £,  B,  covering  the  villi  can  be 
seen.  The  lesions  are  almost  entirely  of  the  mucosa.  The  only  changes  in  the  submucosa,  E, 
are  groups  of  cells  about  the  small  blood-vessels,  T",  f'  HiMory. — Infant  six  months  old ;  mod- 
erate diarrhoea  twelve  days;  severe  symptoms  with  high  temperature  for  six  days.  There  was 
intense  inflanunation  of  the  entire  colon  and  lower  three  feet  of  the  ileum.  Intestine  greatly 
congested  and  thickened.     Specimen  is  from  the  ileum. 

within  the  tubular  glands,  fine  granular  matter  is  seen  from  the  broken- 
down  epithelium.  The  goblet  cells  are  distended  with  mucus,  and  do 
not  stain  clearly.  The  lumen  of  the  tubular  glands  is  narrowed  from 
pressure  due  to  the  swelling  of  the  lymphoid  tissue  which  separates  them, 
which  is  partly  from  cedema,  and  partly  from  cell  infiltration  (Fig.  52). 
Entire  tubular  glands  may  loosen  and  fall  out.  A  thick  layer  of  mucus 
and  round  cells,  adhering  closely  to  the  surface,  may  resemble  pseudo- 
membrane  (Fig.  53).  In  the  milder  varieties  the  infiltration  with  round 
cells  is  not  great  and  is  usually  limited  to  the  mucosa,  the  extent  depend- 
ing principally  upon  the  duration  of  the  process.     In  the  very  severe  cases 


PLATE  VIIL 


A  — 


Extensive  Catarrhal  Ulceration  of  the  Colon. 

Female  child  nine  months  old ;  symptoms  of  acute  ileo-colitis  of  fifteen  days'  dura- 
tion; temperature,  101''  to  104*5°  F.,  and  from  six  to  eight  stools  daily — thin,  green, 
and  yellow,  but  no  blood. 

Extensive  ulceration  throughout  the  colon,  most  marked  in  descending  portion, 
from  which  specimen  is  taken.  , 

A  A  are  small  circular  ulcers :  B  B.  larger  ones  from  coalescence  of  several  of 
these;  C  C,  large  areas  of  ulceration,  the  mucous  membrane  being  almost  entirely 
destroved. 


ACUTE  ILEO-COLITIS.  341 

there  is  found  a  dense  infiltration  of  the  mucosa  and  of  the  submucosa 
also,  which  in  places  extends  quite  to  the  muscular  coat.  These  cases 
closely  resemble  those  of  the  membranous  variety,  lacking  only  the  exuda- 
tion of  fibrin.  The  lymph  nodules  of  the  colon  are  swollen  to  a  greater 
or  less  degree,  chiefly  from  an  increase  in  the  number  of  lymphoid  cells. 
This  swelling  may  be  the  most  prominent  feature  of  the  lesion.  If  the 
process  is  sufficiently  prolonged,  the  lymph  nodules  may  break  down  and 
ulcerate.  The  changes  in  the  lymph  nodules  of  the  small  intestine  and 
in  Peyer's  patches  are  similar  to  those  seen  in  the  colon,  but  are  less 
marked,  and  frequently  absent  altogether.  Ulceration  in  Peyer's  patches 
is  extremely  rare. 

The  small  veins  and  capillaries  of  the  submucosa  and  mucosa  are 
usually  distended  with  blood  ;  small  extravasations  are  very  common,  and 
occasionally  larger  ones  are  seen. 

Catarrhal  inflammation,  except  in  its  very  severe  form,  which  is  not 
frequent,  causes  no  lesions  that  can  not  readily  be  repaired.  The  most 
persistent  change  is  usually  the  swelling  of  the  lymph  nodules,  which  may 
last  a  long  time,  and  appears  to  be  an  important  factor  in  the  tendency  to 
relapses  and  recurring  attacks.  If  there  is  a  continuance  of  the  exciting 
cause,  or  the  patient's  constitution  is  a  bad  one,  the  process  may  become 
chronic. 

Catarrhal  ulceration. — In  the  most  severe  form  of  catarrhal  inflam- 
mation which  does  not  prove  fatal  in  the  earlier  stages,  extensive  ulcer- 
ation occasionally  takes  place ;  usually  these  ulcers  are  seen  throughout 
the  entire  colon,  and,  in  rare  cases,  a  few  are  found  in  the  lower  ileum. 
They  generally  begin  in  the  mucosa  overlying  the  lymph  nodules,  and 
while  they  have  a  wide  superficial  area,  they  do  not  extend  deeper  than 
the  mucosa.  The  small  ulcers  are  circular  and  usually  show  at  the  centre 
a  small  granular  body — the  lymph  nodule.  The  larger  ulcers  result  from 
the  coalescence  of  several  small  ones,  and  are  irregular  in  shape.  They 
may  be  two  or  three  inches  in  diameter.  Sometimes  for  a  considerable 
distance  a  large  part  of  the  mucosa  may  be  destroyed.  Often  the  en- 
tire surface  presents  a  worm-eaten  appearance  (Plate  VIII).  On  micro- 
scopical examination  there  is  seen,  in  the  greater  part  of  the  ulcer,  com- 
plete destruction  of  the  mucosa,  the  submucosa  being  densely  packed 
with  round  cells  quite  to  the  muscular  coat. 

Inflammation  of  the  hjmph  nodules  tvith  nlceratio7i  {follicular  ulcera- 
tion).— Follicular  ulcers  are  found  at  autopsy  in  about  one  third  of  the 
cases  dying  from  diarrhanil  diseases.  They  are  rarely  seen  in  those  which 
have  lasted  less  than  a  week,  and  not  often  before  the  middle  of  the 
second  week ;  the  average  duration  of  the  cases  being  about  two  and  a 
half  weeks. 

In  thirty-six  cases  in  which  follicular  ulcers  were  found  at  autopsy, 
they  were  present  in  the  small  intestine  alone  in  but  three  cases  ;  in  the 


342 


DISEASES   OF  THE  DIGESTIVE  SYSTEM. 


small  iutestine  and  iu  the  colon  in  six  cases;  in  the  remaining  twenty- 
seven  they  were  present  only  iu  the  colon.  When  in  the  small  intestine 
they  were  seen  only  in  the  lower  ileum.  Ulceration  was  seen  a  few  times 
in  one  or  two  of  the  nodules  of  a  Peyer's  patch.  Ulceration  of  the  large 
iutestine  involved  the  wliole  colon  in  about  half  the  cases ;  Avhile  in  the 
remainder  the  process  was  limited  to  its  lower  portion.  The  deepest  and 
also  the  largest  ulcers  were  usually  iu  the  descending  colon  and  sigmoid 
flexure. 

In  the  early  stage  these  ulcers  appear  as  tiny  excavations  at  the  summit 
of  the  prominent  lymph  nodules.  Later,  the  whole  nodule  may  be  de- 
stroyed, and  a  small  round  ulcer  is  formed  from  one  twelfth  to  one  fourth 
of  an  inch  iu  diameter  (Plate  IX).  These  are  quite  deep  and  have  over- 
hanging edges ;  when  closely  set  they  give  the  intestine  a  sieve-like  ap- 


FiG.  5-4. — Lymph  nodule  of  the  colon  in  the  early  stage  of  ulceration — Follicular  ulcer. 

The  nodule,  F,  is  much  enlarared,  and  is  breaking  down  and  discharging  into  the  intestine 
The  other  changes  are  not  marked.  The  superficial  epithelium  is  gone:  the  mucosa,  A,  shows 
a  slight  increase  of  cells,  and  in  the  submucosa,  C.  are  nests  of  cells  about  the  small  vessels,  T,  V. 
History. — Delicate  child,  thirteen  months  old;  slight  diarrhoja  four  weeks ;  severe  symptoms 
five  days.  The  colon  was  filled  with  ulcers  one  twelfth  of  an  inch  in  diameter,  one  of  which 
is  shown  in  the  illustration. 


pearance.  By  the  coalescence  of  several  of  them,  larger  ulcers  may  form 
which  are  an  inch  or  more  in  diameter.  At  the  bottom  of  these  larger 
ones  the  transverse  striae  of  the  circular  muscular  coat  are  often  plainly 
seen.     I  have  never  known  them  to  cause  perforation. 

Microscopical  appearances. — The  lymph  nodules  are  swollen,  principally 
from  the  accumulation  within  them  of  round  cells.  This  is  followed  by 
softening,  which  usually  begins  at  the  summit  of  the  nodule  and  ex- 


PLATE   IX. 


rr  .  ^  ^.  , 


*^  ^s 


^r    ■'^'■*^ 


;.    '-       '     ♦     ^ 


.-  V-.  _' 


Deep  Follicular  Ulcers  of  the  Colon. 

A  delicate  child,  fourteen  months  old,  sick  twelve  days ;  stools  green,  yellow,  brown, 
and  watery:  no  blood  :  temperature,  100    to  lOT  F. 

The  small  intestine  was  normal ;  ulcers  throufjliout  colon.  The  specimen  is  from 
descending  colon ;  the  ulcers  are  deep,  and  most  of  them  extend  to  the  muscular  coat. 
(For  microscopical  apjiearance,  see  Fig.  55.) 


ACUTE   ILEO-COLITIS.  343 

tends  downward  ;  the  reticulum  breaks  down,  and  the  cellular  contents 
escape  into  the  intestine  (Fig.  54).  Softening  may  begin  at  the  centre 
of  the  nodule,  which  ruptures  like  an  abscess.  The  destruction  of  the 
■whole  nodule  leaves  a  cavity,  which  is  the  follicular  ulcer.  At  first  the 
ulcers  correspond  in  size  to  the  nodule,  but  meanwhile  infiltration  of  the 
adjacent  tissue  has  taken  place,  and  this  may  become  necrotic.  In  this 
way  the  ulcer  extends,  chiefly  in  the  submucous  coat.     The  lesion  is  never 


,^^^. 


-:wm 


mm..^,''  '    ''  '''^a- j«'W| 


Fio.  55. — Deep  follicular  ulcer  of  the  colon. 

A  deep  ulcer  is  shown  at  F^  a  smaller  one  at  F' .  The  separation  of  the  mucosa  at  H  is  acci- 
dental. There  is  no  trace  of  the  lymph  nodule  from  which  the  large  ulcer  had  its  origin.  The 
destructive  process  has  extended  laterally  in  the  submucosa,  C\  ancf  the  mucosa,  A,  isl'alling  in 
to  fill  up  the  space.  In  the  vicinity  of  the  ulcers,  the  submucosa  is  densely  infiltrated  with 
round  cells,  L'\  L'\  which  also  are  seen  in  the  lymph  spaces  between  the  bundles  of  circular 
nniscular  fibres,  Z',  Z',  and  some  are  seen  in  the  longitudinal  muscular  coat.  Z,  Z.  History. — 
Thirteen  months  old,  delicate  ;  continuous  diarrha-al  symptoms  for  tliree  w  cel<s.  ricers  found 
throughout  tlie  colon,  the  largest,  one  half  an  inch  in'diameter.  Tlie  illustration  sliows  one  of 
the  small  ones  like  those  in  I'late  IX. 

limited  to  the  lymph  nodules;  but  the  extent  of  the  other  changes  found, 
depends  upon  the  severity  and  the  duration  of  the  process.  In  cases 
dying  after  an  illness  of  a  week  or  ten  da3'S,  we  usually  find  only  moderate 
changes  in  the  mucosa,  and  in  the  submucosa  a  slight  infiltration  of  round 
cells,  especially  about  the  small  blood-vessels  (Fig.  54,  F,  V).  In  those 
■vyhich  have  lasted  three  or  four  weeks  the  ulcers  are  deeper,  and  all  the 
structures  of  the  intestine  in  their  neighbourhood,  are  usually  involved 
(Fig.  55).  The  mucosa  is  densely  packed  with  round  cells,  as  are  also 
all  the  tissues  in  the  vicinity  of  the  ulcers  ;  even  the  muscular  coat  may 
be  infiltrated.  The  ulcers,  however,  rarely  extend  deeper  than  the  circu- 
lar layer. 

Follicular  ulceration  of  the  intestine  in  infancy,  usually  terminates 
fatally  if  the  process  is  an  extensive  one.  In  less  severe  cases,  recovery 
may  take  place,  the  ulcers  healing  by  granulation  and  cicatrization  in  the 
course  of  from  four  to  eight  weeks. 

Acute  membratious  ileo-colitis. — This  is  the  most  severe  form  of  intes- 


344  DISEASES  OF   THE   DIGESTIVE   SYSTEM. 

tiual  iuflammation  seen  among  cliildren.  The  process  differs  quite  mate- 
rially from  that  described  as  occurring  among  adults.  In  only  one  of  my 
own  cases  was  it  associated  with  membranous  inflammation  of  any  other 
mucous  membrane,  in  that  case  with  membranous  gastritis.  A  speci- 
men was  presented  to  the  Xew  York  Pathological  Society  in  1889  by  Sel- 
lew,  in  which  this  lesion  was  associated  with  a  membranous  inflammation 
of  the  pharynx.  Membranous  colitis  usually  runs  a  short,  intense  course, 
with  a  temperature  which  continues  moderately  high,  severe  constitu- 
tional symptoms,  and  death  generally  in  eight  or  ten  days.  The  shortest 
case  I  have  seen  lasted  six  days.  If  recovery  takes  place  it  is  only  after  a 
very  prolonged  illness. 

Gross  appearances. — There  is  visible  to  the  naked  eye  usually  very  little 
pseudo-membrane  and  no  deep  sloughing.  The  lesion  affects  with  remark- 
able uniformity  the  last  two  or  three  feet  of  the  ileum  and  the  entire  colon. 
It  is  exceedingly  rare  to  meet  with  any  marked  lesions  high  in  the  small 
intestine.  The  most  marked  changes  are  near  the  ileo-cscal  valve  or  in 
the  sigmoid  flexure  and  the  rectum.  In  the  ileum  they  are  usually  quite 
as  severe  as  in  the  colon  (Plate  X).  The  intestinal  wall  is  firm  and  stiff, 
and  is  two  or  three  times  its  normal  thickness.  It  is  not  thrown  into  deep 
folds,  as  is  the  healthy  intestine  when  empty.  It  is  very  rare  to  find  false 
membrane  that  can  be  stripj^ed  off  in  patches  of  any  considerable  size. 
Where  membrane  exists,  the  colour  is  a  grayish  green,  and  the  surface  is 
often  fissured,  giving  a  lobulated  appearance.  In  the  parts  where  no 
pseudo-membrane  can  be  seen,  the  surface  is  usually  of  an  intense  red 
colour  and  is  rough  and  granular,  in  striking  contrast  to  the  normal  glist- 
ening appearance.  Here  and  there  small  extravasations  of  blood  may  be 
seen.  In  the  regions  most  affected,  the  normal  structures  of  the  mucous 
membrane — the  villi,  Peyer's  patches,  and  solitary  follicles — can  not  be  dis- 
tinguished. Although  the  whole  colon  is  diseased,  the  lesions  differ  very 
much  in  severity  in  the  different  regions,  and  large  areas  of  pseudo-mem- 
brane are  rare.  In  a  single  instance  I  found  an  exudation  of  fibrin  on  the 
peritoneal  surface  of  the  intestine  for  a  short  distance.  Except  in  the 
lower  ileum  the  small  intestine  shows  no  constant  changes,  and  none  are 
usually  found  in  the  stomach. 

Microscopical  changes. — These  (Fig.  56)  are  much  more  uniform  than 
the  gross  appearances.  The  most  characteristic  feature  is  the  exudation 
of  fibrin,  which  forms  a  distinct  pseudo-membrane  upon  the  surface  of  the 
intestine,  and  may  infiltrate  the  mucosa,  and  even  the  submucosa.  Fibrin 
is  found  under  the  microscope  in  parts  of  the  specimen,  which  to  the 
naked  eye  shows  no  distinct  pseudo-membrane,  but  only  a  granular  ap- 
pearance. In  rare  cases  a  fibrinous  exudation  may  be  found  upon  the 
peritoneal  covering  of  the  intestine.  The  pseudo-membrane  is  made  up 
of  a  fibrinous  network  containing  small  round  cells,  some  red  blood-cells, 
and  bacteria,  chiefly  cocci.     The  mucosa,  and  usually  the  submucosa,  are 


PLATE   X. 


Membranol's  Inflammation  of  the  Ileum. 

A  delicate  cliild,  eleven  months  old;  mild  diarrhoea  for  two  weeks  without  fever; 
acute  severe  symptoms  for  twelve  days;  temperature.  100  to  102-5'  F. ;  green  and 
mucous  stools  :  no  blood. 

The  lesions  involved  the  last  foot  of  ileum  and  entire  colon.  Specimen  is  from 
lower  ileum,  and  shows  the  abru[)t  termination  of  the  lesion;  the  upper  |)art  shows 
normal  small  intestine;  A  is  a  Peyer's  patch:  B  is  tlie  inflamed  part  of  the  intestine; 
it  has  a  rough  granular  appearance  and  is  much  thickened. 


ACUTE  ILEO-COLITIS.  345 

densely  infiltrated  with  small  round  cells,  whieli  in  places  may  be  so  nu- 
merous as  to  efface  the  normal  elements  of  the  intestine.  The  tubular 
follicles  are  in  some  places  quite  destroyed,  not  a;  vestige  of  them  remain- 
ing. In  other  places  they  are  compressed  and  distorted  by  the  accumula- 
tion of  cells.  The  great  thickening  of  the  intestine  is  due  partly  to  the 
cell  infiltration,  partly  to  the  fibrinous  exudation,  and  partly  to  oedema. 
All  the  blood-vessels,  both  in  the    mucosa   and    submucosa,  are  gorged 


Fig.  56. — Membranous  inflammation  of  the  colon. 

The  intestine  is  covered  with  a  pseudo-nietiibrane,  .)/,  which  is  composed  chiefly  of  granu- 
lar fibrin ;  the  mucosa,  A,  is  densely  packed  with  round  cells,  and  the  tubular  foHicles  have 
almost  disappeared,  traces  only  bcintf  left  at  T,  T.  The  submucosa,  C,  is  greatly  thickened, 
partly  from  cells,  but  chiefly  from  fibrin,  which  with  a  high  power  is  seen  to  be  e\"erywhere  in 
this  coat,  as  well  as  the  mucosa.  Kests  of  cells  are  seen  in  the  muscular  coats  at  Z,  L.  At  /"  is  a 
lymph  nodule  covered  by  pseudo-membrane,  but  breaking  down  at  its  centre.  i\  f\  are  small 
blood-vessels  with  nests  ot  cells  about  them.  Ilistori/.— -Fourteen  months  old;  ill  nine  days; 
temperature  101°  to  105°  F. ;  all  .stools  containing  blooi.  Lesions  found  throughout  colon  and 
in  lower  ileum.  Intestine  greatly  thickened.  Specimen  is  from  ascending  colon,  where  lesion 
was  especially  severe. 

with  blood,  and  many  small  extravasations  are  seen.  A  necrotic  process 
with  the  formation  of  deep  ulcers  I  have  never  seen  associated  with  mem- 
branous colitis. 

Associated  lesions  of  ileo-coUtis. — The  most  important  one  is  broncho- 
pneumonia. It  is  found  in  quite  a  large  proportion  of  the  protracted 
cases,  and  not  infrequently  it  is  the  cause  of  death.  I  once  saw  a  pul- 
monary abscess  complicating  ulcerative  colitis.  It  was  at  the  apex,  and 
was  not  associated  with  abscesses  elsewhere  in  the  body.  Bronchitis  is 
a  very  common  complication.  Peritonitis  is  rare,  and  when  present  is 
usually  circumscribed  and  of  the  plastic  variety.  Acute  degeneration  of 
the  epithelium  of  the  kidney  (cloudy  swelling)  is  very  common,  and  in 


346  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 

fact  it  is  usually  found  in  the  cases  which  have  been  marked  by  high  tem- 
perature. Exudative  nephritis  is,  however,  in  my  experience  rare.  There 
are  no  characteristic  or  uniform  changes  found  either  in  the  liver,  spleen, 
heart,  or  brain. 

Symptoms.— (1)  Catarrhal  cases  of  moderate  severity. — The  onset  is 
usually  sudden,  often  with  vomiting,  and  for  twelve,  sometimes  twenty-four, 
hours  the  symptoms  may  be  those  of  acute  indigestion  :  vomiting,  pain, 
fever,  and  frequent  thin  green  or  yellow  stools,  which  are  partly  f^cal  and 
contain  undigested  food.  Later  the  characteristic  discharges  are  seen. 
These  are  composed  of  blood  and  mucus  ;  they  are  preceded  by  pain  and 
usually  accompanied  with  tenesmus.  The  stools  are  very  frequent,  often 
every  half  hour  and  proportionately  small,  sometimes  less  than  a  table- 
spoonful  being  found  upon  the  napkin  after  severe  straining  efforts.  The 
mucus  may  be  clear  and  jelly-like,  or  it  may  be  mixed  with  faecal  matter. 
Blood  is  seen  in  almost  every  stool,  but  rarely  in  clots,  usually  streaking 
the  mucus.  Fluid  blood  may  be  present.  These  stools  are  almost  odour- 
less. After  two  or  three  days  the  blood  usually  disappears,  or  is  seen  only 
as  traces  in  an  occasional  stool.  Mucus  is  still  present  in  large  quantities, 
making  up  the  bulk  of  the  stool.  The  colour  of  the  discharges  now  be- 
comes a  dark  brown  or  a  brownish-green.  Prolapsus  ani  is  frequent,  and 
often  occurs  with  nearly  every  stool.  For  the  first  twenty-four  hours  the 
temperature  is  usually  high,  from  102°  to  104°  F.  Later,  and  thronghout 
most  of  the  attack,  it  ranges  from  ^9°  to  102°  F.  In  the  mildest  cases  it 
may  not  be  above  101°  F.  at  any  time.  The  prostration  is  not  so  great  at 
the  outset  as  in  most  forms  of  intestinal  disease,  but  increases  steadily  for 
several  days.  The  appetite  is  lost  for  the  first  two  or  three  days,  but  there  is 
usually  great  thirst.  Abdominal  pain  is  present  and  is  often  quite  intense 
just  before  the  stool.     In  most  cases  there  is  tenderness  along  the  colon. 

The  duration  of  the  severe  symptoms  is  usually  less  than  a  week,  and 
even  though  the  child  was  previously  in  good  condition  and  properly 
treated,  recovery  is  rarely  rapid.  The  first  symptom  of  imj^rovement  is 
generally  the  disappearance  of  blood  from  the  stools,  -which  at  the  same 
time  become  less  frequent,  and  the  pain  and  tenesmus  cease.  Gradually 
the  stools  assume  more  of  a  faecal  character,  but  mucus  is  likely  to  persist 
for  two  or  three  wrecks  ;  it  may  be  seen  in  all  stools,  or  only  occasionally. 
In  some  cases  both  the  mucus  and  blood  disappear  and  the  stools  become 
thin,  brown,  or  green,  like  those  of  an  ordinary  diarrhoea.  Although 
the  early  stage  of  very  acute  symptoms  may  last  but  a  few  days,  if  there 
is  a  continuance  for  two  or  three  weeks  of  the  brown,  mucous  stools,  with 
emaciation  and  slight  fever,  ulceration  is  probably  present.  This  is  likely 
to  occur  if  the  child  is  in  poor  condition,  if  its  surroundings  are  bad, 
or  if  it  is  improperly  treated  at  the  outset.  Kelapses  are  readily  excited, 
but  cases  like  the  above  are  rarely  fatal  except  in  very  delicate  infants. 
This  is  the  most  common  form  of  ileo-colitis  whieh  terminates  in  recovery. 


ACUTE  ILEO-COLITIS.  347 

(3)  The  severe  catarrhal  form. — The  symptoms  closely  resemble  those 
of  tlie  membranous  variety,  and  a  diagnosis  from  it  is  to  be  made  only  by 
the  absence  of  pseudo-membrane  from  the  stools.  The  most  rapid  case  I 
have  seen  lasted  but  three  days,  but  the  usual  duration  is  from  one  to  two 
weeks.  The  temperature  is  steadily  high ;  the  stools  continue  very  fre- 
quent and  contain  much  blood  ;  there  are  great  prostration,  dry  tongue, 
sordes  on  the  lips  and  teeth,  and  prominent  nervous  symptoms.  Death 
usually  occurs  from  exhaustion  and  profound  sepsis  while  the  acute  symp- 
toms are  at  their  height.  If  the  patient  survives  this  stage,  the  case  may 
drag  on  for  four  or  five  weeks,  very  much  like  the  one  of  follicular 
ulceration,  and  then  terminate  in  recovery  or  in  death  from  slow  as- 
thenia, broncho-pneumouia,  or  an  acute  exacerbation  of  the  intestinal 
symptoms.  The  autopsy  in  such  cases  usually  reveals  the  presence  of  ca- 
tarrhal ulcers.  If  recovery  is  to  be  the  outcome,  after  the  symptoms  have 
been  nearly  stationary  for  a  long  time,  there  is  seen  a  gradual  turn  for 
the  better,  and  improvement  first  in  the  general  and  then  in  the  local  con- 
ditions. Convalescence  is  very  slow,  often  interrupted  by  relapses,  and  it 
may  be  months  before  the  patient  is  quite  well.  In  some  cases  the  child 
never  regains  its  former  vigour. 

(3)  Follicular  ulceration — ulcerative  injiammatioyi  of  the  lymph  nod- 
ules.— Follicular  ulceration  is  not  very  often  met  with  in  infants  under  six 
months  of  age.  Of  thirty-six  cases  in  which  the  diagnosis  was  confirmed 
by  autopsy,  all  but  four  were  between  the  ages  of  six  and  twentv-one 
months.  The  great  majority  of  these  children  were  in  poor  condition  at 
the  time  of  the  attack. 

To  understand  the  symptoms  of  these  cases,  it  must  be  remembered 
that  follicular  ulceration  is  the  terminal  process  to  which  continued  cases 
of  acute  gastro-enteric  infection  tend.  It  may  be  preceded  by  one  or 
more  acute  attacks,  or  by  a  protracted  subacute  attack.  On  account  of 
the  feeble  resistance  of  the  child  or  the  continuance  of  the  exciting  cause, 
the  pathological  process  gradually  extends  from  the  epithelium  to  the 
lymph  nodules  of  the  intestine,  chiefly  the  colon,  which,  as  already  de- 
scribed, pass  successively  through  the  stages  of  swelling,  softening,  and 
ulceration.  The  onset  of  the  illness  may  therefore  be  sudden,  Avith  vom- 
iting and  high  fever;  or  gradual,  Avithout  vomiting  and  with  very  little 
fever.  The  patient  may  be  ill  for  a  week  before  the  exact  type  which  the 
disease  is  assuming  can  be  positively  determined.  It  is  not  possible  to 
mark  the  transition  from  acute  gastro-enteric  infection  to  follicular  ileo- 
colitis. Usually  the  latter  may  be  assumed  to  exist  whenever,  after  one  of 
these  attacks,  there  is  a  continued  temperature  above  101°  F.,  and  when 
the  stools  habitually  contain  large  quantities  of  mucus  without  blood. 

Vomiting  is  not  a  feature  of  these  cases  ;  but  it  is  often  present  at  the 
onset.  Throughout  the  attack  it  is  easily  excited  by  injudicious  feeding 
or  medication.     The  temperature  is  seldom   high,  except   at  the  onset; 


348 


DISEASES  OF  THE   DIGESTIVE  SYSTEM. 


its  usual  range  is  from  99°  to  101°  F. ;  toward  the  close,  even  of  fatal 
cases,  it  may  be  scarcely  above  the  normal.  The  accompanying  chart  (Fig. 
57)  is  a  very  good  illustration  of  the  course  of  the  temperature  in  cases 
beginning  abruptly  and  ending  fatally. 

The  stools  are  not  usually  very  frequent,  the  number  being  from  four 
to  eight  a  dnj.  The  most  constant  feature  is  the  presence  of  mucus, 
which  is  mixed  with  the  stools  and  usually  abundant.  Blood  is  not  gen- 
erally present,  and  a  large  amount  of  blood  is  extremely  rare.     It  was  ab- 


DAY 

71 

2 

H 

4 

T 

6 

7 

71 

9 

10 

11    12 

;? 

14 

;? 

16]l7]l8 

T^ 

20 

21 

— 1 
22 

23]24 

25I26 

27 

28 

Q 

3o|3r 

32 

33 

^ 

DATE 

OCT. 

16 

" 

13 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

29 

30 

31 

iOV 

•2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14J1B 

16 

17 

18 

H 

I 

c 

I 
< 

1- 
< 

cc 

s 
(- 

ST 

106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 
98° 
97° 
96° 
OOLS 

"■ 

"' 

"•' 

.1 

■" 

"' 

... 

"' 

"' 

" 

'  ■ 

«.E 

... 

"' 

-I. 

».E 

"■' 

'■' 

"■' 

.1. 

"• 

'■'• 

"■' 

"' 

"■'■ 

'■'■ 

..E 

"•= 

"• 

"•' 

"■ 

' 

\/ 

h 

A 

/\ 

A 

A 

r 

/ 

/N 

y 

V 

J 

,  A 

Il 

V 

u 

r 

J 

1 

V 

V 

P 

f 

s 

A 

/ 

^ 

I 

/v 

N 

J 

V.i 

\ 

L^ 

/\ 

^ 

\> 

\\ 

k 

\J 

r^ 

V 

7 

6 

6 

3 

2 

2 

3 

5 

4 

5 

4 

5 

5 

5 

2 

3 

3 

3 

5 

5 

4 

4 

6 

4      6 

4 

4 

2 

5 

_1 

_1 

_£. 

.       2| 

Fig.  57. — Temperature  chart  of  ileo-colitis,  fatal  on  thirty-fourth  day.     Autopsy  showed  follicu- 
lar ulcers  throughout  the  colon. 


sent  entirely  in  more  than  half  of  my  cases  in  which  the  diagnosis  was 
confirmed  by  autopsy.  A  small  quantity  of  blood  early  in  the  attack  is 
not  uncommon,  depending  here  upon  congestion.  Large  haemorrhages 
from  ulcers  I  have  never  seen.  The  colour  of  the  stools  is  most  fre- 
quently of  a  dark  green  or  brown.  Fluid  stools  are  seen  only  during  ex- 
acerbations. The  odour  is  usually  offensive,  particularly  in  protracted 
cases.  The  microscope  shows  epithelial  cells  in  great  numbers,  and  very 
often  an  abundance  of  small  round  cells,  which  may  be  looked  upon  as  the 
most  constant  sign  of  ulceration. 

The  failure  in  nutrition  and  steady  loss  in  weight  are  very  constant  in 
these  cases.  As  emaciation  goes  on,  the  skin  hangs  in  loose  folds  on  the 
thighs ;  it  becomes  dry  and  scaly  and  loses  its  elasticity,  and  occasionally 
small  petechial  spots  are  seen  upon  the  abdomen.  The  skin  over  the  but- 
tocks becomes  excoriated,  and  bed-sores  form  over  the  heels,  the  sacrum, 
or  the  occiput.  The  abdomen  may  be  moderately  distended,  or  it  may  be 
relaxed  and  soft.  Tenderness  is  not  usually  present.  The  appetite  is  lost, 
and  in  most  cases  great  difiBculty  is  experienced  in  getting  children  to 
take  a  proper  amount  of  nourishment.  Continued  aversion  to  food  is  an 
unfavourable  symptom.  Occasionally,  when  there  is  fever,  fluids  are 
taken  eagerly.  A  returning  appetite  is  always  an  encouraging  sign. 
The  mouth  is  often  dry,  the  tongue  coated,  sometimes  dry  and  brown; 
there  may  be  sordes  upon  the  lips  and  teeth.  Superficial  ulcers  form 
upon  the  mucous  membrane  of  the  mouth,  and  often  thrush  is  seen.    The 


ACUTE   ILEO-COLITIS. 


349 


urine  is  usually  diminished,  high-coloured,  and  loaded  with  urates.  Al- 
bumin and  easts  are  rarely  present.  In  only  two  cases  have  I  seen 
nephritis  severe  enough  to  form  a  factor  in  the  result.  Tenesmus  and 
jirolapsus  ani  are  uncommon. 

The  average  duration  of  the  fatal  cases  is  about  three  weeks ;  their 
course  is  often  marked  by  exacerbations  and  remissions.  If  recovery  takes 
place,  convalescence  is  always  very  slow  and  relapses  are  easily  excited. 

Very  few  of  these  cases  recover  completely.  Even  those  who  survive 
the  primary  illness  are  likely  to  suffer  from  intestinal  symptoms  for  many 
months.  Fatal  relapses  are  often  brought  on  by  injudicious  feeding  when 
the  children  ai'e  apparently  almost  well.  The  general  health  is  usually  so 
undermined  that  the  patients  continue  to  suffer  from  all  the  symptoms  of 
malnutrition,  and  ultimately  succumb  to  an  attack  of  some  intercurrent 
acute  disease. 

The  diagnosis  of  ulceration  is  to  be  made  from  the  case  as  a  whole 
rather  than  from  any  special  symptoms.  If  a  delicate  infant  which  has 
previously  been  prone  to  diarrhoeal  attacks,  has  green  mucous  stools  with 
low  fever,  and  these  continue  with  unabated  severity  for  ten  or  twelve 
days,  ulceration  is  probable.  If  such  symptoms  continue  for  three  or  four 
weeks  with  steadily  failing  strength  and  loss  of  weight,  the  diagnosis  is 
almost  certain.  If,  on  the  contrary,  after  three  or  four  days  of  acute 
symptoms  there  is  improvement  in  the  stools  and  occasionally  some  which 
are  quite  faecal  in  character,  even  though  it  may  be  a  week  or  more  before 
the  mucus  disappears,  we  may  be  quite  certain  that  no  ulcers  have  formed. 

(4)  The  membranous  form. — This 
occurs  most  frequently  between  the 
ages  of  six  months  and  two  years,  and 
often  attacks  those  previously  in  good 
health.  It  is  the  gravest  form  of  in- 
flammation of  the  intestine  seen  in 
children,  and  its  symptoms  are  severe 
usually  from  the  outset.  It  closely 
resembles  the  most  severe  cases  of 
catarrhal  inflammation.  The  disease 
begins  suddenly,  with  vomiting,  high 
temperature,  and  several  large,  fluid 
stools.  The  vomiting  does  not  often 
continue  after  the  first  twenty-four 
hours.      The    temperature   is   at    first 

from  102°  to  105°  F.,  and  its  course  may  be  steadily  high  (Fig.  58), 
or  remittent.  In  some  cases  the  constitutional  symptoms — prostration, 
stupor,  delirium,  etc. — are  so  severe  at  the  onset  that  the  intestinal  symp- 
toms are  masked  by  them  and  an  erroneous  diagnosis  is  made.  The  abdo- 
men is  usually  tender  and  sometimes  swollen.     There  is  severe  pain,  and 


DAY 

1       2       3       4       5      6 

7   1    8 

DATE 

JULY 

16    17  1  18 

19    20    21 

22  1  23 

I 

I 
< 
u. 

oc 

< 
E 

ST 

106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 
98° 
97° 
96° 
OOUS 

M.E 

ME 

M.E 

M.E 

M.E 

M.E. 

M.E 

M.E. 

M.E 

M.E 

\r 

-1 

JU 

{\l 

/' 

V 

A 

A 

A' 

1/ 

\ 

\ 

/  V 

If 

5 

7 

11 

7 

7 

9 

14     4                    1 

Fig.  58. — Temperature  chart  of  membra- 
nous eoliti.s ;  fatal. 


350  DISEASES  OP  THE   DIGESTIVE  SYSTEM. 

at  times  almost  constant  tenesmus,  during  which  prolapse  of  two  or  three 
inches  of  the  mucous  membrane  of  the  rectum  occurs.  This  is  intensely 
congested,  and  sometimes  shows  patches  of  pseudo-membrane  upon  iis 
surface,  thus  establishing  the  diagnosis. 

The  stools  resemble  those  of  the  catarrhal  variety,  except  that  blood  is 
more  constantly  present  and  usually  more  abundant;  but  the  only  posi- 
tive point  of  difference  is  the  presence  of  shreds  or  patches  of  pseudo- 
membrane.  If  the  stools  are  thoroughly  washed  with  water,  patches  of 
membrane  may  be  seen  as  gray  opaque  masses,  which  are  then  easily  dis- 
tinguished from  the  transparent  mucus.  Large  sheets  of  membrane  are 
seldom  discharged ;  usually  only  small  patches  are  found.  Both  blood 
and  mucus  sometimes  disappear  from  the  stools,  which  may  consist  only 
of  dirty  water.  Under  the  microscope  there  may  be  seen  epithelial  cells, 
red  blood-cells,  and  round  cells  in  great  numbers. 

The  duration  of  the  disease  is  usually  a  little  less  than  two  weeks.  The 
course  closely  resembles  that  of  the  severe  catarrhal  form.  There  may  be 
a  continuous  high  temperature  with  severe  intestinal  symptoms  and  great 
prostration  until  death  takes  place  from  sepsis  or  exhaustion,  or  after 
three  or  four  days  the  temperature  may  fall  to  100°  or  103°  F.,  rising  again 
at  the  termiuation  of  the  disease.  The  most  protracted  fatal  case  I  have 
known  lasted  four  weeks.  It  is  probable  that  almost  every  case  of  the 
severity  described,  terminates  fatally  when  it  occurs  in  an  infant.  In 
older  children  the  prognosis  is  much  better  as  to  life,  but  in  them  tlie 
acute  attack  may  be  followed  by  the  chronic  form  of  the  disease. 

Diagnosis. — Ileo-colitis  is  to  be  distinguished  from  typhoid  fever  and 
intussusception.  In  infancy  a  doubt  between  typhoid  fever  and  ileo- 
colitis does  not  often  arise.  Cases  of  typhoid  fever  under  twenty  months 
are  extremely  rare,  and  are  not  likely  to  be  seen  unless  the  disease  is  epi- 
demic. I  have  never  seen  a  case  under  this  age.  In  children  over  two 
years,  the  two  diseases  are  more  likely  to  be  confused.  Typhoid  is  distin- 
guished by  the  slower  invasion,  more  constant  temperature,  enlargement 
of  the  spleen,  tympanites,  and  most  of  all  by  the  eruption.  The  fact  that 
the  disease  is  epidemic  is  also  to  be  considered.  Acute  colitis  may  be  con- 
founded with  intussusception.  If  the  possibility  of  this  misti^ke  is  kept  in 
mind  it  will  not  often  be  made ;  yet  the  records  of  intussusception  show 
that  a  very  large  proportion  of  them  were  regarded  in  the  beginning  as 
cases  of  dysentery.  In  intussusception,  although  we  have  a  sudden  onset 
with  acute  pain,  tenesmus,  vomiting,  and  marked  prostration,  there  is  no 
fever.  The  later  symptoms — absolute  constipation,  tumour,  tympanites, 
rising  temperature,  stercoraceous  vomiting,  and  collapse — have  nothing  in 
common  with  colitis.  A  diagnosis  between  the  different  varieties  of  ileo- 
colitis is  not  always  possible.  Follicular  ulceration  is  distinguished  by  its 
lower  temperature,  rather  subacute  course,  infrequency  of  blood  in  the 
stools,  and  by  the  fact  that  it  is  usually  preceded  by  one  or  more  attacks  of 


ACUTE   ILEO-COLITIS.  35I 

acute  gastro-enteric  infection,  upon  wliicli  its  peculiar  symptoms  are  grad- 
ually ingrafted.  In  both  the  catarrhal  and  the  membranous  varieties,  the 
symptoms  of  an  acute  inflammation  of  the  colon  are  usually  manifest  from 
the  outset — bloody  stools,  much  pain,  tenderness,  tenesmus,  and  fever. 
They  differ  cliiefly  in  severity,  and  by  the  fact  that  in  the  membranous 
form  shreds  of  false  membrane  may  be  found  in  the  stools.  The  course  is 
shorter  and  the  attack  is  altogether  more  intense  than  in  tlie  follicular 
form.  Death  often  takes  place  in  ten  or  twelve  days,  during  the  period  of 
most  acute  symptoms.  The  protracted  cases  of  catarrhal  ulceration  can 
not  be  distinguished  from  the  more  common  ones  of  follicular  ulceration. 

Prognosis. — This  is  much  worse  in  infants  than  in  older  children.  It 
is  especially  bad  in  cities,  among  the  poorer  classes,  and  in  institutions.  It 
is  rendered  unfavourable  by  previous  rickets  or  malnutrition,  and  by  the 
existence  of  any  complication,  particularly  broncho-pneumonia.  The 
prognosis  is  worse  in  children  who  have  been  badly  fed,  in  those  recently 
weaned,  and  in  those  who  earlier  in  the  season  have  suffered  from  attacks 
of  diarrhoea.  The  particular  symptoms  which  make  the  prognosis  unfa- 
vourable in  a  case  are  continued  high  temperature,  frequent  vomiting, 
rapid  wasting,  an  excessive  amount  of  blood  in  the  stools,  severe  nervous 
symptoms,  and  very  weak  pulse.  These  cases  are  never  out  of  danger 
until  the  end  of  the  hot  season,  on  account  of  the  great  liability  to  re- 
lajises  and  recurrent  attacks. 

Prophylaxis. — What  has  been  said  regarding  general  prophylaxis  in  tlie 
previous  chapter,  applies  equally  well  to  cases  of  ileo-colitis.  Special  em- 
phasis should  be  placed  upon  the  necessity  of  energetic  early  treatment  of 
all  the  milder  forms  of  diarrhtea,  and  particularly  the  cases  of  acute  gastro- 
enteric infection,  in  order  tliat  the  process  may  be  arrested  before  serious 
anatomical  changes  have  taken  place — a  thing  which  is  often  possible. 
Equal  stress  should  be  laid  ujDon  the  importance  of  promjit  and  radical 
treatment  at  the  very  beginning  of  the  cases  with  a  sudden  onset. 

Hygienic  Treatment. — The  general  plan  recommended  in  the  previ- 
ous chapter  should  be  followed  here.  A  change  of  air  is  desirable  for 
every  case  as  soon  as  the  acute  inflammatory  symptoms  have  subsided. 
In  the  protracted  cases  which  drag  on  a  subacute  course,  this  change  will 
often  do  more  than  everything  else.  Some  children  do  better  at  the  sea- 
shore, and  others  in  the  mountains.  If  possible,  patients  should  be  kept 
in  the  country  until  the  last  of  September.  A  return  to  the  city  during 
the  hot  season  is  usually  followed  by  a  second  attack,  and,  if  the  patient 
has  not  quite  recovered,  relapses  are  almost  certain.  Plenty  of  pure  fresh 
air  is  necessary  in  all  cases.  The  indications  for  bathing  are  the  same  as 
in  other  cases  of  acute  diarrhwa.  It  is  undesirable  to  crowd  these  patients 
in  institutions,  as  they  always  do  better  when  they  can  be  separated.  The 
dietetic  treatment  during  the  acute  stage  is  the  same  as  in  cases  of  acute 
gastro-enteric  infection.  Special  stress  should  be  laid  upon  stopping  cow's 
24 


352  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

milk  at  once.  In  the  jirotracted  cases  the  diet  presents  great  difficulties, 
as  the  children  have  little  or  no  appetite,  and  soon  come  to  refuse  every- 
thing in  the  shape  of  food  that  is  olfered.  In  infancy,  the  articles  which 
are  most  to  be  depended  upon  are  skimmed  milk  which  has  been  com- 
pletely peptonized,  beef  Juice,  broths,  and  liquid  beef  peptonoids.  In  some 
cases  rice  or  barley  water  are  well  borne  ;  in  others,  some  of  the  malted 
foods,  although  these  often  increase  the  number  of  stools  and  have  to  be 
stopped  on  that  account.  Food  which  leaves  little  residue  should  al- 
ways be  chosen.  Infants,  when  very  ill,  are  much  more  likely  to  take 
too  little  than  too  much  food.  A  careful  record  should  be  kept  of  the 
amount  actually  taken  in  each  twenty-four  hours.  When  this  is  much 
below  the  requirements  of  nutrition,  gavage  (page  62)  may  be  tried. 
Sometimes  all  food  and  stimulants  may  be  advantageously  given  in  this 
way.  In  no  case  should  food  be  given  oftener  than  every  two  hours,  and 
usually  the  interval  should  be  three  hours,  water  and  stimulants  being 
allowed  between  the  feedings.  In  older  children  the  diet  during  the  acute 
stage  must  be  much  the  same  as  in  infancy.  At  a  later  period,  raw  beef, 
kumyss,  or  matzoon  will  be  found  useful,  and  during  convalescence  boiled 
milk  or  milk  gruels  made  with  rice  or  barley.  Special  care  must  be 
given  to  the  diet  for  a  long  time.  For  months  after  an  acute  attack  the 
intestines  are  very  easily  deranged.  Eelapses  are  excited  by  changes  in 
the  temperature,  by  great  fatigue  or  exhaustion,  but  most  of  all  by  im- 
proper feeding.  Especially  in  older  children  should  such  articles  be 
avoided  as  oatmeal,  potatoes,  corn,  tomatoes,  and  all  fruits.  I  have  seen  a 
single  peach  given  to  a  child  two  years  old,  excite  a  dangerous  relapse,  and 
a  few  raisins  a  fatal  one. 

Medicinal  and  Mechanical  Treatment. — Cases,  the  early  stage  of  which 
is  marked  by  vomiting  and  thin  diarrheal  stools,  are  to  be  managed  at  the 
outset  according  to  the  jilan  outlined  in  the  previous  chapter — viz.,  free 
purgation,  irrigation  of  the  colon,  and  stopping  all  food.  Lesions  of 
any  considerable  severity  are  not  often  present  during  the  first  week. 
In  the  cases  in  which  tlie  symptoms  of  acute  inflammation  are  evident 
from  the  outset,  as  shown  by  the  frequent  bloody  and  mucous  stools  with 
tenesmus  and  pain,  the  measures  to  be  depended  upon  are  castor  oil  and 
irrigation  of  the  colon,  and  later  opium  and  bismuth  by  the  mouth.  Cas- 
tor oil  should  be  administered  in  a  full  dose  at  the  outset — one  drachm 
at  six  months,  two  drachms  at  one  year,  and  half  an  ounce  at  four  years. 
Its  primary  effect  is  to  clear  the  intestines,  and  its  secondary  effect  is  pe- 
culiarly s(?othing  to  the  inflamed  mucous  membrane.  If  the  stomach  is 
at  all  irritable,  calomel  one  fourth  grain  every  hour  to  six  or  eight  doses, 
or  a  saline  purgative,  may  be  substituted.  Opium  is  usually  required  on 
account  of  the  pain  and  tenesmus.  The  dose  should  be  regulated  by  the 
severity  of  these  symptoms  and  by  the  frequency  of  the  stools.  The  de- 
odorized tincture  and  morphine  are,  I  think,  preferable  to  other  prepara- 


ACUTE   ILBO-COLITIS.  353 

tions.  Dover's  powder  may  be  used  if  the  stomach  is  not  irritable.  Re- 
peated small  doses  are  better  than  a  single  large  dose.  It  is  very  important 
that  opium  should  be  withheld  for  at  least  twelve  hours  after  the  initial 
purgative.  As  the  pathological  process  is  principally  in  the  colon,  and 
most  severe  in  the  lower  half  of  the  colon,  it  can  be  much  more  effectively 
treated  by  injections  than  by  drugs  given  by  the  mouth.  Irrigation  of 
the  colon  (page  63)  is  one  of  our  most  valuable  means  of  treatment  in 
these  cases.  It  should  bo  used  in  conjunction  with  the  measures  already 
referred  to.  For  general  purposes  a  tepid  saline  solution  should  be  em- 
ployed (common  salt  one  drachm  to  water  one  pint).  At  least  a  gallon 
should  be  given  at  one  time ;  it  should  be  injected  high  into  the  colon 
through  a  long  rectal  tube,  and  early  in  the  disease  repeated  at  least  twice 
a  day.  Where  the  tenesmus  is  very  great  and  blood  abundant,  either  hot 
water  (100°  to  110°  F.)  or  ice  water  may  be  used,  and  later  astringent  in- 
jections. A  large  amount  of  a  weak  solution  may  be  given  and  allowed 
to  escape,  or  after  irrigating  with  a  saline  solution,  a  smaller  quantity — 
three  or  four  ounces — of  a  much  stronger  astringent  may  be  introduced 
high  into  the  bowel  and  prevented  from  esca2)ing  by  compressing  the 
buttocks.  The  most  useful  astringents  are  tannic  acid  and  hamamelis ; 
as  a  weak  solution,  half  a  drachm  of  tannic  acid  or  one  drachm  of  the 
fluid  extract  of  hamamelis  may  be  used  to  a  pint  of  water ;  and  for  a  strong 
solution,  the  same  quantity  of  the  astringents  to  three  or  four  ounces  of 
water.  Nitrate-of-silver  injections  should  never  be  used  in  acute  eases, 
and  their  advantage  in  chronic  ones  is  questionable.  In  conjunction  with 
opium,  benefit  is  often  seen  during  the  early  stage  by  the  continued  use  of 
castor  oil  in  small  doses — i.  e.,  ten  drops  in  emulsion  every  two  or  three 
hours. 

For  cases  not  influenced  by  the  measure  mentioned,  or  those  not  seen 
at  the  outset,  bismuth  should  be  tried,  but  it  is  of  no  use  whatever  unless 
large  doses  are  administered.  Two  drachms  of  the  subnitrate  must  be 
given  in  twenty-four  hours  to  a  child  a  year  old,  and  proportionate  doses 
for  older  children.  This  should  be  suspended  in  mucilage.  Tenesmus 
and  pain  are  sometimes  relieved  by  the  injection  of  three  or  four  ounces  of 
a  starch  solution  to  which  from  five  to  ten  drops  of  laudanum  are  added. 
Severe  tenesmus,  when  not  controlled  by  the  measures  above  mentioned, 
and  when  associated  with  prolapsus  ani,  is  sometimes  immediately  re- 
lieved by  cocaine  suppositories.  From  one  fourth  to  one  grain  of  cocaine 
may  be  given,  according  to  the  child's  age. 

Stimulants  are  needed  in  nearly  all  cases.  There  are  no  valid  objec- 
tions to  their  use  even  in  the  youngest  infant.  The  feeble  digestion  and 
assimilation  of  these  patients  compel  us  to  use  alcohol  very  frequently. 
Stimulants  are  indicated  by  a  weak  pulse,  poor  circulation,  and  great 
general  prostration,  no  matter  at  what  stage  in  the  disease  these  symp- 
toms are  seen.     Old  brandy  is  usually  to  be  preferred.     Generally  not 


354  DISEASES   OF  THE   DIGESTIVE  SYSTEM. 

more  than  thirty  drops  every  two  hours  are  needed  for  an  infant  one 
year  old,  but  for  short  periods  a  much  larger  quantity  may  be  required. 
Brandy  should  always  be  diluted  with  at  least  six  parts  of  water. 

In  cases  where  symptoms  have  lasted  two  or  three  weeks,  and  the 
active  symptoms  have  subsided,  where  the  temperature  is  scarcely  above 
100°  F.,  and  the  stools  reduced  to  four  or  five  a  day,  it  is  wise  to  stop  all 
medication  and  attend  only  to  food  and  stimulants,  with  irrigation  of  the 
colon  every  other  day.  One  is  often  surprised  at  this  stage  to  find  that 
his  patients  do  better  without  drugs  than  with  them.  The  prevailing 
tendency  is  to  overdose  cases  of  this  type.  Careful  attention  to  diet,  judi- 
cious stimulation,  regular  irrigation  of  the  bowel  every  day  or  two,  with 
change  of  air,  will  do  much  more  than  any  amount  of  medication. 

During  convalescence  general  tonics  are  required,  such  as  arsenic,  iron, 
nux  vomica,  and  wine.  Cod-liver  oil  should  be  deferred  until  the  stom- 
ach and  appetite  are  quite  normal  and  the  stools  free  from  mucus.  It 
should,  however,  be  continued  throughout  the  succeeding  winter  months. 

CHRONIC   ILEO-COLITIS. 

This  is  rarely  seen  except  as  a  result  of  acute  ileo-colitis,  which  is 
usually  catarrhal  or  follicular,  as  the  membranous  variety  is  so  severe 
that  the  patients  rarely  survive  the  acute  stage.  In  the  catarrhal  form 
there  may  be  a  chronic  catarrhal  inflammation  of  the  mucous  membrane 
only,  or  there  may  be  catarrhal  ulcers.  In  the  follicular  form  ulcers  are 
usually  present. 

Lesions. —  Ckitarrhal  form. — In  its  milder  type  it  is  quite  common, 
but  in  its  severe  grade  it  is  exceedingly  rare.  There  may  be  changes  in 
a  large  part  of  the  small  intestine  and  in  the  stomach,  as  well  as  in  the 
lower  ileum  and  colon. 

The  gross  appearance  of  the  intestine  often  differs  very  little  from  the 
normal.  The  mucous  membrane  is  usually  of  a  dull  gray  or  slate  colour. 
Pigmentation  may  occur  as  striaB  in  the  mucous  membrane,  but  more  fre- 
quently it  is  limited  to  Peyer's  patches  and  the  solitary  lymph  nodules ; 
these,  as  well  as  the  mesenteric  lymph  nodes,  are  generally  swollen. 

The  microscopical  changes  are  usually  marked.  The  lesion  is  chiefly 
one  of  the  mucosa.  (Fig.  59).  The  important  features  are  a  disappear- 
ance of  very  many  of  the  tubular  glands,  and  in  the  small  intestine  of 
the  villi  also.  There  is  a  very  marked  cell  proliferation  in  the  adenoid 
tissue  of  the  mucosa,  and  if -the  disease  has  existed  long  enough  there  may 
be  a  production  of  new  connective  tissue.  The  solitary  lymph  nodules 
show  usually  nothing  but  cell  hyperplasia.  The  lesions  are  not  uniformly 
distributed,  but  occur  in  patches  throughout  the  intestine.  When  present 
in  the  stomach,  they  are  of  the  same  kind  as  those  described  in  the  intes- 
tine, although  rarely  so  severe.  In  milder  cases  the  gross  appearances  may 
show  very  little  change  to  the  naked  eye,  except  swelling  of  the  lymph 


CHRONIC   ILEO-COLITIS.  §55 

nodules.  Under  the  microscope  there  may  bo  found  more  or  less  extensive 
cell  infiltration  of  the  mucosa,  but  rarely  any  destructive  changes  or  new 
connective  tissue. 

Ulcerative  form. — Tliis  is  rather  rare,  for  the  reason  that  in  infancy  a 
very  large  proportion  of  the  cases  die  during  the  acute  stage. 

The  ulcers  are  nearly  always  of  the  follicular  variety ;  occasionally  they 
are  catarrhal.  If  the  patient  dies  after  an  illness  of  from  six  to  eight 
weeks,  the  appearances  do  not  differ  essentially  from  those  described  in 
acute  cases.  If  life  is  prolonged  from  two  to  four  months,  ulcers  are  found 
in  various  stages  of  repair,  sometimes  associated  with  the  formation  of 
small  cysts.  Follicular  ulcers  require  from  two  to  four  months  for  cica- 
trization, and  the  broad  catarrhal  ulcers  even  a  longer  time.  It  is  very 
doubtful  whether  stricture  ever  results  from   these  ulcers  in   children. 


iiVv-f«Sj:-*« 


m^^ 


V    C 


Fio.  59. — Chronic  catarrhal  inflammation  of  the  ileum. 


■M^, 


The  lesions  affect  the  mucosa,  .-1,  almost  exclusively.  It  is  somewhat  thickened;  there  is 
extensive  destruction  of  the  tubuhir  follicles,  remains  beino;  seen  at  T,  T:  tliere  is  a  great  in- 
crease in  the  cells,  and  some  new  connective  tissue  in  the  mucosa.  Larire  new  blood-vessels 
are  seen  at  C,  C.  History. — Delicate  child,  thirteen  months  old ;  diarrhoeal  symptoms  for  four 
mouths;  durinor  the  first  two  weeks  there  was  high  fever:  at  death  weighed  eight  pounds. 
The  gross  changes  at  the  autopsy  were  very  slight.     The  section  is  from  the  middle  ileum. 

The  mucous  membrane  shows  almost  invariably  evidences  of  more  or 
less  extensive  chronic  catarrhal  inflammation.  One  of  the  rarest  lesions 
are  cysts  of  the  colon.  Fully  developed  cysts  I  have  seen  but  once. 
The  child  had  an  attack  of  acute  ileo-colitis,  which  became  chronic,  last- 
ing about  five  months.  He  never  regained  his  health,  and  died  one  year 
later  from  intercurrent  disease.  In  the  descending  colon  and  rectum, 
about  twenty  cysts  the  size  of  a  pea,  and  many  smaller  ones,  were  found. 
They  had  a  thin,  translucent  covering.  On  section,  a  thick,  transparent, 
gelatinous  material  escaped.  They  were  situated  in  the  submucosa,  and 
were  undoubtedly  produced  by  the  dilatation  of  some  of  the  tubular  glands 
whose  orifices  had  been  obliterated. 

AsHOciafcd  lesions. — The  important  ones  are  in  the  lungs,  the  most 
common  being  hypostatic  congestion,  subacute  or  chronic  broncho-pneu- 
tnonia,  more  rarely  pulmonary  tuberculosis.  It  is  rare  to  find  the  lungs 
perfectly  healthy.  The  liver  is  often  found  extremely  fatty  in  cases  asso- 
ciated with  great  wasting,  but  in  no  case  have  I  seen  hepatic  abscess.    The 


356  .         DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

kidneys  usually  show  a  more  or  less  intense  cloudy  swelling,  and  sometimes 
there  may  be  well-marked  nephritis.  Dropsical  effusions  into  the  serous 
cavities  are  very  rare.  General  tuberculosis  is  not  infrequently  the  cause 
of  death. 

Symptoms. — These  cases  are  usually  seen  in  the  autumn,  and  com- 
prise those  which  have  barely  managed  to  live  through  the  summer  months. 
No  definite  line  can  be  drawn  between  the  acute  and  the  chronic  stages. 
Under  the  head  of  chronic  cases,  all  those  which  have  lasted  over  six  weeks 
will  be  included ;  although  some  become  chronic  in  a  shorter  time. 

The  symptoms  of  active  inflammation  have  jiassed  away ;  the  tempera- 
ture is  usually  normal ;  there  is  no  pain  or  tenderness.  There  is,  however, 
no  imj^rovement  in  the  general  condition,  and  either  the  weight  remains 
stationary,  or  the  child  continues  to  lose  slowly  until  it  is  little  more 
than  a  skeleton.  The  face  is  pinched,  the  eyes  sunken,  and  the  cheeks 
hollow.  The  lips  are  pale,  often  fissured,  and  bleed  readily.  The  fontanel 
is  depressed.  The  body  is  so  small  that  the  head  seems  much  too  large. 
Almost  every  vestige  of  fat  may  disappear  from  the  subcutaneous  cellular 
tissue  of  the  trunk  and  extremities.  The  skin  hangs  in  loose  folds  on  the 
thighs.  The  abdomen  may  be  distended  and  tympanitic,  or  retracted  and 
soft.  The  mouth  is  often  the  seat  of  thrush,  of  catarrhal,  herpetic,  or 
rarely  of  ulcerative  stomatitis.  The  tongue  may  be  heavily  coated,  but  is 
more  often  dry,  glazed,  and  red.  In  rare  instances  sordes  covers  the 
lips  and  teeth.  The  teeth  sometimes  decay  quite  rapidly  from  the  gen- 
eral malnutrition.  Baginsky  states  that  the  progress  of  dentition  is 
arrested ;  but  I  have  very  often  seen  these  infants,  almost  "  living  skele- 
tons," go  on  cutting  teeth  quite  as  steadily  as  under  normal  conditions, 
and  Eustace  Smith  has  made  the  same  observation. 

Although  they  seldom  cry  for  food,  as  a  rule,  these  children  will  take 
nearly  everything  given  them,  and  an  almost  unlimited  amount.  Notwith- 
standing that  it  is  retained,  the  more  they  are  fed  the  more  rapid  seems 
the  wasting.  Vomiting  is  not  common,  and  seldom  occurs  except  from 
overloading  the  stomach  or  during  an  acute  exacerbation  of  the  symptoms. 

T'he  stools  are  rarely  frequent;  five  or  six  a  day  being  the  average; 
often  there  may  be  only  two  or  three  a  day  for  a  week  at  a  time.  They  are 
thinner  than  normal,  but  are  not  often  fluid.  They  contain  mucus  of  a 
green  or  brownish  colour,  usually  in  large  quantity.  Blood  is  rarely  pres- 
ent. The  stools  are  sometimes  green,  often  greenish  brown,  sometimes  a 
pale  gray.  Undigested  food  is  always  present  in  quantity,  and  upon  the 
diet  depends  very  much  the  gross  appearance  of  the  stool,  the  odour  of 
which  is  almost  always  offensive,  sometimes  extremely  so.  Pus  is  found 
under  the  microscope,  but  is  rarely  visible  to  the  naked  eye.  Nothnagel 
and  Baginsky  have  called  attention  to  a  form  of  stools  which  they  believe- 
to  be  characteristic  of  wide-spread  inflammation  of  the  mucous  membrane 
with  atrophy  of  the  tubular  glands  :  they  are  of  nearly  normal  consistence, 


CHRONIC  ILEO-COLITIS.  357 

homogenous,  dark  green  or  brown  colour,  and  usually  offensive  ;  they 
sometimes  alternate  with  stools  of  a  watery  character;  under  the  micro- 
scope nuclei  are  found,  but  no  unchanged  epithelial  cells ;  the  food-remains 
are  sometimes  unrecognisable,  from  the  extent  to  which  decomposition  has 
taken  place. 

Prolapsus  ani  is  not  so  frequent  as  in  the  acute  cases ;  but  when  it 
occurs  it  is  generally  more  difficult  to  control.  Flatulence  and  colic  are 
prominent  symptoms  in  some  cases,  but  absent  altogether  in  many  others. 
As  a  rule,  there  is  neither  abdominal  pain  nor  tenderness.  When  the 
abdomen  is  enlarged  it  is  usually  uniformly,  but  sometimes  shows  marked 
epigastric  prominence,  which  is  more  often  from  dilatation  of  the  trans- 
verse colon  than  of  the  stomach.  The  skin  of  the  abdomen  often 
seems  very  thin ;  dilatation  of  the  superficial  veins  is  rarely  seen.  The 
liver  and  spleen  are  generally  normal  in  size,  so  far  as  can  be  made  out  by 
physical  examination.  Although  the  mesenteric  glands  are  enlarged,  they 
can  not  be  felt  through  the  abdominal  walls.  Enlargement  of  the  inguinal 
and  other  groups  of  external  lym^Dhatic  glands  is  rarely  striking.  The  skin 
is  loose,  wrinkled,  dry,  and  scaly,  and  in  the  worst  cases  frequently  cov- 
ered with  small  petechiae  over  the  abdomen  and  lower  extremities. 
About  the  anus,  and  over  the  sacrum,  thighs,  genitals,  and  sometimes 
feet,  there  are  excoriations,  and  not  infrequently  ulcerations.  The  pulse 
is  weak,  the  peripheral  circulation  is  poor,  and  the  extremities  are  cold 
much  of  the  time  unless  artificial  heat  is  applied.  The  respiration  is 
usually  shallow,  and  often  irregular  without  any  apparent  cause ;  it  be- 
comes, rapid  from  the  development  of  pulmonary  complications.  The 
temperature  is  elevated  only  during  exacerbations,  or  from  inflammatory 
complications.  A  subnormal  temperature  is  frequently  met  with.  I  have 
occasionally  seen  it  95°  F.  in  the  rectum.  A  continuous  subnormal  tem- 
perature is  a  very  bad  sign.  The  urine  shows  no  constant  changes.  Dropsy 
may  be  present  without  albuminuria.  The  weight  is  stationary,  or  steadily 
falls  to  an  almost  incredible  degree.  I  have  seen  one  infant  weighing  but 
eight  pounds  at  thirteen  months;  another,  thirteen  pounds  at  two  years 
and  four  months.  There  are  marked  cachexia  and  extreme  ana?mia. 
Ulcers  of  the  cornea  are  not  uncommon.  Nervous  symptoms  are  always 
present.  The  children  are  cross  and  irritable,  sleep  badly,  and  frequently 
have  a  low,  whining  cry,  which  is  continued  much  of  the  time.  Sometimes 
they  are  dull,  apathetic,  and  quite  indifferent  to  their  surroundings.  Per- 
sistent opisthotonus  is  occasionally  seen ;  and  there  may  be  contractions 
of  the  extremities,  but  rarely  general  convitlsions. 

The  duration  of  the  disease  is  from  two  months  to  a  year.  Compara- 
tively few  patients  survive  more  than  four  months.  The  progress  is  irregu- 
lar, and  marked  by  periods  of  improvement,  during  which  for  a  time  the 
patient  may  hold  his  own,  or  even  gain  in  weight.  Any  trivial  cause  may 
excite  a  relapse,  and  the  downward  progress  is  rapid.     Death  often  occurs 


358  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 

during  one  of  these  exacerbations,  or  it  may  be  due  to  broncho-pneumonia, 
tuberculosis,  or  slow  asthenia. 

Diagnosis. — The  problem  usually  presented  is,  whether  the  condition 
of  the  bowel  is  of  itself  a  sufficient  explanation  of  the  general  condition, 
or  whether  there  is  some  underlying  constitutional  disorder,  of  which  the 
diarrhoea  is  only  one  of  the  symptoms.  It  is  important  to  distinguish  the 
cases  in  which  the  cachexia  is  quite  marked  and  convalescence  slow — 
although  ultimately  resulting  in  complete  recovery — from  those  which 
present  at  a  certain  stage  almost  identical  symptoms,  and  yet  go  on 
steadily  from  bad  to  worse,  terminating  fatally.  The  difference  in  these 
cases  is  really  a  difference  in  the  character  and  extent  of  the  lesions. 
The  first  group  are  probably  cases  of  superficial  catarrhal  infiammation, 
or  of  follicular  inflammation  which  has  not  gone  on  to  ulceration,  these 
lesions  being  capable  of  repair.  The  second  group  are  the  cases  of  follicu- 
lar or  catarrhal  ulceration,  in  which  complete  recovery  from  the  lesions  is 
impossible,  and  repair  only  partial,  if  indeed  any  occurs.  In  distinguishing 
between  these  cases  the  most  important  guide  is  the  nature  of  the  symp- 
toms during  the  antecedent  acute  attack.  The  longer  the  acute  febrile 
symptoms  have  lasted  and  the  higher  has  been  the  temperature,  the  greater 
probably  is  the  extent  of  the  lesions,  and  the  more  severe  their  character. 

The  diagnosis  of  chronic  ileo-colitis  from  general  tuberculosis  is  diffi- 
cult, particularly  so  from  the  fact  that  tuberculosis  is  not  an  infrequent 
sequel  to  the  intestinal  disease.  The  points  in  common  are  the  existence 
of  diarrhoea  (which  may  occur  in  tuberculosis  in  summer  apart  from  the 
presence  of  intestinal  tuberculosis),  antemia,  cachexia,  and  the  signs  of  con- 
solidation in  the  lungs ;  these,  in  the  one  case,  depending  upon  broncho- 
pneumonia, and  in  the  other  upon  tuberculous  deposits.  Tuberculosis  is 
more  likely  to  be  met  with  in  iustitutions,  among  the  poor  of  cities,  and 
in  children  previously  delicate  and  with  a  tuberculous  family  history.  In 
chronic  ileo-colitis  the  wasting  and  anaemia  follow  the  intestinal  symptoms, 
and  are  usually  just  in  proportion  to  their  severity.  For  the  differential 
diagnosis  of  the  pulmonary  condition  see  the  chapter  on  Pulmonary  Tu- 
berculosis. Of  the  constitutional  symptoms  the  most  important  differen- 
tial one  is  fever.  This  is  rarely  absent  in  general  tuberculosis  or  in  tu- 
berculous ulceration  of  the  intestine  if  extensive,  though  it  is  not  high  and 
its  course  is  ver}'  irregular.  It  is  absent  in  chronic  ileo-colitis,  except  from 
complications  and  from  the  occasional  acute  exacerbation. 

Prognosis. — The  prognosis  depends  upon  the  child's  previous  consti- 
tution, upon  the  duration  of  the  intestinal  symptoms,  upon  our  ability  to 
carry  out  proper  treatment,  upon  the  presence  of  complications ;  but,  most 
of  all,  upon  the  severity  and  extent  of  the  intestinal  lesions.  The  pos- 
sibility of  error  always  exists  in  estimating  the  gravity  of  the  lesions,  so 
that  no  case  should  be  considered  hopeless.  Every  physician  who  sees 
much  of  this  form  of  disease,  has  met  with  cases  so  weak,  so  wasted,  and 


CHRONIC   ILEO-COLITIS.  359 

SO  anaemic  that  recovery  seemed  out  of  the  question  ;  and  yet  after  a  few 
weeks,  under  favourable  conditions,  they  have  begun  slowly  to  improve, 
and  finally  have  gone  on  to  complete  recovery.  If,  however,  continuous 
symptoms  have  existed  for  eight  or  ten  weeks  without  any  sign  of  improve- 
ment, recovery  is  extremely  doubtful.  The  patient  may  linger  for  two  or 
three  months  longer,  but  usually  only  to  be  carried  off  by  the  first  acute 
disturbance  which  occurs. 

Treatment. — Little  or  nothing  is  to  be  expected  from  drugs.  No 
greater  mistake  is  made  than  to  give  these  children  week  after  week  the 
various  diarrhroa-mixtures,  with  the  expectation  that  ultimately  the  for- 
mula which  exactly  meets  the  wants  of  the  particular  case  will  be  found. 
Drugs  are  to  be  used  only  for  the  relief  of  special  symptoms.  Thus 
a  dose  of  opium  may  be  needed  when  the  movements  are  unusually 
frequent,  or  castor  oil  once  in  four  or  five  days  when  the  stools  are  par- 
ticularly offensive.  The  essential  and  important  part  of  the  treatment 
consists  in  injections,  careful  feeding,  stimulation,  and  change  of  air. 
Astringent  enemata,  however,  are  of  considerable  value.  They  should  be 
given  daily  or  every  other  day,  but  from  time  to  time  should  be  discon- 
tinued to  see  what  the  condition  of  the  stools  is  without  them.  They 
should  be  used  as  described  in  the  treatment  of  acute  cases  after  irrigating 
the  colon  with  a  tepid  salt  solution  (one  ounce  to  the  gallon).  The 
stronger  astringent  solutions  should  be  used,  and  held  in  place  for  half 
an  hour. 

Alcoholic  stimulants  must  be  given  in  almost  all  cases,  and  they  may 
be  continued  for  a  long,  time  with  advantage.  Old  port  or  sherry  will 
sometimes  do  better  than  brandy  or  whisky.  The  diet  mentioned  in  the 
later  stages  of  the  acute  cases  should  be  continued.  Usually  we  give  that 
which  the  patient  will  take  most  readily.  The  predigested  foods  are  use- 
ful; so  also  are  such  beef  prejiarations  as  boviniue,  and  the  liquid  beef 
peptonoids.  Raw  scraped  beef  may  be  used  with  great  benefit.  Fats  and 
starchy  foods  should  be  excluded  entirely  or  given  in  very  small  quantities. 
It  is  usually  better  to  give  the  carbohydrates  in  the  form  of  the  malted 
foods.  Kumyss  and  matzoon  are  useful.  The  diet  must  be  carefully 
watched  and  directed  according  to  the  effect  upon  the  stools  of  the  various 
articles  employed.  In  some  of  these  cases  nutrition  may  be  promoted 
by  inunctions  of  cocoa  butter,  cod-liver  oil,  or  some  other  form  of  fat. 

The  patient  must  first  be  put  in  the  best  possible  surroundings  ;  in  no 
disease  is  a  change  of  air  more  to  be  desired  than  in  this.  These  cases  are 
trying  ones  to  the  physician ;  for  unless  he  can  absolutely  control  the 
matter  of  diet,  it  is  almost  useless  to  attempt  to  do  anything.  Still,  by 
careful  study  of  the  individual  case  and  attention  to  minute  details,  suc- 
cess may  sometimes  be  achieved  even  when  the  outlook  seemed  at  the 
outset  the  most  hopeless.  The  danger  of  relapses  and  second  attacks 
continues  long  after  the  primary  attack  has  sudsided. 


360 


DISEASES  OF   THE  DIGESTIVE  SYSTEM. 


AMYLOID  DEGENERATION   OP   THE    INTESTINES. 

This  is  rarely  met  with  in  infants.  It  is  not  so  infrequent  in  older 
children,  where  it  is  associated  with  amyloid  changes  in  the  liver,  spleen, 
and  kidneys,  usually  as  a  result  of  prolonged  suppuration  in  connection 
with  bone  tuberculosis.  It  is  sometimes  met  with  in  syphilis.  The  ileum 
is  the  part  of  the  intestine  most  affected.  The  j^rocess  begins  in  the  walls 
of  the  arterioles  and  capillaries,  particularly  of  the  villi,  and  later  involves 
the  vessels  of  the  submucosa ;  subsequently  the  epithelium  may  be  affected. 
The  mucous  membrane  in  these  cases  is  pale,  rather  translucent.  The 
condition  is  recognised  by  the  application  of  the  iodine  test.  This  is  best 
seen  in  the  lower  ileum,  where  the  affected  villi  become  of  a  brownish-red 
or  mahogany  colour. 

Amyloid  degeneration  produces  no  definite  symptoms.  Diarrhoea  is 
frequent  but  by  no  means  constant.  The  angemia  and  waxy  cachexia 
which  are  present  are  probably  dependent  much  more  upon  the  associated 
lesions  of  the  liver  and  kidneys  than  upon  the  changes  in  the  intestines. 
The  treatment  is  symptomatic. 

TUBERCULOSIS  OF   THF  INTESTINES  AND   MESENTERIC  LYMPH 
NODES  (MESENTERIC   GLANDS). 

These  two  conditions  are  usually,  but  not  invariably,  associated,  and 
may  conveniently  be  considered  together. 

Frequency.— In  109  autopsies  of  my  own  upon  tuberculous  cases  in 
which  the  condition  of  the  intestines  was  noted,  they  were  involved  in  37 
per  cent.  The  great  majority  of  the  patients  were  under  three  years  of 
ao-e.  In  131  autopsies  upon  tuberculous  cases  published  in  the  Pendlebury 
Hospital  Reports,  the  intestines  were  involved  in  50  per  cent.  These 
patients  were  mainly  between  four  and  fourteen  years  old,  very  few  of 
them  being  infants.  In  209  autopsies  upon  tuberculous  children,  chiefly 
infants,  reported  by  Miiller,  the  intestines  were  involved  in  28  per  cent. 
In  1,346  autopsies  collected  by  Biedert  there  were  intestinal  lesions  in  31-6 
per  cent.  These  figures  show  that  the  intestines  are  not  one  of  the  most 
frequent  seats  of  tuberculosis  in  children,  and  that  it  is  rather  less  fre- 
quent in  infancy  than  at  a  later  age.  It  is  most  common  from  the 
third  to  the  eighth  year.  The  figures  for  tuberculosis  of  the  mesenteric 
lymph  nodes  are  nearly  the  same  as  those  for  the  intestines.  They 
were  tuberculous  in  35  per  cent  of  my  own  autopsies,  and  in  59  per 
cent  of  the  Pendlebury  cases.  Miiller  and  Biedert  do  not  give  the  pro- 
portion. 

Etiology.— In  all  or  nearly  all  cases,  the  mesenteric  lymph  nodes  are 
infected  from  the  intestines.  It  is  of  course  possible,  but  unlikely,  that 
the  infection  may  be  through  the  general  circulation.  With  tuberculous 
ulcers  of  the  intestine,  the  lymph  nodes  are,  I  think,  invariably  found  by 


TUBERCULOSIS   OF   THE   INTESTINES.  361 

inoculations  to  be  tuberculous  ;  although  they  may  not  yet  bo  caseous. 
The  infection  of  the  intestinal  mucous  membrane  is  from  bacilli  in  the 
canal.  Mucli  stress  has  been  laid  upon  tuberculous  milk  as  a  means  by 
which  children  are  infected.  There  is  little  pathological  support  to  be 
found  for  the  view  that  children  often  contract  the  disease  in  this  way. 
In  119  autopsies  upon  tuberculous  children,  chiefly  infants,  there  w^as  not 
found  one  in  which  the  most  advanced,  and  therefore  presumably  the 
primary,  lesion  was  in  the  intestines  or  stomach.  In  127  autopsies,  also 
upon  tuberculous  infants,  Northrup  found  the  most  advanced  lesion  in  the 
intestines  in  but  a  single  case.  While  infection  from  milk  is  possible,  it 
is  certainly  extremely  infrequent.  In  my  own  autopsies,  intestinal  lesions 
have  been  found  only  in  nuirked  cases  of  generalized  tuberculosis.  In  not 
more  than  one  fourth  of  the  cases  in  which  such  lesions  were  present 
were  they  severe.  They  were  usually  associated  with  an  advanced  pul- 
monary process,  and  were  doubtless  due  to  swallowing  tuberculous  sputum. 

Lesions. — Intestines. — Tuberculosis  usually  affects  the  small  intestine; 
Avith  very  extensive  disease  the  large  intestine  may  also  be  involved,  and 
exceptionally  it  alone  may  be  affected.  The  disease  in  the  small  intestine 
is  usually  found  in  the  jejunum,  and  in  the  lower  ileum  near  the  ileo- 
caecal  valve.  Of  the  large  intestine,  the  cfecum  is  most  often  diseased  ; 
ulcers  are  often  found  in  the  appendix. 

If  seen  very  early  there  may  be  only  tuberculous  deposits,  usually 
widely  scattered,  involving  the  solitary  lymph  nodules,  or  Peyer's  patches. 
These  appear  as  tiny  yellow  nodules.  Usually,  however,  ulcers  are  present, 
and  often  only  ulcers  are  seen.  Their  size  and  number  vary  greatly  ; 
there  may  be  only  five  or  six  tiny  ulcers,  or  there  may  be  forty  or  fifty, 
the  largest  being  two  or  three  inches  in  diameter.  They  very  frequently 
involve  the  Peyer's  patches.  The  typical  tuberculous  ulcer  is  of  irregular 
shape,  with  rounded  borders  and  with  its  longest  diameter  at  right  angles 
to  the  intestinal  axis.  When  large,  it  may  nearly  encircle  the  gut.  The 
ulcers  are  excavated  ;  they  have  overhanging,  infiltrated  edges  of  a  deep 
red  colour.  The  surface  is  covered  with  granulations.  In  those  which 
have  partly  healed  a  distinct  puckering  of  the  intestine  occurs,  which  is 
especially  noticeable  upon  the  peritoneal  surface.  The  small  ulcers  involve 
,the  mucosa  only  ;  the  larger  and  older  ones  the  submucosa  and  the  mus- 
cular coats,  and  not  infrequently  also  the  serous  coat.  Perforation  may 
occur,  but  rarely  into  the  general  peritoneal  cavity,  as  a  localized  plastic 
inflammation  precedes  it.  There  may  be  adhesions  of  adjacent  intestinal 
coils,  and  fistulas  may  form,  owing  to  ulceration  at  their  point  of  contact. 
With  these  severe  cases  there  is  always  associated  more  or  less  extensive 
tuberculous  peritonitis,  frequently  of  the  ulcerative  variety.  Like  other 
tuberculous  processes,  the  infiltration  and  ulceration  may  cease  at  any  stage, 
and  cicatrization  follow.  If  the  ulcers  have  been  large  ones,  there  is 
alwuvs  some  narrowing  of  the  lumen  of  the  intestine.     Stricture  rarely 


362  DISEASES  OF   THE   DIGESTIVE   SYSTEM. 

results,  because  the  patients  die  from  the  general  disease  before  it  has  had 
time  to  occur.  Monti  has  reported  a  case  of  obstruction  at  the  ileo-csecal 
valve,  due  to  an  old  tuberculous  cicatrix,  in  an  infant  of  twenty-one  months. 

Mesenteric  hjmph  nodes. — Usually  these  tuberculous  lymph  nodes  are 
from  half  an  inch  to  an  inch  in  diameter ;  occasionally  they  may  reach 
the  size  of  a  hen's  Q^g.  From  a  fusion  of  several  of  them,  tumours  of 
considerable  size  may  be  formed.  I  have  seen  one  as  large  as  the  head  of 
a  child  at  birth. 

The  process  is  the  same  as  that  which  occurs  in  other  lymph  nodes  in 
the  body.  There  is  a  tuberculous  inflammation,  followed  by  caseation, 
softening,  and  abscess,  or  by  calcification.  Localized  peritonitis  is  found 
in  all  the  marked  cases ;  this  is  usually  plastic,  but  may  be  suppurative 
when  due  to  the  rupture  of  an  abscess.  Pressure  upon  the  vena  cava 
may  lead  to  dropsy  in  the  lower  extremities.  Ollivier  has  reported  a  case 
in  which  thrombosis  of  the  vena  cava  occurred.  Pressure  upon  the  portal 
vein  may  lead  to  ascites  and  dilatation  of  the  superficial  abdominal  veins. 
There  may  be  pressure  ujdou  the  thoracic  duct. 

Symptoms. — The  symptoms  of  intestinal  tuberculosis  are  exceedingly 
irregular.  Ulcers  are  very  frequently  found  at  autopsy  when  there  have 
been  no  marked  intestinal  symptoms  ;  this  is  especially  true  of  the  small 
ulcers  seen  in  infants.  On  the  other  hand,  diarrhoea  is  not  uncommon 
in  cases  of  advanced  general  tuberculosis  where  no  ulcers  are  present. 
It  is  the  most  frequent  symptom,  and  may  be  exceedingly  obstinate.  The 
stools  do  not  differ  essentially  from  those  in  chronic  ileo-colitis,  except 
in  the  occurrence  of  haemorrhages  and  in  the  presence  of  tubercle  ba- 
cilli. Haemorrhages  are  not  very  frequent,  but  they  may  be  so  large  as 
to  be  the  cause  of  death.  This  occurred  in  one  of  my  cases,  an  infant 
nine  months  old,  the  blood  coming  from  a  single  ulcer  in  the  ileum. 
Hemorrhage  is  more  common  in  older  children.  In  some  cases  localized 
abdominal  pain  or  tenderness  is  present.  In  advanced  cases  the  symp- 
toms of  intestinal  ulceration  are  usually  mingled  with  those  of  peri- 
tonitis, and  there  are  also  present  the  enlarged  mesenteric  lymph  nodes, 
which  may  aid  in  the  diagnosis.  In  the  vast  majority  of  cases,  these 
nodes  are  recognised  only  by  palpating  the  abdomen.  They  can  rarely 
be  felt  unless  they  are  at  least  an  inch  in  diameter.  In  making  palpation,, 
the  hands  should  be  placed  upon  the  abdomen  laterally,  and  slowly  brought 
together  at  the  spine.  The  tumours  are  generally  felt  as  irregular  nodular 
masses,  lying  close  against  the  si^ine,  not  movable,  and  sometimes  tender 
on  pressure.  The  other  symptoms  are  due  to  the  complications  which 
have  been  already  mentioned. 

Diagnosis. — The  only  positive  evidence  of  intestinal  tuberculosis  is  the 
discovery  of  the  bacilli  in  the  stools.  In  the  absence  of  this  evidence,  the 
disease  is  differentiated  from  simple  ileo-colitis,  first,  by  the  signs  of  tuber- 
culosis elsewhere  in  the  body,  especially  in  the  lungs,  these  being  almost 


CHRONIC  INTESTINAL  INDIGESTION.  363 

invariably  involved  ;  secondly,  by  the  slow  onset  and  gradual  development 
of  the  symptoms,  while  in  chronic  ileo-colitis  an  acute  attack  has  almost 
invariably  preceded.     Large  hajmorrhages  always  suggest  tuberculosis. 

The  large  mesenteric  glands  are  recognised  only  as  abdominal  tumours. 

Prognosis. — This  depends  altogether  upon  the  extent  of  the  tuberculous 
disease  elsewhere,  as  it  is  extremely  rare  for  the  intestinal  lesion  to  be  the 
cause  of  death.  Once  formed,  the  ulcers  probably  remain,  cicatrization 
being  very  rare,  and  then  only  partial. 

Treatment. — The  only  symptom  which  ordinarily  demands  treatment 
is  the  diarrhoea.  When  severe,  this  is  to  be  managed  much  as  in  cases  of 
ileo-colitis,  except  that  irrigation  of  the  colon  is,  of  course,  not  called  for. 
The  chief  reliance  must  be  upon  diet  and  internal  medication.  The 
drugs  which  are  most  useful  are  bismuth,  opium,  and  creosote,  which 
should  be  given  in  pills  coated  with  shellac. 


CHAPTER  IX. 
DISEASES  OF  THE  INTESTINES  .—{Continued.) 

CHRONIC   INTESTINAL   INDIGESTION. 

As  the  larger  and  more  complex  part  of  the  process  of  digestion  goes 
on  in  the  intestine,  so  intestinal  indigestion  is  a  more  common  and  more 
complicated  disturbance  than  gastric  indigestion.  In  many  cases  we  find 
the  two  associated,  but  in  perhaps  the  majority  the  symptoms  relate  en- 
tirely to  the  intestinal  process.  The  conditions  seen  in  young  infants  are 
so  different  from  those  in  older  children  that  the  cases  may  be  best  con- 
sidered separately. 

Ix  Young  Infants. —The  general  causes  are  the  same  as  those  men- 
tioned in  connection  with  chronic  gastric  indigestion  :  they  are  constitu- 
tional debility,  either  congenital  or  acquired,  unfavourable  surroundings, 
and  previous  attacks  of  acute  disease.  Chronic  intestinal  indigestion  is 
especially  common  during  the  first  six  months,  and  is  seen  both  in  nursing 
infants  and  in  those  who  are  artificially  fed.  In  the  case  of  breast-fed 
infants  the  mother  is  often  highly  nervous,  delicate,  and  anemic,  and  is 
taking  large  quantities  of  fluids  of  every  description,  by  means  of  whiich 
an  abundant  flow  of  milk  is  maintained.  Why  it  is  that  the  milk  causes 
so  much  disturbance  can  not  always  be  discovered  even  by  the  most  care- 
ful analysis.  The  difficulty  seems  to  be  most  frequently  with  the  proteids, 
which  are  often  in  excess.  Sometimes,  proteids  differing  in  character 
from  those  normally  present  seem  to  be  produced,  as  the  stools  show  that 
they  are  not  digested.  The  microscope  in  some  cases  reveals  the  presence 
of  many  colostrum  corpuscles  in  the  milk.     In  another  group  of  cases, 


364  DISEASES   OF   THE  DIGESTIVE   SYSTEM. 

where  the  condition  of  the  nurses  is  all  that  can  be  desired,  the  trouble 
is  simply  that  the  milk  is  too  rich  ;  it  being  then  high  both  in  fat  and  pro- 
teids.  It  may  come,  although  rarely,  from  the  fact  that  the  child  gets  too 
much,  being  nursed  either  too  frequently  or  for  too  long  a  time. 

In  infants  who  are  being  fed  upon  cow's  milk,  the  most  common  cause 
is  that  the  proteids  are  too  high ;  this  is  usually  the  mistake  when  infants 
are  fed  upon  plain  milk  which  has  been  simply  diluted.  In  other  cases 
the  fat  may  be  excessive,  as  in  many  of  the  milk-and-cream  mixtures  in 
vogue.  Sometimes  both  the  fat  and  the  proteids  are  too  high.  Next  to 
this  mistake  in  proportions,  is  that  of  over-feeding.  When  other  sub- 
stances than  cow's  milk  are  used  as  foods,  the  usual  trouble  is  that  they 
contain  a  large  proportion  of  starch. 

Lesions. — Strictly  speaking,  chronic  indigestion  is  a  functional  dis- 
order without  anatomical  changes.  Where  the  condition  has  lasted  for 
many  weeks  or  months,  as  often  happens,  there  may  result  a  low  grade  of 
catarrhal  inflammation  in  the  colon,  attended  by  hyperplasia  of  the  lymph 
nodules  of  the  mucous  membrane  (Plate  XI),  and  sometimes  by  a  similar 
process  in  the  mesenteric  lymph  nodes.  Chronic  indigestion  may  be  the 
principal  and  the  only  symptom  in  cases  of  chronic  ileo-colitis  which  have 
followed  an  acute  attack. 

Symptoms. — The  general  symptoms  are  those  of  malnutrition,  or  in 
the  more  severe  form,  those  of  marasmus.  These  have  already  been  fully 
described  (page  204),  and  need  only  be  mentioned  here.  The  most  im- 
portant are  stationary  or  losing  weight,  anaemia,  poor  circulation,  often 
subnormal  temperature,  almost  constant  fretfulness  and  crying,  with  very 
little  quiet  sleep.  The  tongue  is  usually  coated  and  the  appetite  often 
good,  these  infants  taking  food  whenever  given,  and  in  an  almost  unlim- 
ited quantity.  There  are  few  cases  in  which  occasional  vomiting  does  not 
occur,  but  it  is  rarely  persistent.  So  far  as  the  intestinal  condition  is 
concerned,  the  cases  may  be  divided  into  those  with  diarrhoea  and  those 
with  constipation.  It  may  happen  that  the  same  child  will  suffer  for  a 
long  time  from  diarrho-a  and  then  from  constipation,  or  the  reverse ;  but 
usually  one  condition  or  the  other  is  habitual.  The  diarrhoeal  stools 
are  thin,  green,  and  almost  invariably  contain  curds,  either  in  large  lumps 
or  small,  flaky  masses.  They  vary  in  number  from  three  to  ten  in  twenty- 
four  hours.  They  are  commonly  passed  without  pain,  although  there 
may  be  flatulence.  The  stools  have  usually  a  sour,  unpleasant  odour,  but 
they  are  rarely  foul.  They  may  be  irritating  to  the  skin,  and  cause 
troublesome  excoriations  or  intertrigo.  In  some  cases  the  stools  contain 
but  little  solid  matter,  the  character  being  that  of  yellowish-green  water. 
In  most  of  the  cases,  after  the  process  has  lasted  two  or  three  weeks, 
mucus  is  present,  and  may  then  become  a  constant  feature. 

If  there  is  constipation,  the  stools  are  usually  gray  or  white  ;  they 
are  smooth  and  pasty  or  like  hard  balls  passed  after  much  straining,  often 


PLATE   XI. 


Chronic  Hyperplasia  ok  the  Lymph  Nodules  (Solitary  Follicles) 
of  the  (.'olon. 

Child  ten  months  old  ;  death  from  pneumonia  without  intestinal  symptoms, 
five  months  old,  nearly  all  stools  were  green  or  brown  and  contained  mucus. 
The  condition  shown  existed  throughout  the  colon. 


Until 


CHRONIC   INTESTINAL  INDIGESTION.  3^5 

coated  with  mucus  and  sometimes  streaked  with  Vjlood.  Often  the  bowels 
will  not  move  for  days  except  after  the  use  of  laxatives  or  enemata. 
The  latter  often  have  but  little  effect,  as  the  rectum  may  be  empty.  Con- 
stipated cases  are  especially  prone  to  suffer  much  from  flatulence  and 
colic,  the  attacks  of  which  may  be  very  severe. 

The  duration  of  these  symptoms  is  indefinite.  There  is  little  or  no 
tendency  to  spontaneous  improvement,  and  they  may  drag  on  for  several 
months  or  until  the  problem  of  diet  is  solved.  The  progress  of  these  cases 
is  marked  by  frecjuent  exacerbations,  during  which  there  is  vomiting,  and 
usually  fever.  These  symptoms  are  generally  dependent  upon  intestinal 
toxemia.  A  low  irregular  fever  may  continue  for  days  or  even  weeks. 
Although  the  general  symptoms  of  failing  nutrition  are  present  in  most 
cases,  a  mild  degree  of  chronic  intestinal  indigestion  with  frequent  loose 
movements  may  sometimes  last  for  months,  during  which  the  patients 
may  gain  steadily  in  weight  and  give  every  indication  of  being  well  nour- 
ished. This  is  much  more  common  in  nursing  infants  than  in  those  who 
are  artificially  fed. 

Diagnosis. — It  is  not  generally  difficult  to  determine  that  an  infant  is 
suffering  from  chronic  intestinal  indigestion  ;  but  one  should  endeavour 
to  go  further  in  his  diagnosis  and  discover  which  of  the  elements  of  the 
food  is  causing  the  chief  disturbance.  Thus,  in  an  infant  fed  on  cow's 
milk,  we  wish  to  know  whether  it  is  the  casein,  the  fat,  or  the  sugar ;  or, 
in  another  case,  whether  it  is  the  starch  of  some  proprietary  food.  Much 
valuable  information  may  be  gained  from  a  careful  history  of  what  has 
already  been  tried  in  the  case ;  often  some  gross  error  can  be  detected  in 
the  formula  used  or  in  the  preparation  of  the  food.  Difficulty  with  the 
casein  is  usually  shown  by  colic,  constipation  more  often  than  diarrhoea, 
and  by  curds  in  the  stools;  often  there  is  vomiting.  Difficulty  with  the  fat 
is  indicated  by  loose  movements,  usually  of  a  yellow  colour.  Sometimes 
they  are  white,  smooth  and  formed,  with  a  peculiarly  offensive  odour ;  there 
may  be  vomiting  or  the  regurgitation  of  food  in  small  quantities.  Diffi- 
culty with  the  sugar  is  less  common  than  with  either  the  casein  or  fat, 
but  there  may  be  colic  and  diarrhoea,  with  thin,  sour,  irritating  stools.  Diffi- 
culty with  the  starch  leads  to  much  flatulence  and  colic,  diarrhre-a  alternat- 
ing with  constipation,  and  offensive  stools.  One  may  find  the  foregoing 
symptoms  in  any  combination,  for  in  protracted  cases  the  trouble  is  rarely 
limited  to  a  single  element  in  the  food.  If  one  is  feeding  cow's  milk,  the 
best  way  to  arrive  at  a  diagnosis  is  to  begin  with  what  would  be  a  proper 
formula  for  a  healthy  infant  somewhat  younger,  and  watch  the  stools 
closely  for  two  or  three  days.  The  proportion  of  the  offending  element 
should  then  be  reduced  until  the  symptoms  it  is  causing  disappear.  By 
carefully  modifying  milk  in  this  way,  a  diagnosis  can  usually  be  reached 
in  a  few  days.  Without  it,  all  treatment  is  haphazard  experimen- 
tation. 


3(36  DISEASES  OF   THE   DIGESTIVE  SYSTEM. 

Prognosis. — This  depends  almost  entirely  upon  how  early  the  cases 
come  under  treatment  and  how  they  are  managed.  There  is  very  little 
tendency  to  spontaneous  improvement  or  recovery.  The  existence  of 
chronic  intestinal  indigestion  is  one  of  the  most  important  predisposing 
causes  to  more  serious  forms  of  intestinal  disease,  and  in  that  consists  its 
chief  danger. 

Treatment. — Drugs  have  no  part  in  the  treatment  of  these  cases,  ex- 
cept now  and  then  for  particular  symptoms,  such  as  constipation  or 
colic.  These  infants  are  cured  by  proper  dietetic  and -hygienic  measures, 
and  by  these  alone.  The  problem  of  diet  has  already  been  discussed  in 
the  chapter  on  Infant  Feeding  (page  180).  For  the  general  management 
of  the  case,  which  is  not  less  important,  the  reader  is  referred  to  the 
chapter  on  Malnutrition. 

In  Older  Children. — Chronic  intestinal  indigestion  is  exceedingly 
common  in  children  from  the  first  to  the  fourth  year.  It  is,  however, 
seen  throughout  childhood,  but  after  the  age  mentioned  it  is  much  less 
frequent.  The  younger  children  have  usually  been  badly  fed  from  the 
time  of  weaning  from  the  bieast  or  bottle.  The  almost  universal  mistake 
is  that  an  excess  of  carbohydrates  has  been  given,  particularly  potato  and 
oatmeal.  In  many  children  these  articles  have  been  the  most  important 
part  of  the  diet.  Children  suffering  from  rickets  are  very  much  more 
prone  to  chronic  intestinal  indigestion  than  are  others,  but  it  is  seen  in 
many  in  whom  there  is  no  trace  of  rickets,  and  in  all  grades  of  society — 
quite  as  often  among  the  better  class  as  in  dispensary  practice,  although 
the  type  is  usually  less  severe. 

Symptoms. — The  clinical  picture  which  these  cases  present  is  a  very 
common  one,  and  the  symptoms  are  quite  uniform.  Patients  are  gener- 
ally very  thin,  with  very  small  extremities,  a  small  amount  of  fat,  and 
large,  protuberant  abdomens.  There  is  much  flatulence,  and  in  cases  of 
long  standing  there  is  marked  tympanites.  The  children  are  pale, 
angemic,  and  sallow  in  complexion  ;  they  have  dark  rings  under  the  eyes  ; 
they  are  easily  fatigued  on  slight  exertion  ;  they  are  very  cross,  irri- 
table, and  emotional  to  an  unnatural  degree.  They  are  hard  to  amuse, 
hard  to  control,  and  altogether  exceedingly  difficult  patients  to  deal  with. 
Their  growth  is  retarded  if  the  symptoms  have  lasted  long.  They  are 
much  below  the  average  in  height  and  weight.  Even  when  not  rachitic 
they  walk  late,  and  their  general  development  is  very  slow.  The  sleep  is 
always  unnatural  and  disturbed  ;  they  can  rarely  be  made  to  sleep  with 
any  regularity  during  the  day,  and  at  night  they  toss  about  their  cribs, 
waking  frequently,  crying  out  and  often  grinding  their  teeth  ;  this  some- 
times leading  to  the  diagnosis  of  intestinal  worms.  They  perspire  very 
readily,  and,  like  infants  thus  affected,  they  suffer  from  cold  extremities. 

The  bowels  are  usually  constipated,  the  stools  being  of  a  light  gray 
colour  or  perfectly  white.     They  are  always  formed  and  generally  lumpy. 


CHRONIC   INTESTINAL   INDIGESTION.  3fj7 

The  odour  from  the  discharges  is  nsujilly  extremely  foul.  In  other  cases 
there  is  chronic  diarrhcea.  The  stools  are  not  very  frequent,  rarely  ex- 
ceeding four  or  five  a  day,  but  they  are  large,  thin,  gray,  green,  or  brown 
in  colour,  very  offensive,  and  always  contain  undigested  food.  They  are 
often  excited  by  the  taking  of  food.  From  time  to  time,  in  many 
patients,  large  quantities  of  mucus  are  passed  from  the  intestine ;  in  some 
cases  this  comes  to  be  a  constant  feature  of  the  disease.  It  results 
from  an  intestinal  catarrh,  which  has  been  set  up  by  the  irritation  from 
the  hard  f;x;cal  masses  or  from  the  chronic  functional  derano-ement. 
Large  quantities  of  gas  are  expelled  per  anum.  Pain  is  not  a  very  com- 
mon symptom  in  most  cases,  although  in  a  few  patients  a  localized  pain 
of  considerable  severity  may  be  complained  of  at  certain  times,  lasting 
for  a  day  or  more.  The  appetite  is  capricious,  and  usually  poor,  but 
some  patients  will  eat  everything  offered.  Because  of  the  disinclination 
to  take  simple  food,  the  most  indigestible  and  highly  seasoned  articles  are 
often  given,  with  the  effect  of  increasing  the  severity  of  the  symptoms. 
The  tongue  is  often  coated,  although  it  may  be  quite  clean  ;  the  breath 
is  foul. 

The  nervous  symptoms  which  these  patients  present  are  exceedinglv 
varied,  and  often  of  the  most  puzzling  character.  In  many  cases  they  are 
so  severe  and  so  persistent  as  to  lead  to  the  diagnosis  of  organic  disease  of 
the  brain.  In  addition  to  the  condition  of  general  nervous  irritability, 
there  may  be  opisthotonus,  tetany,  fainting  attacks  resembling  some- 
what the  seizures  of  jjetit  /iial,  exaggerated  reflexes,  attacks  of  dulness  or 
sometimes  stupor,  with  retracted  abdomen,  irregular  pulse  and  respiration, 
and  other  sym})toms  strongly  suggestive  of  tuberculous  meningitis.  Some 
patients  have  shown  transient  paralysis.  Convulsions  are  not  very  un- 
common. Headache  and  frequent  attacks  of  vomiting,  which  are  perhaps 
to  be  interpreted  as  instances  of  migraine,  are  occasionally  seen.  In  fact, 
there  is  almost  no  end  to  the  complexity  of  these  cases  and  the  combina- 
tions of  nervous  symptoms  which  they  may  present.  Most  of  these  are 
toxic  in  their  origin.  The  skin  shows  frequently  eruptions  of  erythema 
or  of  urticaria. 

Slight  fever,  also  of  toxic  origin,  is  sometimes  present  for  many 
weeks,  the  temperature  usually  varying  between  99°  and  lOO-S"  F. .  Some- 
times for  several  days  it  may  be  normal,  and  occasionally  may  rise  to  102° 
or  103°  F.  during  a  slight  exacerbation  in  the  symptoms.  The  urine  of 
many  of  these  patients  contains  a  large  quantity  of  indican;  the  amount 
present  indicates  very  accurately  the  degree  of  intestinal  putrefaction 
going  on,  and  often  fluctuates  regularly  with  the  nervous  symptoms. 

Intercurrent  attacks  of  acute  indigestion,  with  diarrhoea  and  vomiting, 
are  common  and  quite  easily  excited.  The  course  and  duration  of  these 
symptoms  are  indetinite.  In  the  most  severe  forms,  if  untreated,  the  pa- 
tients gradually  waste  until  thev  die  from  exhaustion,  or  fall  easv  victims 
25  ' 


368  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

to  any  acute  disease  which  tliey  may  happen  to  contract.  There  is  but 
little  tendency  to  spontaneous  recovery. 

Prognosis. — This  depends  upon  the  duration  of  the  symptoms,  the 
general  condition  of  the  patient  at  the  time  treatment  is  begun,  and  upon 
how  thoroughly  it  can  be  carried  out.  The  symptoms,  in  the  great 
majority  of  cases,  have  existed  for  several  months  at  the  time  the  case 
comes  under  observation.  Generally,  the  greater  the  mistakes  in  feeding 
have  been,  and  the  more  gross  the  violation  of  hygienic  and  dietetic  rules, 
the  better  the  prognosis.  A  child  who  has  developed  chronic  intestinal 
indigestion  of  a  severe  type,  in  spite  of  the  fact  that  the  hygienic  sur- 
roundings were  good,  and  where  the  dietetic  errors  were  not  flagrant,  is 
not  nearly  so  hopeful  a  subject  for  treatment  as  one  whose  hygienic  sur- 
roundings have  been  poor  and  whose  diet  has  been  especially  bad.  In 
cases  like  the  latter,  a  removal  of  the  causes  and  the  institution  of  proper 
methods  of  treatment  almost  invariably  result  in  immediate  and  striking 
improvement,  unless  the  general  vitality  of  the  patient  has  been  reduced 
to  a  very  low  point.  In  the  other  cases,  where  the  mistakes  have  been 
less  marked,  and  the  condition  is  due  more  to  constitutional  than  to  local 
causes,  the  improvement  is  slower  and  less  striking.  Thus,  as  a  rule, 
hospital  patients  improve  more  rapidly  than  those  seen  in  private  j^ractice, 
because  their  previous  treatment  has  been  so  much  worse. 

Treatment. — In  no  class  of  cases  that  the  lihysician  is  called  upon  to 
treat  are  results  more  satisfactory  than  in  many  of  those  of  chronic  intes- 
tinal indigestion,  where  the  intelligent  co-operation  of  the  parents  or  a 
trained  nurse  can  be  secured.  If  the  parents  themselves  are  lax  in  disci- 
pline, and  are  unable  to  control  the  child,  an  efficient  trained  nurse  should 
be  secured,  into  whose  hands  the  exclusive  management  of  the  child 
should  be  placed.  The  essential  part  of  the  treatment  is  that  relating  to 
diet.  In  the  second  and  third  years  the  most  important  thing  is  to  stop 
all  starchy  food  for  a  considerable  time,  and  put  the  patient  upon  an 
exclusive  diet  of  rare  beef  or  beef  juice  and  milk.  The  milk  for  many  of 
the  patients  must  be  peptonized,  as  the  casein  of  cow's  milk  is  often  very 
difficult  of  digestion  even  by  children  three  years  old.  By  some  the  fat 
also  cannot  be  digested,  and  skimmed  milk_  should  then  be  used  ;  in  very 
obstinate  cases  it  should  be  peptonized  for  two  hours ;  in  the  majority  of 
cases,  however,  it  is  sufficient  to  peptonize  it  from  fifteen  to  twenty  min- 
utes. Additional  carbohydrates  are  often  best  given  in  the  form  of  some 
of  the  malted  foods,  which  may  be  continued  until  the  child  can  digest 
some  form  of  starch.  The  number  of  feedings  should  be  five  a  day  during 
the  second  year,  and  four  a  day  for  children  during  the  third  and  fourth 
years.  These  should  always  be  at  regular  intervals,  and  nothing  what- 
ever given  between  meals.  The  meat  should  be  rare  scraped  beefsteak 
or  mutton  ;  from  one  to  thi'ee  tablespoonfnls  may  be  allowed  once  a  day. 
Fresh  fruit,  especially  oranges,  may  usually  be  allowed  once  a  day,  given 


CHRONIC   INTESTINAL    INDIGESTION.  ,3»;y 

one  hour  before  meals.  Kuinyss  or  inatzoon  is  often  of  very  great  value 
in  children  who  are  not  fond  of  milk,  or  who  become  tired  of  tlie  diet. 
Although  at  first  they  are  taken  with  difficulty,  in  many  cases  a  fondness 
for  them  is  very  soon  acquired.     Sometimes  they  are  invaluable. 

After  improvement  has  been  going  on  for  a  month,  bread  may  be  added, 
at  first  in  small  quantities  and  once  a  day.  This  should  preferably  be  stale 
bread,  cut  thin  and  dried  in  the  oven  until  it  is  crisp,  and  given  with- 
out butter.  Two  or  three  times  a  week  raw  oysters  may  be  tried.  Mutton, 
chicken,  or  beef  broth,  without  vegetables,  may  be  given  occasionally  in 
the  plaee  of  one  of  the  milk  feedings.  After  this  diet  has  been  kept  up 
for  three  or  four  months,  if  improvement  continues,  one  of  the  green  vege- 
tables may  be  added  once  a  day,  preferably  either  spinach,  stewed  celery, 
or  asparagus.  After  two  or  three  months  more  of  continued  improvement, 
thoroughly  cooked  rice  or  macaroni  may  be  given  twice  a  week.  With 
these  articles  of  diet  one  can  get  along  very  comfortably  for  a  year,  and 
no  larger  variety  should  be  given  until  all  the  symptoms  have  disappeared. 
When  starchy  food  is  finally  allowed,  it  should  be  only  in  small  quantities, 
and  usually  with  some  preparation  of  malt.  Potato  and  oatmeal  should 
be  forbidden  for  a  long  time. 

Intestinal  irrigation  (page  63)  is  useful  in  all  cases  in  which  there  is 
much  mucus  passed.  A  saline  solution  should  be  employed.  The  irriga- 
tion should  be  given  at  first  daily,  and  after  a  week  or  two  every  other 
day,  and,  later  still,  once  or  twice  a  week.  This  seems  not  only  to  exert 
a  favourable  influence  upon  the  catarrh  in  the  colon,  but  also  upon  the 
lower  part  of  the  small  intestine. 

The  constipation  can  usually  be  controlled  by  the  diet  mentioned.  If 
not  readily  so,  calomel  should  be  administered  occasionally,  and  abdominal 
massage  employed.  Calomel  seems  to  exert  a  very  marked  influence  upon 
the  cases,  even  when  the  constipation  is  not  severe.  It  is  often  wise  to 
administer  a  full  dose  of  this  drug  every  five  or  six  days.  In  some  pa- 
tients, a  purgative  dose  of  castor  oil  given  every  few  days,  acts  more  satis- 
factorily than  the  calomel.  It  is  sometimes  objectionable,  however,  from 
its  tendency  to  aggravate  the  constipation. 

Drugs  directed  toward  the  process  of  putrefaction  are  extremely  un- 
satisfactory even  in  older  children,  but  sometimes  diminution  in  the 
amount  of  flatulence  follows  the  use  of  salol  or  salicylate  of  soda  in  five- 
grain  doses  after  meals.  General  tonics  are  required,  and  may  add  ma- 
terially to  the  improvement  of  the  patients.  Altogether  the  best  one  is 
nux  vomica.  It  may  be  given  in  combination  with  the  bitter  wine  of  iron 
just  before  meals,  three  times  a  day.  This  increases  the  appetite  and  acts 
favourably  upon  the  constipation.  Cod-liver  oil,  particularly  in  the  early 
stage,  is  badly  borne,  and  aggravates  the  symptoms.  It  should  be  with- 
held in  all  cases  until  very  marked  improvement  in  the  condition  of  the 
digestion  is  assured. 


370  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

Kelapses  are  easily  excited  by  indiscretion  in  diet,  and  parents  should 
be  impressed  at  the  very  beginning  with  the  necessity  of  adhering  rigidly  to 
the  diet  prescribed.  It  very  often  happens  that  the  improvement  which  is 
seen  after  one  or  two  months  of  careful  treatment  is  so  marked  as  to  lead 
the  parents  to  the  belief  that  a  cure  has  been  accomplished,  so  that 
they  relax  their  vigilance  and  allow  improper  articles  of  food — conditions 
which  are  almost  certain  to  induce  a  relapse.  If  the  case  is  an  aggra- 
vated one,  and  the  symptoms  of  long  standing,  it  is  wise  to  tell  parents 
at  the  outset  that  a  year's  treatment  is  the  minimum  in  which  anything 
permanent  can  be  accomplished. 

The  general  treatment  of  the  patient  must  not  be  overlooked.  Proper 
clothing,  regular  exercise  in  the  open  air,  cool  sleeping  rooms,  sponging 
every  morning  with  cold  water,  are  all  of  very  great  importance,  and  con- 
tribute almost  as  much  to  the  results  obtained  as  the  local  measures 
adopted.     (See  chapter  on  Malnutrition.) 

The  improvement  in  the  nervous  symptoms  of  the  patient  is  one  of 
the  first  things  noticed,  and  is  often  marked  in  a  few  days  after  the 
beginning  of  treatment.  From  an  irritable,  fretful,  peevish  child  the 
patient  is  sometimes  totally  changed  in  disposition  in  two  weeks,  so  as  to 
become  quiet,  affectionate,  docile,  and  playful. 

INTESTINAL  COLIC. 

The  term  colic  is  applied  to  any  severe  paroxysmal  pain  occurring  in  the 
intestines.  It  may  be  due  to  many  causes.  The  colic  of  lead  and  arsenic 
poisoning  are  both  very  rare  in  children  ;  but  colicky  pains  are  present  in 
appendicitis,  intussusception,  ileo-colitis,  and,  in  fact,  in  all  the  severe  forms 
of  intestinal  inflammation.  Colic  may  be  due  to  swallowing  certain  sub- 
stances, especially  foreign  bodies  and  the  seeds  of  fruits  ;  and  in  rare 
cases  it  may  be  excited  by  the  presence  of  round  worms  when  they  are 
numerous.  In  all  the  conditions  mentioned,  colic  is  only  one  of  the  symp- 
toms, although  it  may  be  a  very  prominent  one. 

The  special  and  peculiar  colic  of  infancy  is  that  which  is  associated 
with  flatulence,  and  is  due  to  indigestion.  Here  it  is  a  symptom  only,  but 
may  be  a  most  troublesome  one.  This  form  of  colic  belongs  essentially  to 
the  first  six  months  of  life,  and  is  more  frequent  during  the  first  three 
months.  It  may  be  seen  at  any  time  when  digestion  is  very  feeble.  Many 
young  infants  suffer  from  colic  a  large  part  of  the  time ;  others  have  only 
occasional  attacks,  which  are  often  repeated  at  a  certain  time  in  the  day. 

The  flatulence  to  which  the  colic  is  usually  due,  may  be  from  decom- 
position in  the  food  or  intestinal  secretions,  or  in  both.  It  is  seen  quite 
as  often  in  nursing  infants  as  in  those  who  are  artificially  fed.  Any  of 
the  elements  of  the  milk  may  be  a  cause  of  colic,  but  in  fully  four  fifths 
of  the  cases  it  is  the  proteids.  The  colic  of  nursing  infants  is  nearly  al- 
ways due  to  the  fact  that  the  milk  is  excessive  in  proteids,  or  else  that 


INTESTINAL   COLIC.  37I 

these  are  digested  with  special  difficulty.  If  cow's  milk  is  the  food,  it  is 
the  casein  which  is  usually  at  fault.  It  is  rare  that  the  quantity  of  sugar 
present  in  cow's  milk  is  sufficient  to  be  a  cause  of  colic ;  but  this  may 
happen  when  sugar  has  been  added,  much  more  frequently  with  cane  sugar 
than  with  milk  sugar.  It  is  extremely  rare  for  the  fat  to  be  a  cause  of 
colic.  In  infants,  whose  food  consists  largely  of  farinaceous  substances, 
colic  is  also  very  common. 

As  a  result  of  the  decomposition  taking  place  in  the  intestine,  gas  ac- 
cumulates, and,  the  intestines  lacking  sufficient  muscular  force  to  expel  it, 
distention  follows.  To  this  in  part  the  pain  is  due.  But  spasm  of  the 
muscular  walls  of  the  intestine  is  also  an  element  in  producing  the  pain. 
In  some  of  the  most  severe  cases  it  is  possible  that  the  spasm  may  be  accom- 
panied by  a  slight  intussusception.  Colic  may  occur  without  flatulence,  as 
in  cases  when  it  follows  cold  feet  or  chilling  the  surface.  In  these  cases 
also,  muscular  spasm  appears  to  be  the  principal  factor  in  causing  the 
pain.  Intestinal  colic  may  occur  alone,  or  it  may  alternate  with  or  accom- 
pany gastric  colic. 

Symptoms. — These  are  in  most  cases  so  typical  as  to  be  easily  recog- 
nised. They  are  always  more  severe  in  delicate  and  highly-nervous  chil- 
dren. In  the  severe  attacks  there  are  contraction  of  the  features,  the  loud 
paroxysmal  cry,  subsiding  for  a  few  moments  and  then  beginning  with 
renewed  intensity,  drawing  up  of  the  lower  extremities,  and  in  male  in- 
fants contraction  of  the  scrotum.  With  these  symptoms  the  abdomen  is 
usually  found  tense  and  hard.  With  the  expulsion  of  the  gas,  the  symp- 
toms subside  at  once,  and  the  child  usually  falls  asleep.  In  the  most 
severe  attacks  there  may  be  considerable  prostration,  cold  extremities,  and 
perspiration.  When  the  symptoms  are  less  severe  there  is  only  continual 
fretfulness,  and  the  child  can  not  sleep.  When  colic  is  habitual  there  are 
very  few  hours  in  the  twenty-four  when  the  child  seems  to  be  entirely 
comfortable.  In  nursing  infants  there  may  at  times  be  difficulty  in  dis- 
tinguishing the  cry  of  colic  from  that  of  hunger,  as  infants  suffering 
from  colic  will  usually  take  food  eagerly,  and  this  is  often  followed  by 
temporary  relief.  In  colic,  however,  the  pain  soon  returns,  and  often  is 
more  severe  than  before.  The  cry  of  colic  is  usually  violent  and  parox- 
ysmal ;  that  of  hunger  is  apt  to  be  prolonged  and  continuous,  and  is  not 
accompanied  by  the  other  symptoms  mentioned  as  indicating  abdominal 
pain.  In  older  children  the  less  frequent  causes  of  colic  mentioned  at 
the  beginning  of  this  article,  especially  appendicitis,  should  be  borne 
in  mind. 

Treatment. — When  colic  is  due  to  flatulence  of  the  intestine,  nothing 
given  by  the  mouth  has  much  effect  in  relieving  the  symptoms.  Certainly 
food  should  not  be  given.  The  purpose  of  treatment  during  the  attack  is 
to  assist  the  child  to  get  rid  of  the  gas ;  as  this  is  usually  in  the  colon,  the 
most  efficient  means  is  by  enemata.     At  first  an  injection  of  four  or  five 


372  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

ounces  of  lukewarm  water  should  be  used.  If  this  is  not  successful,  two 
ounces  of  cold  water  with  half  a  teaspoonful  of  gl3'ceriu  may  be  tried. 
This  rarely  fails  to  start  peristalsis  and  expel  the  gas.  In  conjunction 
with  these  measures,  dry  heat  should  be  applied  to  the  abdomen  by  means 
of  hot  flannels  or  a  hot-water  bag,  and  the  feet  should  be  Avell  warmed. 
In  cases  of  colic  not  associated  with  flatulence,  where  the  pain  is  probably 
the  result  of  muscular  spasm,  opium  in  some  form  is  required  in  addition 
to  heat  or  counter-irritation.  The  treatment  between  the  attacks  and  tlw. 
treatment  of  habitual  colic  should  be  directed  toward  the  indigestion, 
upon  which  they  depend. 

CHRONIC   CONSTIPATION. 

Constipation  may  be  said  to  exist  whenever  the  stools  are  less  fre- 
quent, harder,  and  drier  than  normal.  During  the  first  six  months  in- 
fants usually  have  two  movements  a  day.  Many,  however,  have  only  one  ; 
but  if  this  is  normal  in  character  the  child  is  not  constipated.  In  other 
cases,  although  there  are  two  and  even  three  stools  a  day,  they  may  all  be 
small,  dry,  and  hard,  having  all  the  characters  of  constipated  stools,  and 
the  case  should  be  treated  accordingly. 

Etiology. — The  causes  of  chronic  constipation  are  many  and  far-reach- 
ing. It  may  be  due  to  a  diminution  in  the  secretion  of  the  intestinal 
glands  or  of  the  liver.  The  movements  are  then  hard,  dry,  very  light- 
coloured,  and  are  associated  with  much  flatulence  and  other  signs  of 
intestinal  indigestion.  Very  often  the  principal  factor  in  constipation  is 
insufficient  muscular  contraction  in  the  intestine.  The  faecal  masses  are 
then  propelled  so  slowly  and  remain  so  long  in  the  intestine  that  the  fluid 
portion  is  absorbed,  the  residue  becoming,  in  consequence,  so  dry  and  hard 
that  it  is  difficult  to  evacuate.  In  other  cases  constipation  depends  upon 
the  fact  that  there  is  insufficient  volume  to  the  stools,  as  may  be  the  case 
when  the  food  given  leaves  very  little  residue.  Constipation  may  depend 
upon  local  causes,  as,  for  example,  where  an  evacuation  of  the  bowels  is 
resisted  on  account  of  pain  from  fissure  of  the  anus  or  from  hffimorrhoids. 
Although  not  the  primary  cause,  this  condition  may  be  sufficient  to  keep 
up  the  constipation  indefinitely.  It  may,  in  rare  cases,  be  due  to  a  con- 
genital condition,  such  as  a  narrowing  of  the  large  intestine  at  some  point. 
The  most  important  causes  of  constipation  may  be  grouped  under  two 
heads :  diet,  and  conditions  giving  rise  to  muscular  atony. 

Diet. — In  breast-fed  infants  the  trouble  is  usually  a  lack  of  fat  and  an 
excess  of  proteids  in  the  milk.  In  those  who  are  artificially  fed  it  is  often 
because  the  fat  is  too  low,  and  sometimes  because  both  the  fat  and  the 
proteids  are  too  low,  the  stool  lacking  volume.  In  other  cases  the  cause 
of  constipation  is  indigestion,  in  still  others  the  use  of  "  sterilized  "  milk. 
During  the  second  and  third  years  the  cause  may  be  too  much  cow's  milk, 
particularly  that  whioh  has  been  boiled,  or  the  use  of  an  excessive  amount 


CHRONIC   CONSTIPATION.  373 

of  starchy  food.  As  during  the  first  year,  the  trouble  with  cow's  milk  is 
that  it  contains  too  much  casein,  the  digestibility  of  which  has  often  been 
rendered  more  difficult  by  the  boiling.  In  older  children  the  cause  may 
be  an  excess  of  starchy  food  and  a  lack  of  sufficient  green  vegetables,  meat, 
and  fruit. 

Muscular  atony. — The  most  common  cause  of  muscular  atony  is  habit; 
in  a  large  number  of  cases  this  is  the  principal,  and  often  it  is  the  only 
factor.  If  the  inclination  to  have  a  stool  is  regularly  disregarded  it  soon 
ceases  to  be  felt.  The  ordinary  irritation  from  fa?cal  masses  produces  no 
effect  whatever.  The  longer  such  a  condition  continues  the  more  obsti- 
nate does  it  become.  This  is  an  important  factor  in  all  ca^es.  Another 
potent  cause  of  muscular  atony  is  rickets.  In  this  disease  the  mviscular 
walls  of  the  intestine  suffer  like  the  muscles  of  the  extremities,  and  be- 
come incapable  of  doing  their  work.  Again,  any  form  of  malnutrition  in 
which  there  is  feeble  muscular  tone  may  cause  or  aggravate  constipation. 
It  is  often  seen  as  a  sequel  to  acute  attacks  of  diarrhceal  diseases,  particu- 
larly when  these  have  been  prolonged.  Want  of  sufficient  muscular  ex- 
ercise is  a  frequent  cause.  There  are  many  children  who  rarely  suffer 
from  constipation  in  summer  when  they  have  plenty  of  out-of-door  ex- 
ercise, who  very  often  do  so  in  winter  when  such  exercise  is  wanting.  A 
loss  of  muscular  tone  is  not  an  infrequent  result  of  the  prolonged  and  in- 
discriminate vise  of  purgative  drugs  or  enemata. 

Symptoms. — In  some  cases  no  symptoms  are  present  except  the  local 
ones,  the  general  health  being  excellent  and  the  nutrition  in  no  way 
disturbed.  In  the  majority,  however,  there  are  symptoms  of  greater  or 
less  severity,  depending  somewhat  upon  the  cause  of  the  constipation. 
There  may  be  simply  flatulence  and  colicky  pains,  or  the  irritation  of 
the  hardened  ffecal  masses  may  produce  a  slight  catarrhal  inflammation 
of  the  sigmoid  flexure  and  the  rectum,  so  that  mucus  and  even  traces  of 
blood  may  be  passed  with  the  stool.  Haemorrhoids  may  develop  even 
in  infancy,  and  frequently  the  constant  straining  leads  to  the  production 
of  hernia.  In  many  of  the  most  obstinate  cases  there  are  from  time  to 
time  nervous  symptoms  resulting  from  the  absorption  of  various  toxic 
materials  from  the  intestine.  There  may  be  headache,  dulness,  fretful- 
ness,  disturbed  sleep,  and  often  associated  signs  of  intestinal  indigestion. 
The  urine  often  contains  indican  in  considerable  quantity,  and  there  may 
be  slight  fever.  This  is  more  likely  to  be  present  in  infants  than  in  older 
children.  In  many  cases  it  is  hard  to  separate  the  symptoms  due  to  the 
constipation  from  those  which  depend  upon  the  indigestion  with  which  it 
is  associated. 

Diagnosis. — This  includes  the  discovery  of  the  cause  and  the  principal 
seat  of  the  constipation.  To  arrive  at  the  former  the  most  careful  and 
thorough  investigation  should  be  made  of  the  child's  diet  and  habits.  It 
is  not  always  possible  to  determine  whether  the  seat  of  trouble  is  the  rec- 


37-i  DISEASES  OF   THE   DIGESTIVE   SYSTEM. 

turn,  the  upper  part  of  the  colon,  or  the  small  intestine ;  but  there  are 
some  symptoms  that  will  aid  us.  If  a  suppository  is  almost  immediately 
followed  by  a  stool  nearly  or  quite  normal  in  character,  one  may  be  sure 
that  the  rectum  only  is  at  fault,  and  that  it  needs  but  a  little  extra  stimu- 
lus to  make  it  do  its  work.  This  is  a  very  common  condition  in  infants 
who  are  too  young  to  make  any  voluntary  efforts  to  have  a  stool.  In  such 
cases  there  are  no  other  symptoms  present.  In  others,  the  white  or  gray 
stools,  marked  flatulence,  offensive  breath,  and  general  irritability,  leave 
no  doubt  of  the  fact  that  the  trouble  is  in  the  small  intestine  and  depends 
upon  indigestion. 

Prognosis.* — This  depends  altogether  upon  the  cause  of  the  constipa- 
tion, and  upon  how  completely  circumstances  will  admit  of  its  being 
removed. 

Treatment. — This  is  always  difficult,  and  in  obstinate  cases  must  be 
continued  for  a  long  time.  It  is  absolutely  indispensable  to  have  the  co- 
operation of  an  intelligent  mother  or  nurse.  To  establish  the  habit  of 
regular  stools  should  be  the  first  step,  for  without  this  regularity  nothing 
can  be  done.  In  infancy  this  can  generally  best  be  accomplished  by  sup- 
positories. An  older  child  must  be  taught  to  heed  the  first  impulse  to 
evacuate  the  bowel.  Eegular  habits  can  hardly  be  formed  unless  the  same 
time  each  day  is  chosen  for  the  movement.  That  to  be  preferred  is  soon 
after  the  morning  meal,  as  taking  food  into  the  stomach  nsually  starts  a 
peristaltic  wave  which  is  continued  throughout  the  intestine,  and  of  this 
advantage  must  be  taken.  Even  in  infants  only  a  few  months  old  the 
habit  of  regular  stools  is  often  easily  formed  if  the  child  is  put  upon  the 
chamber  or  chair  invariably  at  the  same  hour.  This  will  do  much  to  pre- 
vent the  formation  of  a  constipated  habit.  In  older  children  nothing 
should  be  allowed  to  interfere  with  the  movement  of  the  bowels.  Break- 
fast should  be  early  enough  to  allow  ample  time  for  this  duty  before  the 
other  engagements  of  the  day.  All  children  must  be  carefully  watched 
in  this  respect,  and  nurses  should  be  impressed  with  the  importance  of  the 
early  formation  of  proper  habits. 

Food. — With  nursing  infants  who  get  good  breast-milk  constipation  is 
rare.  Where  the  milk  is  low  in  fat  and  high  in  proteids,  constipation  is 
not  uncommon.  For  the  measures  by  which  such  milk  can  be  improved, 
see  page  IG-t.  Where  the  fat  can  not  be  increased  by  dietetic  treatment 
of  the  nurse,  the  infant  may  be  given  immediately  after  nursing,  from  one 
half  to  two  teaspoonfuls  of  cream,  according  to  the  degree  of  constipation. 

In  feeding  cow's  milk,  constipation  is  overcome  by  getting  the  exact 
proportions  of  casein  and  fat  which  are  suited  to  the  infant.  With  most 
infants  during  the  early  months  from  2  to  3  per  cent  fat  and  1  per  cent 
casein  succeed  best ;  with  those  a  little  older,  from  3  to  4  per  cent  fat  and 
1*5  per  cent  casein.  During  the  last  half  of  the  first  year  4  per  cent  fat 
and  from  2  to  3  per  cent  casein  will  be  found  satisfactory.     (See  pages 


CHRONIC  CONSTIPATIOX.  375 

174-lTG.)  However,  to  feed  a  young  infant  upon  2  per  cent  fat  and 
2  per  cent  casein — which  is  what  is  usually  given  when  cow's  milk  is 
simply  diluted  once  with  water — almost  invariably  produces  constipation. 
With  most  infants  during  the  first  year,  constipation  may  be,  if  not  cured, 
at  least  prevented  by  such  a  modification  of  the  milk.  This  is  generally 
easy  if  proper  feeding  is  begun  early  ;  but  when  the  constipated  habit 
has  become  firmly  established  a  proper  adjustment  of  the  elements  of  food 
is  often  not  sufficient. 

During  the  second  year,  children  who  suffer  from  constipation  should 
have  both  cream  and  water  added  to  the  milk,  so  that,  instead  of  the  3*5 
per  cent  fat  and  4  per  cent  casein  of  plain  milk,  they  get  4  per  cent  fat, 
and  3  per  cent  casein.  (See  formula  IX,  page  185.)  These  proportions 
can  be  obtained  by  adding  two  tablespoonf uls  of  cream  to  two  thirds  of  a 
glass  of  milk,  and  filling  up  the  glass  with  water.  Further  improvement 
may  be  brought  about  by  reducing  the  quantity  of  starchy  food,  and  add- 
ing more  meat  or  beef  juice,  which  is  quite  laxative  on  account  of  its  salts. 
Fruits  are  valuable  in  all  these  cases  ;  baked  apples,  oranges,  stewed  prunes, 
grapes — especially  the  hothouse  variety — and  in  summer,  fresh  peaches, 
plums,  and  pears,  may  be  given  in  small  quantities  ;  but  all  berries  should 
be  avoided. 

For  older  children  who  are  upon  a  mixed  diet  the  amount  of  starchy 
food  should  be  moderate,  oatmeal  being  perhaps  the  best  cereal.  Milk 
should  be  given  rather  sparingly,  and  even  then  may  be  advantageously 
modified  as  for  the  second  year.  It  is  sometimes  advisable  to  stop  milk 
altogether  and  give  only  cream,  from  four  to  eight  ounces  of  which  may  be 
allowed  daily.  It  may  be  used  with  the  breakfast  cereal,  mixed  with  jio- 
tato  or  rice,  added  to  soups  or  broths,  and  taken  in  various  other  ways. 
All  bread  should  be  made  from  whole  wheat  or  unbolted  flour.  Meat 
may  be  allowed  freely,  also  all  green  vegetables,  one  of  which  should  be 
given  every  day.  All  fruits  allowed  infants  may  be  used,  but  in  larger 
quantities,  and  in  addition  raw  apples.  Of  the  dried  fruits,  only  dates, 
prunes,  and  figs  are  admissible,  and  these  are  better  stewed  than  raw. 
Fresh  fruit  is  preferably  given  in  the  morning,  oranges  being  especially 
useful  when  taken  on  rising. 

Either  hot  or  cold  water,  when  taken  an  hour  before  breakfast,  may  be 
of  considerable  benefit  to  older  children.  The  sparkling  waters,  like  Vichy 
or  Apollinaris,  are  often  better  than  plain  water. 

Massage,  when  properly  employed,  is  useful  in  conjunction  with  other 
measures,  but  rarely  succeeds  alone.  It  should  be  given  for  five  or  ten 
minutes  after  retiring  and  just  before  rising.  The  hand  must  be  warm, 
but  no  oil  used,  the  purpose  being  not  to  make  friction  upon  the  skin, 
but  to  move  the  skin  and  abdominal  walls  upon  the  intestines.  This 
should  be  done  with  a  circular  motion,  changing  the  point  from  time  to 
time  until  the  whole  abdomen  has  been  thoroughly  covered.     In  addition  to 


376  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

this  a  general  kneadiug  of  the  abdomen  may  be  employed.  Only  slight 
pressure  should  be  made  until  the  child  becomes  accustomed  to  the  process, 
when  quite  deep  pressure  will  be  tolerated.  The  intestinal  coils  may  often 
be  felt  contracting  under  the  hand  during  massage.*  In  general  torpor 
of  the  intestines  massage  is  useful,  and  when  properly  done  may  affect  the 
small  as  well  as  the  large  intestine. 

A  proper  amount  of  active  muscular  exercise  is  necessary  and  should 
be  made  a  part  of  the  treatment  in  every  case.  Yale  (New  York)  has 
called  attention  to  the  importance  of  posture  during  the  stool,  he  having 
found  that  in  many  cases  a  cure  was  effected  simply  by  substituting  a  low 
seat  on  a  nursery  chair  or  closet  for  the  high  one  previously  used.  The 
low  seat  afforded  the  child  an  opportunity  to  strain  to  some  purpose,  while 
the  higher  one  with  the  legs  dangling,  made  tliis  almost  impossible. 

Supjjositorie,-:. — In  many  cases,  particularly  in  young  infants  who  are 
not  old  enough  to  initiate  the  muscular  effort,  a  slight  stimulus  to  the  ren- 
tum  is  all  that  is  required.  The  cone  of  oiled  paper  has  a  great  reputa- 
tion in  domestic  practice  and  is  not  objectionable.  It  may  be  of  assistance 
in  establishing  the  habit  of  a  daily  movement  at  a  regular  time.  Soap  sup- 
positories produce  a  more  marked  irritation  ;  although  their  immediate 
effect  is  quite  satisfactory,  they  should  not  be  continued  indefinitely.  They 
are,  however,  less  objectionable  than  glycerin  suppositories.  The  lat- 
ter, for  an  immediate  effect,  are  convenient  and  usually  efficient;  but 
their  prolonged  use,  especially  in  infants,  is  likely  to  set  up  a  catarrlial 
proctitis.  The  gluten  suppositories  produce  less  imtation  and  are  conse- 
quently slower  in  their  effect,  but  they  have  not  the  disadvantages  of  the 
soap  or  glycerin.  Medicated  suppositories  are  certainly  one  of  our  most 
efficient  measures ;  if  drugs  must  be  employed,  they  are  perhaps  open  to 
the  fewest  objections  when  used  in  this  way.  The  following  are  the  best 
drugs  for  this  purpose,  the  dose  being  that  for  a  child  of  two  or  three 
years  :  ext.  nux  vomica,  gr.  -^ ;  ext.  belladonna,  gr.  gV  '■>  ^^t-  hyoscyamus, 
gr.  ^ ;  sulphur,  gr.  ij  ;  purified  aloes,  gr.  i ;  aloin,  gr.  -^^.  A  good  com- 
bination is  aloin,  gr.  -^j  ;  ext.  belladonna,  gr.  ^^^  ;  ext.  nux  vomica,  gr.  Jj  ; 
ol.  theobrom.,  gr.  x.  In  obstinate  cases  this  may  be  used  night  and  morn- 
ing, and  later  at  night  only.  After  some  improvement  has  occurred  the 
aloin  may  be  omitted.  Many  of  the  proprietary  suppositories  contain  the 
ingredients  mentioned,  particularly  belladonna,  the  dose  of  which  is  often 
considerably  larger  than  should  be  given.  Suppositories  are  most  useful 
where  the  seat  of  trouble  is  the  rectum  and  lower  colon ;  but  very  little  is 
to  be  expected  from  them  when  it  is  in  the  small  intestine. 

Enemata. — These  should  be  restricted  to  cases  in  which  only  temporary 
relief  is  desired.  An  injection  of  an  ounce  of  sweet  oil  may  facilitate  the 
passage  of  very  hard  and  dry  stools,  and  larger  injections  of  soap  and  water 


*  See  Karnitzky,  Archiv  fiir  Kimlerheilkunde,  Bd.  xii,  p.  66. 


CHRONIC  CONSTIPATIOX.  377 

may  be  used  to  break  np  luml  faecal  accumulations.  For  immediate  effect 
an  injection  of  one  drachm  of  glycerin  in  half  an  ounce  of  water  is  perhaps 
the  most  efficient  means  at  our  command.  Cases  of  ftecal  impaction  are 
rarely  met  with  in  children.  They  are  to  be  managed  as  in  adults,  by 
repeated  injections  of  warm  water  or  of  ox-gall,  and  sometimes  by  me- 
chanical removal.  For  continuous  use  enemata  are  not  to  be  advised,  for 
larger  and  larger  quantities  are  required  to  produce  the  effect. 

Medicinal  treatment. — This  is  the  least  important  part  of  the  manage- 
ment of  chronic  constipation.  No  plan  is  worse  than  to  give  some  active 
purgative  every  third  or  fourth  day  and  trust  matters  to  take  care  of  them- 
selves the  rest  of  the  time.  Tiie  most  valuable  drugs  are  those  which 
stimulate  the  muscular  walls  of  the  intestine,  such  as  cascara,  nux  vomica, 
belladonna,  and  hyoscyamus.  These  are  particularly  useful  in  atonic  con- 
stipation associated  with  rickets  and  following  diarrhreal  diseases,  but  they 
are  valuable  in  all  cases.  With  most  drugs  the  prolonged  use  of  small 
doses  is  better  than  the  occasional  use  of  large  ones.  Calomel  is  indicated 
in  cases  attended  with  dry,  very  Avhite  stools  and  marked  flatulence ; 
one  fourth  to  one  half  grain  of  the  tablet  triturates  may  be  given  for  two 
or  three  successive  nights  in  conjunction  with  other  means.  Cascara  may 
be  used  either  in  the  form  of  the  elixir,  dose  from  one  half  to  one  drachm, 
or  the  fluid  extract,  from  one  to  five  drops.  Ehubarb,  either  in  the  form 
of  the  syrup  or  the  mixture  of  rhubarb  and  soda,  may  be  given  occa- 
sionally, but  it  is  not  adapted  to  continuous  use.  Of  salines,  phosphate 
of  soda  is  best  for  continuous  use  in  infants.  All  the  preparations  of 
malt  possess  slight  laxative  properties,  and  are  useful  in  conjunction  with 
dietetic  and  other  medicinal  means ;  either  Trommer's  extract  of  malt 
or  maltine  may  be  employed.  Castor  oil  should  seldom  be  given  for 
chronic  constipation.  The  frequent  use  of  small  quantities  of  olive  oil 
is  often  a  good  means  of  treatment  in  the  case  of  young  infants,  the  oil 
being  added  to  the  food. 

Sutnmanj. — The  treatment  of  constipation  is  palliative  and  curative. 
The  jjalliative  measures  are  drugs,  suppositories,  injections,  and  enemata. 
Cure  is  accomplished  only  by  diet,  massage,  exercise,  and  the  formation  of 
regular  habits.  An  average  case  of  chronic  constipation  in  a  child  four 
years  old  may  be  managed  as  follows  :  Massage  for  eight  minutes,  morning 
and  night ;  the  juice  of  half  an  orange  and  a  glass  of  Vichy  immediately 
upon  rising ;  a  breakfast  of  oatmeal  with  one  ounce  of  cream,  dried  bread 
with  butter,  an  egg.,  half  a  glass  of  milk  with  cream  and  water  added  ; 
a  dinner  of  soup,  one  starchy  vegetable — e.  g.,  potato  with  cream,  and 
one  green  vegetable,  beef-steak,  baked  apple  or  prunes,  dried  bread  and 
butter,  and  water  to  drink  ;  for  supper,  cream-toast,  egg.,  dried  bread  and 
butter,  or  Graham  crackers,  half  a  glass  of  milk  with  cream  and  water 
added  ;  a  suppository  containing  nux  vomica  and  hyoscyamus  given  at 
bedtime. 


378  DISEASES   OF   THE    DIGESTIVE   SYSTEM. 

Hypertrophy  and  Dilatation  of  the  Colon. — It  is  ])robable  that  in  many 
cases  of  chronic  constipation,  especially  among  rachitic  infants,  a  consid- 
erable degree  of  dilatation  of  the  colon  occurs.  However,  it  seems  to  be 
but  a  temporary  condition,  disappearing  by  the  third  or  fourth  year. 

There  is  another  form  of  dilatation  which  may  be  permanent ;  it  is 
associated  with  a  marked  degree  of  hypertrophy  of  the  muscular  walls  of 
the  colon.  The  reported  cases  thus  far  are  few  in  number,  but  have  been 
observed  both  in  infants  (Hirschsprung,*  Myaf)  and  in  older  children 
(Osier,  Hughes]:).  'J-'he  prominent  symptoms  are  two:  obstinate  con- 
stipation, which  in  most  of  the  cases  has  continued  from  early  infancy, 
and  is  sometimes  so  severe  that  the  patients  have  gone  for  two  weeks 
without  a  movement  of  the  bowels;  and  distention  of  the  abdomen,  which 
may  be  extreme,  but  which  may  disappear  and  the  abdomen  become  per- 
fectly flat  after  the  faeces  and  flatus  have  been  discharged.  There  is  usu- 
ally emaciation,  and  from  time  to  time  there  may  be  diarrhosa.  Death 
may  occur  in  infancy,  or  the  patients  may  live  to  adult  life. 

In  the  cases  which  have  come  to  autopsy  there  has  been  found  an 
enormous  dilatation  of  the  large  intestine,  chiefly  of  the  transverse  colon 
and  the  sigmoid  flexure.  In  one  case  (Hughes'),  in  a  boy  of  three  years, 
the  colon  was  four  inches  in  diameter,  and  held  fourteen  pints  of  water. 
In  none  of  the  cases  was  there  stricture  at  any  point.  The  mucous  mem- 
brane has  invariably  been  found  ulcerated,  this  clearly  being  a  secondary 
process.  The  muscular  walls  have  been  greatly  hypertrophied.  The  con- 
dition is  without  doubt  a  congenital  one.  Treatment  is  palliative  only. 
In  some  of  the  cases  the  condition  seems  to  have  been  aggravated  by  the 
use  of  large  enemata. 

INTUSSUSCEPTION. 

Intussusception  consists  in  the  invagination  of  one  portion  of  the 
intestine  into  another.  It  occurs  most  frequently  in  infancy,  being  at 
this  age  the  most  common  cause  of  acute  intestinal  obstruction.  The 
accident  is  not  a  common  one,  but  the  life  of  the  patient  generally  depends 
upon  its  prompt  recognition. 

Varieties.— Jjswallj  the  upper  part  of  the  intestine  is  invaginated  into 
the  lower,  although  the  reverse  is  occasionally  seen.  Intussusceptions  may 
occur  at  any  point  in  the  intestinal  tract.  Those  of  the  small  intestine 
are  called  enteric ;  those  of  the  colon,  colic ;  and  those  occurring  at  the 
ileo-c«cal  valve,  ileo-cwcal  (Fig.  60).  Of  90  cases  under  ten  years  of  age, 
in  which  the  variety  was  determined  by  autopsy  or  operation,  75  were 
ileo-caecal,  9  colic,  and  6  enteric.      In  the  ileo-ca?cal  form  a  few  inches 


*  Hirschsprung,  Jahrbuch  fiir  Kindeih..  Bd.  xxvii.  p.  1. 

t  Mya,  Revue  Mensuelle  des  Maladies  de  I'Enfance,  vol.  xii.  p.  633. 

X  Osier.  Archives  of  Pediatrics,  vol.  xi,  p.  112. 


INTUSSUSCEPTION. 


379 


of  the  ileum  pass  through  the  ileo-ciieciil  valve,  and  then  invagination  of 
the  colon  occurs.  Cases  in  which  the  ileum  passes  through  the  valve,  but 
without  invagination  of  the  colon,  are  sometimes  classed  separately  as  an 
ileo-colic  variety. 

Intussusceptions  of  the  dying,  as  they  have  been  called,  are  met  with 
in  my  experience  in  about  eight  per  cent  of  all  autopsies  made  upon  in- 
fants ;  they  are  not  often  found  in  children  over  two  years  of  age.  They 
are  distinguished  by  the  fact  that  they  are  always  descending,  enteric,  and 


Fi(i.  60. — lleo-e-;i-eal  iiitus-susceptiou. 


A   sfieciiueu   rtinoved  from  ii   cliild  iu  the  New  York 
Infant   Asvlum. 


multi])le — usually  from  eight  to  twelve  invaginations  being  present.  They 
are  more  frequently  in  the  jejunum  than  in  the  ileum.  They  usually  in- 
volve but  two  or  three  inches  of  the  intestine,  but  may  include  ten  or 
twelve  inches.  They  are  found  in  auto])sies  upon  patients  dying  of  all  va- 
rieties of  disease,  and  are  probably  produced  in  the  death  agony.  These 
intussusceptions  are  without  symptoms,  and  are  of  no  clinical  importance. 
Etiology. — Of  385  collected  cases  under  ten  years,  the  following  are 


380  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

the  ages  reported  :  under  four  months,  28  cases ;  from  four  to  six 
months,  113;  seven  to  nine  months,  71  ;  ten  to  twelve  months,  18;  one 
to  two  years,  32  ;  two  to  ten  years,  96.  Three  fourths  of  the  cases 
which  occur  in  childhood  are,  therefore,  in  the  first  two  years,  and  one 
half  of  them  between  the  fourth  and  ninth  months.  The  greater  fre- 
quency in  infancy  is  attributed  to  the  thinness  of  .the  intestinal  walls,  the 
greater  mobility  of  the  caecum  and  ascending  colon,  and  the  presence 
of  other  intestinal  derangements  at  this  age. 

Males  are  more  often  affected  than  females.  Of  268  cases  in  which 
the  sex  was  mentioned,  there  were  174  males  and  94  females.  For  this 
fact  there  is  no  explanation.  The  exciting  causes  of  an  attack  are  ex- 
tremely obscure.  The  great  majority  of  cases  occur  in  children  who  were 
apparently  in  perfect  health.  Some  previous  intestinal  disorder  was  pres- 
ent in  about  three  per  cent  of  the  cases  I  have  collected — diarrhoea,  dysen- 
tery, colic,  chronic  indigestion,  and  constipation,  all  being  mentioned.  In 
four  cases  the  intussusception  was  ascribed  to  injury  of  the  abdomen. 
The  association  with  the  general  diseases  is  too  infrequent  to  be  of  any 
importance. 

Lesions. — l^othnagel's  vivisection  experiments*  have  shown  conclusively 
that  intussusceptions  are  formed  by  the  irregular  action  of  the  muscular 

walls  of  the  intestine.     They  can  be 
produced  or  released  at  will  by  vary- 

-. ing  the  application  of  the  electrical 

Pj^  gj  current.     In  the  artificial   intussus- 

ception there  is  first  a  contraction 
of  a  certain  part  of  the  intestine,  and  if  this  ceases  abruptly  the  normal 
gut  below  this  point  turns  upward  and  folds  over  upon  the  contracted 
portion,  thus  forming  a  minute  intussusception  (Fig.  61).  When  once 
begun,  the  intussusception  increases  solely  at  the  expense  of  the  external 
layer   (Fig.  62).     Thus,  while   the  apex  of  the  tumour  D  remains  un- 


FiG.  62. — Mechanism  of  intussusceptioii.     (  Treves.) 

changed,  the  part  of  the  sheath  at  A  passes  to  B  and  then  to  C,  so  that 
the  lower  part  of  the  intestine  is  drawn  over  the  upper,  rather  than  the 
upper  crowded  into  the  lower.  The  mechanism  of  the  invagination  was 
apparently  the  same  when  a  part  of  the  intestine  was  first  paralyzed  by 


*  Beitrage  zur  Physiologie  und  Pathologie  des  Darms,  Berlin,  1884.  A  full  abstraot 
is  to  be  found  in  Treves's  Intest'nal  Obstruction,  London,  1884,  to  which  I  am  indebted 
for  many  points  in  this  article. 


INTUSSUSCEPTION.  381 

crushing,  as  in  the  cases  in  which  a  spasm  of  the  intestine  was  first  pro- 
duced. 

There  is  no  doubt  that  pathological  intussusceptions  are  produced  in 
the  same  way  as  in  these  experiments.  As  the  invagination  takes  place, 
the  mesentery  is  drawn  in  with  the  bowel,  and  always  lies  between  the 
sheatli  and  the  inner  layer.  To  allow  intussusception  to  occur,  the  mes- 
entery must  be  unduly  long,  stretched,  or  lacerated.  Its  attachment  to 
the  spine  causes  the  intussusception  to  describe  an  arc  of  a  circle,  the  con- 
cavity of  which  is  always  toward  the  spine.  It  also  causes  a  puckering 
of  the  tumour.  Invagination  does  not  necessarily  produce  either  obstruc- 
tion or  strangulation,  but  usually  both  are  present,  and  are  the  chief 
causes  of  the  symptoms.  Traction  upon  the  mesentery  leads  to  obstruc- 
tion in  its  vessels,  causing  congestion,  oedema,  haemorrhages,  and  even 
gangrene.  Obstruction  is  chiefly  due  to  swelling.  It  may  be  due  to 
dragging  of  the  mesentery,  which  brings  the  apex  of  the  tumour  against 
the  side  of  the  gut,  or  to  bending  of  the  intussusception. 

The  great  cause  of  irreducibility  in  the  first  two  or  three  days  is  swell- 
ing. I  have  several  times  seen  at  autopsy  or  operation  the  intussuscep- 
tion easily  reduced,  except  the  last  two  or  three  inches  of  the  caecum  or 
ileum,  which  was  swollen  to  the  thickness  of  from  a  fourth  to  half  an 
inch.  Adhesions  may  prevent  reduction,  but  rarely  before  the  fourth  day ; 
they  are  often  absent  as  late  as  the  sixth  or  seventh  day.  They  are  usually 
between  the  internal  and  middle  layers  of  the  iutussusceptuni,and  are  due 
to  local  peritonitis.  In  chronic  cases,  however,  they  form  the  principal 
obstacle  to  reduction.  Other  causes  of  irreducibility  are  twisting  of  the 
tumour  and  pinching  of  the  prolapsed  intestine,  especially  of  the  ileum 
by  the  ileo-caecal  valve. 

Gangrene  and  sloughing  of  the  gangrenous  portion  of  the  intestine 
occur  much  more  often  in  acute  than  in  chronic  cases.  Portions  of 
intestine  were  passed  per  anum  in  24  of  362  cases  under  ten  years,  or 
about  six  per  cent ;  but  only  two  of  these  were  in  infants.  Toward  the 
end  of  the  second  week  is  the  time  when  the  separation  of  the  sloughs  is 
to  be  looked  for.  The  amount  of  intestine  discharged,  varies  from  a  few 
inches  to  several  feet.  Two  cases  are  on  record  in  which  the  entire  colon 
was  passed,  the  patients  recovering,-  but  dying  several  months  later  from 
other  causes.  At  the  autopsies  the  ileum  was  found  attached  to  the  lower 
part  of  the  rectum  just  above  the  anus.  In  acute  cases  gangrene  occurs 
about  the  upper  end  of  the  tumour,  and  the  intestine  usually  comes  away 
in  one  large  mass.  In  chronic  cases  shreds  of  intestine  nuiy  be  discharged 
for  several  weeks. 

Symptoms. — The  clinical  picture  of  a  case  of  intussusception  is  a 
striking  one,  and  when  acute  the  symptoms  are  so  uniform  that,  once 
seen,  they  can  scarcely  be  overlooked  a  second  time.  The  patient, 
usuallv  between  six  and  twelve    months   of   as:e,  is   taken    suddenlv  ill 


382  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

with  severe  pain  and  vomiting ;  the  pain  recurring  paroxysmally  every 
few  minutes,  and  the  vomiting  being  first  of  the  contents  of  the  stom- 
ach, and  afterward  bilious.  There  may  be  one  or  two  loose  fscal  stools, 
then  only  blood  or  blood  and  mucus  are  passed  without  any  admixture  of 
faeces.  The  general  symptoms  are  those  of  great  prostration,  or  even  col- 
lapse— pallor,  feeble  pulse,  apathy,  and  normal  or  subnormal  tempera- 
ture. The  abdomen  is  relaxed.  A  tumour  is  present  in  the  left  iliac 
fossa^or  it  is  felt  per  rectum.  Later  there  is  tympanites ;  the  vomiting  and 
pain  continue ;  there  is  a  steady  increase  in  the  prostration,  and  toward 
the  end  a  rapidly  rising  temperature,  which  may  reach  105°  or  106°  F. 
before  death  occurs  from  collapse.  If  the  symptoms  continue  longer  the 
signs  of  peritonitis  are  added.  In  subacute  cases  the  onset  is  less  abrupt, 
and  pain,  vomiting,  and  constipation  less  constant  and  less  severe ;  but 
the  same  symptoms  are  present.  In  chronic  cases  the  onset  is  with  vague, 
indefinite  intestinal  symptoms;  pain,  vomiting  and  bloody  discharges  are 
usually  wanting;  there  are  progressive  wasting  and  more  or  less  diar- 
rhcea,  but  only  the  presence  of  the  tumour  leads  to  the  recognition  of 
the  disease. 

Onset. — Of  193  cases  iinder  ten  years  in  which  data  upon  this  point 
could  be  obtained,  the  onset  was  sudden  in  181  and  gradual  in  12  cases. 
By  far  the  most  frequent  symptoms  of  onset  are  pain  and  vomiting.  In 
a  smaller  number  of  cases  the  initial  symptom  is  diarrhoea  or  a  discharge 
of  blood  and  mucus. 

Pain. — This  is  rarely  continuous,  but  is  intermittent,  recurring  in 
paroxysms  like  those  of  ordinary  colic,  but  of  great  severity.  No  pain  in 
infancy  is  to  be  compared  with  it.  The  child  often  shrieks  so  as  to  be  heard 
all  over  the  house.  Pain  is  a  prominent  symptom  in  over  three  fourths 
of  the  cases,  and  is  very  rarely  absent.  It  is  generally  more  marked  for 
the  first  two  days,  but  may  continue  throughout  the  attack.  In  a  few 
cases  the  pain  is  localized,  being  usually  referred  to  the  region  of  the  um- 
bilicus. 

Vomiting  is  more  marked  at  the  onset,  but  may  continue  throughout 
the  disease.  Like  pain,  it  is  more  frequent  in  the  acute  cases.  It  is  due 
to  intestinal  obstruction.  Vomiting  is  present  in  fully  four  fifths  of  all 
cases.  Usually  it  is  persistent  and  uncontrollable ;  it  is  often  projectile. 
If  food  is  given,  vomiting  often  occurs  as  soon  as  it  reaches  the  stomach. 
Stercoraceous  vomiting  occurs  in  about  fifteen  per  cent  of  the  cases  in 
children  under  ten  years,  but  is  not  common  in  infancy.  It  is  rarely  pres- 
ent before  the  third  or  fourth  day.  Although  a  bad  sign,  it  is  not  by 
any  means  a  fatal  one,  as  nearly  one  half  the  cases  in  which  it  has  been 
noted  have  recovered  ;  it  is  to  be  regarded  as  indicating  complete  intes- 
tinal obstruction  rather  than  strangulation. 

Tumour. — This  is  one  of  the  most  important  symptoms  for  diagnosis 
because  of  its  frequency  and  its  peculiar  character.     It  is  present  early  in 


INTUSSUSCEPTION. 


383 


the  disease,  often  in  a  few  hours  after  the  initial  symptoms.  The  follow- 
ing table  shows  the  frequency  with  which  a  tumour  was  present  in  the 
different  varieties,  and  the  position  which  it  occupied  in  each.  The  an- 
atomical variety  was  determined  either  by  autopsy  or  operation. 

The  Relation  between  the  Tumour  and  the  Different  Varieties  of  Intussus- 
ception in  188  Cases  under  Ten  Years. 


SEAT  OF  INTUSSUSCEPTION. 

Seat  of  Tcmour. 

neo- 
caecal. 

Ileo- 
colic. 

Colic. 

Enteric. 

Not 
stated. 

Total. 

Kegion  of  c;ccum 

'i 

3 
3 
4 
25 
9 

'i 

3 

i 

'i 

7 
1 

1 

i 

1 

7 
12 
13 
18 

8 
28 
12 

"2 

11 
13 
16 

21      , 
13 
61 
22 
1 

"       "  ascending  colon .. . . 
"       "  transverse  colon.. .  . 
"       "  descending  colon..  . 
"       "  sigmoid  flexure  .... 
Rectal 

Protruding  from  anus 

Umbilical  region 

Movable 

3 

Site  unknown 

1 

Total 

46 
10 

4 
2 

9 

3 
1 

100 
13 

162 
26 

No  tumour  felt 

Tumour  was  thus  made  out  during  life  in  eighty-six  per  cent  of  the 
cases ;  and  in  the  great  majority  of  these  it  Avas  discovered  at  the  first 
careful  examination. 

It  will  be  noted  that  in  one  half  of  the  cases  the  tumour  was  either 
felt  in  the  rectum  or  protruded  from  the  anus,  and  that  in  over  two  thirds 
it  had  advanced  as  far  as  the  descending  colon  or  beyond.  The  tumour 
may  reach  the  rectum  in  a  surprisingly  short  time,  even  when  the  invagi- 
nation begins  at  the  ileo-cascal  valve.  In  one  of  my  own  cases  it  was  felt 
in  the  rectum  in  less  than  twelve  hours  from  the  onset.  The  usual  de- 
scription, "  sausage-shaped,"  is  accurate  when  the  invagination  is  large,  the 
tumour  then  being  from  four  to  six  inches  long  and  about  an  inch  and  a 
half  in  diameter.     It  is  often  curved. 

During  manipulation,  or  during  an  attack  of  pain,  the  tumour  may  be- 
come more  prominent  and  may  be  distinctly  erectile.  To  the  touch  the 
rectal  tumour  closely  resembles  the  os  uteri,  the  central  opening  being  the 
apex  of  the  intussusception.  When  protruding  from  the  body,  the  tu- 
mour is  rarely  more  than  two  inches  long.  It  is  usually  of  a  deep  purplish 
colour,  and  may  be  gangrenous.  It  has  been  mistaken  for  prolapsus  ani, 
polypus,  and  even  hemorrhoids.  In  a  case  which  came  subsequently 
under  my  observation,  the  tumour  was  discovered  by  the  mother  before 
the  physician  had  suspected  the  condition. 

Condition  of  the  boivels. — Bloody  stools  are  a  very  constant  symptom. 
Of  186  cases  under  ten  years  in  which  this  condition  of  the  bowels  was 
2b 


384  DISEASES   OF   THE  DIGESTIVE  SYSTEM. 

noted,  blood  in  the  stools  was  present  in  seventy-six  per  cent.  There  are 
very  often  two  or  three  thin,  diarrhoeal  movements,  and  then  only  blood 
and  mucus  are  passed  with  no  trace  of  faeces  and  wath  no  faecal  odour. 
The  amount  of  blood  varies  from  a  quantity  sufficient  to  stain  the  mucus 
to  an  ounce  of  semifluid  blood.  It  rarely  occurs  without  some  mucus. 
Such  discharges  frequently  follow  attacks  of  severe  colicky  pain,  and  may 
occur  several  times  in  an  hour.  They  may  continue,  or  after  a  day  or  two 
they  may  be  succeeded  by  absolute  stoppage.  Diarrhoea  throughout  the 
attack  is  rare  in  children,  particularly  so  in  infants.  It  belongs  generally 
to  chronic  cases.  Constipation  is  complete  in  most  of  the  acute  cases, 
neither  gas  nor  fsces  being  passed  ;  a  fact  which  the  discharge  of  blood 
and  mucus  may  lead  one  to  overlook. 

Tenesmus  is  very  common  if  the  tumour  is  rectal.  Relaxation  of  the 
sphincter  is  met  with  in  a  considerable  proportion  of  the  cases  when  the 
tumour  is  in  the  sigmoid  flexure,  or  rectum. 

During  the  first  twenty-four  or  forty-eight  hours  the  abdominal  walls 
are  soft  and  relaxed,  and  may  even  be  retracted.  Usually  there  is  then 
little  resistance  to  abdominal  palpation.  After  the  second  or  third  day 
there  is  tympanites;  but  this  does  not  necessarily  mean  that  peritonitis 
exists.  Localized  tenderness  is  a  symptom  of  some  importance  when  a 
tumour  is  absent.  Scanty  urine  has  been  noted  in  a  few  cases,  but  is  of 
no  special  value  in  showing  the  seat  of  obstruction. 

In  the  acute  cases  the  general  symptoms  are  very  striking.  They  are 
the  ordinary  ones  of  severe  shock — marked  prostration,  pallor  with  an 
anxious  exj^ression  of  the  face,  general  muscular  relaxation,  cold  extrem- 
ities, cold  perspiration,  and  often  a  subnormal  temperature.  Early  there 
is  marked  restlessness,  and  even  convulsions  may  occur.  Later  there  are 
apathy,  dulness,  and  semi-stupor.  The  temperature  during  the  first  twenty- 
four  hours  is  usually  not  elevated,  and  is  frequently  subnormal.  Toward 
the  close  of  the  disease  it  rises  rapidly  to  103°,  104°  F.,  or  even  higher, 
quite  independently  of  peritonitis.  A  rapidly  rising  temperature  is  always 
a  bad  symptom,  and  usually  betokens  death  within  twenty-four  hours. 
AVasting  is  seen  in  the  chronic  cases,  and  may  be  quite  rapid. 

Course,  Duration  and  Termination. — Of  198  cases  under  ten  years,  155 
were  classed  as  acute,  lasting  less  than  seven  days;  33  as  subacute,  last- 
ing from  one  to  four  weeks ;  10  were  chronic,  lasting  over  four  weeks. 
Nearly  all  the  cases  occurring  in  infancy  are  acute.  The  duration  of  the 
disease  in  92  fatal  cases  was  as  follows :  less  than  twenty-four  hours,  2 
cases ;  two  to  four  days,  44  cases ;  five  to  seven  days,  22  cases ;  one  to  tw^o 
weeks,  18  cases ;  two  to  three  weeks,  6  cases.  Thus  one  half  the  cases 
died  upon  the  third,  fourth,  or  fifth  day.  Of  57  cases  terminating  in 
recovery,  66  per  cent  were  reduced  in  the  first  or  second  da}'.  (See  table, 
page  386.) 

Spontaneous  reduction  is,  without  doubt,  possible  in  intussusception. 


INTUSSUSCEPTION.  385 

Treves  and  others  are  of  the  opinion  that  this  happens  much  more  fre- 
quently than  is  generally  supposed,  and  that  many  cases  of  severe  colic  are 
really  cases  of  slight  intussusception.  There  are  seen  in  both  conditions 
the  tendency  to  vomit,  the  paroxysmal  pain,  the  constitutional  depression, 
and  often  the  sudden  cessation  of  the  symptoms,  especially  under  the 
influence  of  opium ;  but  to  make  a  positive  diagnosis  of  invagination  in 
such  cases  is  impossible.  Intussusception  may  be  cured  spontaneously  by 
sloughing  of  the  invaginated  part,  the  continuity  of  the  intestine  being 
preserved  by  adhesions.  Such  a  result  is  rare  at  all  ages,  and  is  almost 
never  seen  in  infancy.  Even  though  recovery  from  the  attack  takes  place, 
complete  restoration  to  health  is  very  rare. 

The  most  frequent  cause  of  death  in  acute  cases  is  shock.  Peritonitis 
is  not  found  at  autopsy  or  operation  so  often  as  might  be  expected.  In 
58  autopsies,  it  was  seen  but  twenty  times,  and  in  seven  of  these  it  was 
limited  to  the  intussusception.  In  but  7  cases  was  there  perforation.  In 
chronic  cases  death  is  usually  from  exhaustion  or  complications. 

Diagnosis. — This  usually  presents  no  difficulty  in  acute  cases  provided 
the  physician  has  the  condition  in  mind.  The  great  majority  of  such 
cases  present  nearly  all  the  classical  symptoms — viz.,  sudden  onset,  re- 
curring colicky  pains,  frequent  vomiting,  bloody  and  mucous  stools 
without  fffical  matter,  general  prostration  or  collapse,  and  low  tempera- 
ture. The  records  show  that  the  most  common  error  is  to  regard  the  case 
for  the  first  few  days  as  one  of  gastro-enteritis  or  ileo-colitis,  the  physi- 
cian's attention  being  engrossed  by  the  vomiting  and  bloody  stools.  Given 
the  other  usual  symptoms,  the  presence  of  the  characteristic  tumour  is 
conclusive  evidence  of  intussusception.  Unless  the  patient  is  very  much 
relaxed,  a  satisfactory  examination  is  possible  only  under  full  anaesthesia. 
In  any  case  of  acute  obstruction  in  infants,  intussusception  should  first  be 
considered.  Chronic  cases  present  no  diagnostic  symptoms  except  the 
tumour.  In  both  acute  and  chronic  cases  the  rectal  examination  is  most 
important  for  diagnosis,  and  often  settles  the  question  at  once. 

Prognosis. — The  prognosis  of  intussusception  depends  upon  the  age  of 
the  patient,  upon  the  variety  of  the  disease — whether  acute,  subacute,  or 
chronic — and  upon  the  time  when  proper  treatment  is  begun. 

There  were  collected  by  Pilz*  in  1870,  94  cases  under  one  year,  the 
mortality  being  84  per  cent.  Of  135  cases  of  the  same  age  reported  be- 
tween 1870  and  1891  the  mortality  was  59  per  cent.  In  Pilz's  table,  of  51 
cases  between  one  and  ten  years  of  age,  the  mortality  was  G8  per  cent ; 
while  of  82  cases  between  one  and  ten  years  of  age,  from  1873  to  1891, 
the  mortality  was  but  46  per  cent.  Formerly  recovery  was  rare,  except 
in  cases  of  sloughing;  but  with  earlier  diagnosis  and  a  better  under- 
standing of  the  proper  methods  of  treatment,  the  mortality  has  been  very 

*  Jahrbuch  fur  Kinderh.,  Bd.  iii,  p.  6. 


386  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

much  reduced.     Combining  the  figures  of  Pilz  with  my  own,  there  are  362 
cases  with  231  deaths,  or  63  "5  per  cent. 

The  following  table  shows  the  duration  of  the  disease  in  57  cases 
that  were  reduced  either  by  injection  or  inflation,  or  which  recovered 
after  laparotomy  : 

The  Duration  of  Invagination  in  57  Acute  Cases  uhich  icere  reduced. 


Cured  on  1st  day  by  injection,  8 ;  inflation,  8 ;  laparotomy,  5 
"   2d        "  '  "  9;         "  6;  "  2 

"   3d        "  "  3;         "  0;  "  2 

"   4th       "  "  6;        "  5;  "  2 

"  5th       "  "         1;        "         0;  "  0 


total,  21  cases. 

"      17      " 

5      " 

"      13      " 

"        1  case. 


In  two  thirds  of  the  cases,  therefore,  reduction  was  eifected  on  the  first  or 
second  day.     After  this  time  the  chances  of  success  are  much  reduced. 

Treatment. — In  the  management  of  a  case  of  intussusception  almost 
the  same  rules  may  be  applied  as  in  strangulated  hernia — viz.,  first,  a  thor- 
ough attempt  at  reduction  by  mechanical  means,  with  the  assistance  of 
taxis,  and,  this  failing,  an  early  resort  to  laparotomy.  Only  two  methods 
of  mechanical  reduction  can  be  relied  upon,  inflation  and  injections. 

hiflation  should  always  be  done  under  an  anaesthetic,  unless  there  is  ex- 
treme relaxation.  The  position  is  not  of  great  importance ;  preferably 
the  child  should  lie  upon  the  back,  with  thighs  flexed.  From  time  to 
time  inversion  may  be  practised,  to  get  the  assistance  of  traction  of  the 
intestine  above  upon  the  seat  of  invagination.  An  ordinary  hand  bellows 
with  a  catheter  attached  is  the  best  apparatus  for  inflation.  It  should  be 
done  very  slowly,  and  the  air  prevented  from  escaping  by  pressing  the  but- 
tocks tightly  together.  It  is  well  to  continue  a  gentle  manipulation  ol  the 
tumour  through  the  abdominal  walls  during  inflation.  The  amount  of  air 
which  it  is  safe  to  inject  must  be  left  to  the  judgment  of  the  physician. 
The  best  guide  to  the  amount  which  has  been  introduced  is  the  tension 
of  the  abdominal  walls.  A  thorough  trial  of  this  method  should  occupy 
from  fifteen  to  thirty  minutes. 

Reduction  is  sometimes  indicated  by  rumbling  sounds,  and  by  the 
abdomen  resuming  its  normal  contour  because  the  whole  of  the  colon  is 
filled,  in  place  of  the  unequal  distention  before  present.  In  several  in- 
stances a  distinct  change  in  the  expression  of  the  features  has  been  noted. 
In  some  cases  a  gush  of  fluid  faeces  has  followed  disinvagination.  Not  in- 
frequently all  such  decisive  symptoms  are  absent,  and  the  physician  may 
be  in  doubt  whether  or  not  reduction  has  taken  place.  The  air  is  al- 
lowed to  escape,  best  by  introducing  the  catheter  high  into  the  colon,  so 
that  careful  palpation  of  the  abdomen  can  be  made  while  the  patient  is 
still  under  chloroform.  The  right  iliac  fossa  should  be  examined  with  the 
greatest  care,  as  it  often  happens  that  all  the  tumour  except  the  last  few 
inches  has  been  reduced,  this  being  impossible  because  of  swelling.     If  the 


INTUSSUSCEPTIOX.  387 

examination  is  negative,  the  question  of  reduction  must  be  decided  by  the 
general  symptoms.  If  vomiting  continues,  if  no  gas  or  faeces  pass  the 
bowels,  if  there  is  no  improvement  in  the  pulse  or  the  general  condition, 
and,  most  of  all,  if  the  temperature  rises,  it  is  certain  that  reduction  has 
not  been  effected,  and  a  second  attempt  should  be  made.  In  a  very  acute 
case  two  or  three  hours'  delay  is  all  that  should  be  permitted.  Inflation 
may  be  repeated  or  an  injection  of  water  tried,  but  in  either  case  consent 
to  immediate  laparotomy  should  be  obtained  if  this  effort  does  not  suc- 
ceed. In  cases  not  so  acute,  where  three  or  four  days  have  passed  without 
symptoms  indicating  strangulation,  it  is  admissible  to  make  further  at- 
tempts at  reduction  and  delay  laparotomy  a  little  longer. 

Injections  of  fluids. — The  patient  is  prepared  as  for  inflation  and  the 
abdomen  manipulated  during  tlie  injection.  Plain  water  may  be  used,  a 
saline  solution,  milk  and  water,  or  thin  gruel.  The  other  substances 
possess  some  advantages  over  plain  water  in  being  rather  less  irritating. 
The  temperature  should  be  from  100°  to  105°  F.  for  the  relaxing  effect. 
The  fluid  is  placed  in  a  fountain  syringe  suspended  four  or  five  feet  above 
the  patient's  bed.  The  injections  should  be  made  through  a  catheter,  the 
escape  of  the  fluid  being  prevented  as  in  inflation.  From  time  to  time 
the  flow  of  water  should  be  interrupted,  the  pressure  being  maintained 
continuously.  It  may  be  desirable  to  increase  the  pressure  by  raising  the 
syringe  to  the  height  of  six  or  eight  feet,  but  more  is  rarely  advisable. 
The  occurrence  of  reduction  during  injections  is  not  usually  quite  so  evi- 
dent as  during  inflation,  and  herein  consists  one  of  the  advantages  of  the 
latter  procedure.  After  from  ten  to  twenty  minutes  the  water  is  allowed 
to  escape,  and  the  abdomen  examined.  In  making  further  attempts  at 
reduction  by  injections  one  should  be  governed  by  the  same  considerations 
as  in  inflation. 

The  choice  between  inflation  and  injection  depends  somewhat  upon 
individual  experience.  My  own  preference  is  for  inflation,  mainly  for  the 
reasons  given  above,  that  it  is  easier  to  determine  whether  reduction  has 
taken  place  both  during  and  after  its  use.  The  danger  of  rupturing 
the  intestine  belongs  alike  to  both  ;  but  that  it  is  not  likely  to  occur 
in  either  is  conclusively  shown  by  the  fact  that  in  a  series  of  225  col- 
lected cases,  all  in  children,  and  including  nearly  all  those  reported 
between  18T0  and  1891,  this  accident  has  been  recorded  only  once.  In 
rare  cases  the  symptoms  may  continue  after  reduction.  Pick  records 
a  case  in  which  laparotomy  was  done  subsequently  to  inflation,  with 
the  belief  that  reduction  had  not  been  effected.  Xo  intussusception 
was  found,  and  the  continuance  of  the  symptoms  was  attributed  to 
paralysis. 

The  treatment  after  reduction  consists  in  keeping  the  patient  abso- 
lutely quiet  and  moderately  under  the  influence  of  opium  for  two  or  three 
days,  to  allay  the  excessive  irritability  of  the  intestinal  walls.     The  diet 


388  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

should  be  very  light.  Cathartics  especially  should  be  avoided  for  several 
days. 

Eecurreuce  of  the  invagination  is  not  uncommon.  It  was  noted  in 
13,  or  about  six  per  cent,  of  my  collected  cases  under  ten  years ;  of 
this  number  nine  recovered  and  four  died.  Eecurrence  is  more  likely  to 
happen  in  the  first  twenty-four  hours  after  reduction  ;  this  was  the  time 
in  nine  of  the  thirteen  cases.  It  may,  however,  be  as  late  as  a  month, 
rarely  later.  In  one  half  the  cases  there  was  but  a  single  recurrence,  but 
three,  four,  and  even  six  recurrences  in  the  course  of  a  few  weeks  have 
been  seen.  Ludwig  reports  a  case  in  an  infant  eight  months  old  in  whom 
twenty-two  recurrences  were  seen  in  one  month.  This  was  of  the  colic 
variety ;  it  could  hardly  happen  in  any  other  form. 

Laparotomy  is  indicated  as  soon  as  a  thorough  trial  of  reduction  by 
inflation  or  injection  has  been  made  without  success.  In  the  very  acute 
cases  the  operation  should  not  be  delayed  an  hour  after  such  failure  is  evi- 
dent. Needless  delays  have  caused  death  in  many  instances.  The  opera- 
tion should  not  be  looked  upon  as  a  last  resort  in  hopeless  cases,  but  as  a 
measure  which,  if  employed  reasonably  early,  offers  a  fair  prospect  of  suc- 
cess where  disinvagination  can  not  be  accomplished  by  any  other  means. 
I  have  collected  72  cases  in  which  the  abdomen  has  been  opened  for  the 
relief  of  intussusception  in  children.  In  35  of  these  the  operation  was 
done  at  so  late  a  period  that  reduction  of  the  invagination  was  impos- 
sible owing  to  swelling,  adhesions,  gangrene,  or  other  causes.  In  every 
instance  the  child  died.  In  the  37  cases  in  which  reduction  was  ef- 
fected at  the  operation,  14,  or  thirty-eight  per  cent,  recovered.  More 
than  half  the  cases  were  under  one  year,  and  all  but  three  were  under 
two  years,  showing  that  early  infancy  is  no  barrier  to  the  operation.  In 
over  one  third  of  the  cases  the  operation  was  done  in  the  first  twenty- 
four  hours,  and  in  half  of  them  on  the  first  or  second  day.  The  time  of 
operation  has  therefore  more  to  do  with  the  result  than  any  other  factor. 
Of  16  operations  in  the  first  and  second  days  there  were  7  recoveries,  or 
forty-four  per  cent.  Of  44  operations  on  or  after  the  third  day  there  were 
7  recoveries,  or  sixteen  per  cent,  and  two  of  these  were  chronic  cases. 

Summary. — Cathartics  are  absolutely  contra-indicated  in  all  circum- 
stances. Opium  is  to  be  administered  as  soon  as  the  diagnosis  is  made, 
for  the  relief  of  pain  and  to  prevent  the  increase  of  the  intussusception, 
also  in  all  cases  after  reduction  by  mechanical  means  or  operation.  Infla- 
tion and  injection  are  to  be  tried  successively,  preferably  under  an  anaes- 
thetic, combined  with  manipulation  of  the  abdomen,  sometimes  with  in- 
version of  the  patient.  Not  more  than  two  trials  should  be  made  in  acute 
cases.  The  abdomen  should  then  be  opened  without  an  hour's  unnecessary 
delay. 


APPENDICITIS.  389 


CHAPTER   X. 
DISEASES  OF  THE  INTESTINES.— {Continued.) 

APPENDICITIS. 

The  terms  typhlitis,  perityphlitis,  and  perityjMitic  abscess  were  for- 
merly much  use<l  to  denote  certain  forms  of  inflammation  occurring  in 
the  riglit  iliac  fossa.  Of  late  these  terms  are  but  little  employed,  as  it 
has  been  shown  that  these  conditions  are  almost  invariably  due  to  disease 
of  the  vermiform  appendix.  The  existence  of  typhlitis  as  a  separate  and 
independent  disease  is  exceedingly  rare,  if  indeed  it  ever  occurs  except  as 
a  result  of  faecal  impaction. 

Inflammation  of  the  appendix  may  be  catarrhal,  ulcerative,  or  perfora- 
tive, and  it  may  be  acute,  chronic,  or  recurrent. 

Etiology. — The  predominance  of  the  male  sex  holds  even  in  childhood. 
Of  101  collected  cases  under  fifteen  years,  72  were  males  and  29  females. 
This  difference  has  never  been  satisfactorily  explained.  Appendicitis  is 
exceedingly  rare  before  the  fourth  year,  but  from  this  time  it  is  of  quite 
frequent  occurrence  throughout  childhood,  especially  after  the  tenth  year. 
Of  104  cases,  3  were  under  three  years,  47  between  the  fourth  and  ninth 
years,  and  54  between  the  tenth  and  fourteenth  years.  The  youngest 
recorded  case  is  in  a  child  of  seven  wrecks,  reported  by  Demme.  The 
exciting  cause  is  nearly  always  a  foreign  substance  ;  this  is  usually  a  faecal 
concretion,  which  is  moulded  by  the  appendix  into  the  form  of  a  date- 
stone,  and  often  regarded  as  such.  Small  seeds,  however,  may  form  the 
nucleus  of  a  faecal  concretion,  or  less  frequently  they  may  be  the  only 
foreign  body.  In  one  of  my  own  cases  a  pin  was  found  in  the  appendix, 
and  I  have  found  references  to  two  similar  cases.  Given  the  presence 
of  a  foreign  substance,  it  is  easy  to  see  how  inflammation  may  some- 
times be  excited  by  a  blow,  fall,  strain,  or  other  slight  accident.  Chronic 
constipation  is  a  factor  of  considerable  importance.  The  micro-organism 
usually  found  in  abscesses  due  to  appendicitis  is  the  bacterium  coli  com- 
mune, sometimes  associated  with  other  pyogenic  germs,  but  very  often  in 
pure  culture. 

Lesions. — The  position  of  the  appendix  is  extremely  variable.  It  may 
be  found  in  the  pelvis,  in  the  region  of  the  kidney,  and  sometimes  near 
the  umbilicus.  Tliis  anatomical  peculiarity  accounts  for  the  variation 
seen  in  the  situation  of  abscesses  due  to  appendicitis.  According  to 
Treves,  the  appendix  is  covered  by  peritona?um  at  every  jioint. 

Catarrhal  appendicitis. — In  this  form  there  is  thickening  of  the  walls 
of  the  appendix  from  infiltration  of  its  coats  with  cells.    Its  communication 


390 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


with  the  ca3cum  is  temporarily  or  permanently  shut  off.  The  appendix 
is  distended  with  mucus,  pus,  and  usually  some  foreign  substance,  so 
that  it  may  be  as  large  as  the  thumb,  or  even  larger.  There  is  congestion 
of  the  j^eritoneal  surface.  This  inflammation  may  subside  without  any 
serious  consequence,  or  it  may  result  in  ulceration  and  perforation.  These 
may  follow  the  first  attack,  but  more  frequently  not  until  several  attacks 
have  occurred. 

Ulcerative  or  perforative  appendicitis. — Ulceration  of  the  appendix 
may  be  found  in  cases  of  typhoid  fever  and  in  tuberculosis.  In  severe 
tuberculosis  of  the  intestine  I  have  nearly  always  found  ulcers  here. 
These  ulcers  rarely  perforate,  and  as  a  rule  they  give  rise  to  no  clinical 
symptoms. 

The  important  form  of  ulceration  is  that  due  to  an  inflammation  ex- 
cited by  a  foreign  body,  and  this  variety  is  apt  to  perforate.  The  inflam- 
mation may  result  in  the  gradual  production  of  a  small  perforation  by  a 
process  of  ulceration,  or  the  appendix  may  be  distended  by  inflamma- 
tory products,  and  gangrene  take  place  with  the  sudden  production  of 
a  large  opening.  The  nature  of  the  perforation  varies  with  the  inten- 
sity of  the  preceding  inflammation.  The  consequences  will  depend  upon 
whether  this  occurs  slowly  or  suddenly,  and  whether  or  not  the  ap- 
pendix is  in  such  a  situation  that  adhesions  readily  form.  If  ulceration 
takes  place  slowly,  lymph  is  usually  thrown  out  about  the  appendix, 
effectually  protecting  the  general  peritoneal  cavity.  If  perforation  occurs 
suddenly,  the  first  effect  is  usually  an  intense  congestion  of  the  whole 
peritonaeum,  and  there  may  even  be  beginning  inflammation.  If  the 
situation  of  the  appendix  is  favourable  for  the  production  of  adhesions, 
the  inflammation  in  a  very  short  time  is  limited  by  the  plastic  exuda- 
tion, and  remains  as  a  local  peritonitis.  If  perforation  in  either  of  these 
varieties  has  carried  infectious  materials  into  the  peritoneal  cavity,  there 
usually  results  a  peritoneal  abscess.  If  not,  there  is  simply  a  localized 
plastic  peritonitis  with  adhesions.  I  have  said  that  these  abscesses  are 
in  the  peritoneal  cavity.  This  is  the  view  which  is  now  almost  uni- 
formly adopted,  although  it  was  formerly  held  that  the  abscesses  were 
extra-peritoneal,  being  situated  in  the  cellular  tissue  about  the  cscum 
(perityphlitic  abscess).  The  situation  of  the  abscess  will  depend  upon 
the  location  of  the  appendix.  It  is  usually  in  the  iliac  fossa,  but  may  be 
in  the  lumbar  region  or  in  the  pelvis.  When  left  to  itself  it  may  open 
externally,  or  into  any  of  the  neighbouring  viscera,  usually  the  rectum ; 
or  it  may  rupture  into  the  general  peritoneal  cavity,  setting  up  a  diffuse 
peritonitis.  Karely,  a  large  abscess  may  excite  general  peritonitis  without 
rupture.  If  the  appendix  is  so  situated  that  adhesions  can  not  readily 
form  about  it,  or  if  these  fail  or  are  incomplete,  sudden  perforation  of 
the  appendix  excites  general  peritonitis,  usually  of  a  septic  variety,  which 
runs  a  rapid  and  intense  course.     Among  the  secondary  lesions  which 


APPENDICITIS.  391 

have  been  met  with  in  children,  are  suppurative  pylephlebitis,  abscesses  of 
the  liver,  general  pyaemia,  empyema,  and  pneumonia. 

Symptoms. —  Catarrhal  appendicitis  in  many  cases  is  not  diagnosticated. 
Often,  a  positive  diagnosis  is  impossible.  The  symptoms  by  which  it  is 
recognised  are  local  pain,  tenderness,  and  fever ;  there  may  also  be  vomit- 
ing and  constipation.  Both  pain  and  tenderness  are  moderate,  but  per- 
sist for  several  days.  The  tenderness  is  generally  at  McBurney's  point. 
The  elevation  of  temperature  is  usually  slight,  100°  to  101°  F.  These 
symptoms  are  often  so  mild  that  the  child  makes  but  few  complaints,  and 
is  usually  up  and  about.  Very  frequently  they  are  passed  over  by  young 
patients  without  any  notice  whatever,  and  recovery  may  take  place  with- 
out any  diagnosis  having  been  made.  How  frequently  such  cases  occur 
we  have  no  means  of  knowing  positively,  but  they  are  undoubtedly  much 
more  common  than  was  formerly  believed. 

Perforative  appendicitis  usually  follows  after  several  days  the  some- 
what indefinite  symptoms  of  the  catarrhal  form,  the  patient  perhaps  having 
been  hardly  sick  enough  to  go  to  bed.  In  rare  cases  the  first  symptoms 
may  be  those  of  perforation.  These  are  usually  severe  and  characteristic. 
There  is  sudden  and  intense  pain  in  the  right  iliac  fossa,  accompanied  by 
vomiting.  The  pain  is  acute,  lancinating,  and  continuous ;  the  vomiting 
is  repeated,  sometimes  being  persistent ;  it  is  first  of  the  contents  of  the 
stomach  and  then  bilious.  Occasionally  there  is  a  chill.  There  is  alwavs 
much  prostration,  and  the  child  from  the  outset  has  the  appearance  of 
being  very  seriously  ill.  With  such  an  onset  the  disease  may  follow  one 
of  three  courses,  according  as  the  perforation  is  followed  by  localized 
plastic  peritonitis,  localized  suppurative  peritonitis,  or  general  peritonitis. 

1.  With  localized  plastic  peritonitis. — The  symptoms  in  these  cases  usu- 
ally last  about  a  week.  They  are  severe  only  for  the  first  two  or  three 
days,  and  then  gradually  pass  away.  At  the  onset  there  are  severe  pain 
and  tenderness,  usually  localized  in  the  region  of  the  appendix.  There  are 
vomiting,  constipation,  and  slight  fever,  the  temperature  being  from  100° 
to  102°  F.  The  temperature  gradually  falls  to  normal ;  the  tenderness 
becomes  less  acute ;  and  the  somewhat  diffuse  infiltration  in  the  iliac  fossa, 
which  was  at  first  present,  gradually  lessens  in  area,  until  there  is  only  a 
nodular  tumour  about  the  size  of  a  hen's  egg.  This  may  be  slow  in  dis- 
appearing, often  lasting  for  weeks,  and  sometimes  for  months.  These 
patients  are  always  liable  to  recurrent  attacks. 

2.  With  localized  suppurative  peritonitis. —  In  some  of  the  cases  with 
early  symptoms  like  those  above  mentioned  there  is  a  continuance  of  the 
fever,  pain,  and  tenderness,  with  the  rapid  formation  of  an  abscess.  A 
distinct  tumour  may  be  noticed  in  the  course  of  two  or  three  days,  and 
pus  may  be  found  by  aspiration  or  exploratory  incision  as  soon  as  the  third 
or  fourth  day  from  the  onset.  At  other  times  the  early  stage  is  like  that 
of  the  cases  which  terminate  in  resolution,  and  marked  improvement  takes 


392  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

place  after  two  or  three  days  of  severe  symptoms.  The  temperature  does 
not,  however,  quite  reach  the  normal.  After  a  variable  period  of  quietude, 
lasting  from  two  or  three  days  to  as  many  weeks,  the  temperature  gradu- 
ally rises ;  the  pain  and  tenderness  become  more  severe  and  are  felt  over 
a  larger  area ;  the  induration,  which  has  been  stationary,  enlarges  and  be- 
comes more  prominent,  and  the  existence  of  abscess  is  unmistakable.  In 
a  small  number  of  the  cases  terminating  in  abscess  the  onset  is  very  grad- 
ual, without  any  of  the  acute  symptoms  mentioned.  It  may  be  accompa- 
nied by  slight  pain  only,  retraction  of  the  right  thigh,  and  moderate  fever. 
Whether  the  formation  of  the  abscess  is  rapid  or  slow,  the  subsequent 
course  may  be  the  same.  The  sac  is  gradually  distended  with  pus,  which 
may  accumulate  in  immense  quantities  ;  as  much  as  five  pints  have  been 
evacuated.  At  the  present  time  but  few  abscesses  are  allowed  to  open  ex- 
ternally, incision  being  commonly  made  before  that  time.  Large  abscesses 
in  the  lumbar  region  or  in  the  pelvis,  may  be  mistaken  for  some  other 
disease,  or  may  be  overlooked.  Pelvic  abscess  may  be  easily  recognised 
by  rectal  examination.  The  termination  in  a  single  abscess  is  a  favourable 
one,  for  with  proper  surgical  treatment  these  cases  almost  invariably 
recover. 

3.  With  general  peritonitis. — In  these  cases  the  early  symptoms  of  pain, 
tenderness,  vomiting,  and  fever  are  followed  by  those  of  general  peritoni- 
tis. The  vomiting  continues  ;  the  tenderness  and  pain  are  rapidly  dif- 
fused over  the  abdomen  ;  there  are  constipation,  tympanites,  and  very 
great  prostration.  The  temperature  is  variable,  and  its  height  is  no  guide 
to  the  severity  of  the  attack  ;  it  usually  ranges  from  101°  to  102-5°  F.,  but 
may  be  normal  or  even  subnormal.  The  general  prostration  is  very  great ; 
the  pulse  is  rapid  and  feeble ;  and  in  the  worst  cases  there  are  cold  perspira- 
tion, hiccough,  stercoraceous  vomiting,  collapse,  and  death.  The  duration 
of  these  cases  may  be  but  two  or  three  days,  but  it  is  oftener  from  five 
to  seven.  The  symptoms  usually  go  on  steadily  from  bad  to  worse. 
Sometimes,  after  the  first  intense  onset,  there  may  be  a  lull  in  the  acute 
symptoms  for  a  day  or  two,  to  be  followed  by  a  recurrence  of  the  ago- 
nizing pain,  vomiting,  and  collapse.  Such  symptoms  indicate  that  the 
first  perforation  was  followed  by  some  limiting  adhesions,  which  subse- 
quently gave  way,  causing  all  the  symptoms  of  a  new  perforation.  The 
symptoms  of  perforative  peritonitis  may  come  on  late  in  the  disease,  when 
it  is  due  to  the  rupture  of  an  abscess  into  the  peritoneal  cavity.  In  a 
small  number  of  cases  the  early  symptoms  of  perforation  are  slight,  or  en- 
tirely wanting,  the  patient  passing  gradually  into  a  state  of  great  prostra- 
tion and  profound  sepsis,  with  the  symptoms  of  general  peritonitis.  In  a 
few  cases  general  peritonitis  complicates  large  abscesses  without  rupture. 
This  termination  is  the  most  serious  one,  and  is  what  occurs  in  nearly 
all  the  fatal  cases. 

The  frequency  of  the  different  varieties. — Of  98   cases   in   children 


APPENDICITIS.  393 

under  fourteen  years  in  which  the  exact  variety  was  known,  10  termi- 
nated in  resolution,  50  in  abscess,  and  38  in  general  peritonitis.  These 
figures  certainly  do  not  represent  the  actual  proportion  terminating  in 
resolution,  for  such  cases  are  much  more  likely  to  be  overlooked,  or,  if 
diagnosticated,  they  are  not  so  commonly  reported.  Of  the  cases  termi- 
nating in  abscess,  all  but  six  were  operated  upon ;  four  of  these  opened 
into  the  rectum  with  a  favourable  result,  one  was  allowed  to  open  exter- 
nally, and  one  caused  death  by  rupture  into  the  peritonaeum.  From 
these  statistics  it  would  appear  that  general  peritonitis  is  of  more  frequent 
occurrence  in  children  than  in  adults. 

Prognosis. — Of  113  cases,  there  were  63  recoveries  and  50  deaths — a 
mortality  of  45  per  cent.  General  peritonitis  was  the  cause  of  death  in 
eighty  per  cent,  pyaemia  in  eight  per  cent,  all  of  them  being  protracted 
cases.  The  statement  has  been  made  (Matterstock,  in  Gerhardt's  Hand- 
buch)  that  the  majority  of  cases  of  peritonitis  in  children  terminate  fatally 
within  the  first  three  days.  This  is  not  borne  out  by  my  statistics.  Of  43 
fatal  cases,  nearly  all  of  them  from  general  peritonitis,  only  6  died  during 
the  first  three  days,  19  from  the  fourth  to  the  seventh  day,  13  in  the  second 
week,  and  5  in  the  third  week.  Recurrent  attacks  do  not  appear  to  be 
quite  so  common  in  children  as  in  adults.  They  were  noted  in  but  two 
cases  of  this  series. 

Cases  terminating  in  the  formation  of  a  single  abscess  usually  recover 
when  properly  treated.  If  general  peritonitis  occurs,  whether  early  or 
late,  the  chances  of  recovery  are  small.  In  three  cases  recovery  took 
place  where  general  peritonitis  was  stated  to  be  present  at  the  time  of 
operation. 

Diagnosis. — The  diagnostic  symptoms  of  appendicitis  are  a  sudden 
severe  pain  in  the  right  iliac  fossa  with  localized  tenderness  and  vomiting. 
Persistence  of  such  tenderness  is  especially  significant,  as  is  also  an  un- 
natural resistance  of  the  abdominal  walls.  Constipation  is  much  more 
frequent  than  diarrhoea.  There  is  usually  some  elevation  of  temperature, 
but  rarely  high  fever.  The  catarrhal  and  perforative  forms  can  not  always 
be  distinguished  from  each  other.  In  some  of  the  catarrhal  cases  the  onset 
may  be  sudden  and  severe,  while,  on  the  other  hand,  perforation  may  take 
place  without  any  of  its  characteristic  symptoms.  The  exploring  needle, 
it  is  now  generally  agreed,  should  be  used  only  when  a  tumour  is  present. 

Appendicitis  may  be  confounded  with  colic,  indigestion,  and,  in  infants, 
with  intussusception  ;  in  older  children,  with  abscesses  due  to  psoitis. 
Colic  is  distinguished  by  the  absence  of  localized  tenderness  and  fever,  by 
its  short  duration,  and  by  the  fact  that  the  pain  is  generally  less  intense. 
Severe  colic  in  older  children  should,  however,  always  be  regarded  Avith 
suspicion.  From  acute  indigestion  the  diagnosis  is  often  difficult  at  the 
onset,  and  it  may  be  impossible  for  twenty-four  hours.  Very  many  of  the 
cases  of  appendicitis  have  been  regarded  in  the  beginning  as  attacks  of 


394  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

indigestion.  Here,  however,  the  pain  is  rarely  so  severe,  but  in  children 
the  fever  is  higher.  The  pain  is  not  usually  localized  ;  and,  if  so,  it  is  more 
apt  to  be  in  the  epigastrium  or  at  the  umbilicus.  But  it  should  be  remem- 
bered that  the  pain  is  not  always  localized  in  appendicitis.  The  presence 
of  pain,  vomiting,  and  localized  tenderness,  and  the  greater  severity  of 
the  constitutional  symptoms,  indicate  appendicitis.  Indigestion  is  more 
likely  to  be  accompanied  by  diarrhoea  than  by  constipation,  while  the 
opposite  is  true  of  appendicitis. 

I  have  twice  known  2:)neumonia  at  the  right  base  to  be  mistaken  for 
appendicitis.  There  was  severe  localized  pain  in  the  iliac  fossa,  which 
was  evidently  to  be  explained  by  pleurisy  implicating  the  lower  intercostal 
nerves. 

Intussusception,  from  its  intense  pain,  colic,  and  vomiting,  may  sug- 
gest appendicitis,  but  it  is  very  rare  except  in  infants.  Tenesmus  and 
bloody  stools  are  very  constant ;  the  temperature  is  not  elevated  in  the  be- 
ginning ;  if  a  tumour  is  present  it  is  usually  in  the  left  side  of  the  abdomen. 

Between  the  various  forms  of  local  suppuration  in  the  right  iliac  fossa 
and  appendicitis  the  diagnosis  is  rarely  difficult.  It  should  always  be 
borne  in  mind  that  acute  or  subacute  suppuration  in  this  region  is  usually 
due  to  appendicitis.  Abscesses,  however,  should  not  be  confounded  with 
those  due  to  Pott's  disease,  or  with  a  psoitis,  which  is,  however,  generally 
traumatic  and  accompanied  by  deformity  due  to  the  retraction  of  the 
thigh,  which  may  be  so  severe  as  to  lead  to  the  diagnosis  of  hip  disease. 
The  constitutional  symptoms  of  appendicitis  are  wanting. 

Treatment. — Absolute  rest  in  bed  should  be  insisted  upon  in  every 
case,  no  matter  how  mild  it  may  appear,  and  all  patients  should  be  closely 
watched.  As  a  local  application  the  ice-bag  is  to  be  preferred,  unless 
strongly  objected  to  by  children,  when  hot  fomentations  should  be  sub- 
stituted. Morphine  should  be  given  in  sufficient  quantities  to  relieve 
pain,  but  the  effect  should  not  be  carried  further  than  this.  An  unneces- 
sary use  of  opium  is  objectionable,  as  obscuring  important  symptoms.  The 
colon  should  be  kept  empty  by  the  daily  use  of  large  enemata.  All  ca- 
thartics are  to  be  avoided.  Blisters,  though  formerly  so  much  in  vogue 
for  the  purpose  of  promoting  resolution,  with  the  better  understanding  of 
the  nature  of  the  disease,  are  now  very  seldom  employed. 

Appendicitis  is  in  the  great  majority  of  cases  a  surgical  disease,  and 
surgical  advice  should  be  sought  early.  It  is  undoubtedly  true  that  in  the 
past  many  lives  have  been  needlessly  sacrificed  because  surgical  interfer- 
ence was  too  late  resorted  to.  Oi^eration  is  clearly  indicated  in  two  con- 
ditions :  first,  as  soon  as  there  is  positive  evidence  of  the  existence  of  ab- 
scess ;  secondly,  when  the  symptoms  point  to  perforation  into  the  general 
peritoneal  cavity.  In  such  cases  immediate  operation  should  be  done, 
as  offering  the  only  chance  of  recovery.  Regarding  other  cases  surgi- 
cal opinion  is  at  the  present  time  divided.     One  group  of  surgeons  advise 


INTESTINAL  WORMS.  395 

exploratory  incision  in  every  case  as  soon  as  the  symptoms  are  definite 
enough  to  indicate  the  existence  of  appendicitis,  wliether  catarrhal  or  ul- 
cerative, with  the  hope  of  anticipating  sudden  perforation  with  its  result- 
ing dangers.  There  is  no  doubt  that  by  these  surgeons  a  good  many  eases 
will  be  operated  upon  whicli  might  terminate  in  resolution.  But  it  is 
claimed  first,  that  the  dangers  of  the  operation  per  se  are  at  the  present 
time  very  slight,  while  in  cases  which  resolve  the  danger  of  subsequent  at- 
tacks is  always  present ;  and  secondly,  that  we  have  no  means  of  knowing 
which  of  these  cases  may  suddenly  develop  symptoms  of  perforative  peri- 
tonitis. The  other  group  of  surgeons  advocate  deferring  operation  until 
there  is  evidence  of  the  formation  of  pus,  except  when  symptoms  point  to 
perforation  into  the  general  peritoneal  cavity.  It  must  remain  for  future 
experience  to  decide  which  of  these  two  plans  will  receive  the  general 
sanction  of  the  profession,  liegarding  recurrent  attacks  of  appendicitis 
opinion  is  also  divided.  For  the  details  of  the  surgical  management  the 
reader  is  referred  to  surgical  works. 


INTESTINAL  WORMS. 

Judging  by  published  reports,  intestinal  worms  are  much  more  com- 
mon in  Europe  than  in  this  country.  In  10,000  patients  treated  for  med- 
ical diseases  in  my  dis23ensary  service,  there  Avas  positive  evidence  of 
worms  in  but  79  cases.  Of  these,  9  had  tapeworms,  40  roundworms,  27 
threadworms,  and  3  both  round  and  threadworms.  In  private  practice 
among  the  better  classes,  worms  are  certainly  rare.  I  have  not  seen  more 
than  a  dozen  cases  in  ten  years. 

Cestodes — Tapeworms. — Cestodes  are  usually  introduced  into  the 
body  by  the  ingestion  of  some  form  of  food  containing  larvae  (cysticerci). 
The  larva  of  the  tcenia  solium  is  most  frequently  found  in  pork ;  that  of 
the  tmnia  mediocanellata  in  beef ;  that  of  the  hothriocephalus  latus  in 
fish ;  that  of  the  tcenia  cucumerina  inhabits  dog  or  cat  lice,  being  intro- 
duced into  the  intestinal  tract  accidentally  by  the  hands. 

In  the  intestine  the  larva?  develop  into  the  mature  tapeworms,  usually 
in  from  three  to  three  and  a  half  months ;  after  which  the  terminal  seg- 
ments becoming  mature,  separate,  and  are  discharged  in  the  faeces,  some- 
times singly,  sometimes  connected.  New  segments  continually  form  next 
to  the  head  as  the  terminal  ones  are  cast  olf,  so  that  the  length  of  the 
worm  is  not  diminished.  The  duration  of  life  of  the  worm  is  estimated 
to  be  from  ten  to  .thirty  years.  Each  mature  segment  is  provided  with 
both  male  and  female  sexual  organs,  and  contains  ova  in  great  numbers. 
The  ova  escape  after  the  rupture  of  the  segment  outside  the  body.  They 
find  their  way  into  the  stomach  usually  of  herbivorous  animals  with  their 
food.  Here  the  thick  shells  of  the  ova  are  dissolved  by  the  gastric  juice 
and  the  embr3'o  set  free.     By  means  of  the  booklets  with  which  it  is  pro- 


396 


DISEASES   OP   THE   DIGESTIVE  SYSTEM. 


vided,  it  migrates  from  the  stomach  or  intestine  and  may  be  found  in  the 
muscles  or  in  any  organ  of  the  body,  even  the  brain  and  eye.  When  it 
readies  its  final  resting  place  it  loses  its  hooks  and  gradually  becomes 
transformed  into  a  vesicle,  from  the  inner  surface  of  which  there  projects 
something  resembling  the  head  of  the  future  tapeworm.  In  this  stage  it 
is  known  as  the  bladder  worm  or  cysticercus.  The  cysticerci  of  the  tcenia 
solium  are  sometimes  found  in  man,  but  the  other  varieties  very  rarely. 
For  the  further  development  of  the  larval  form  it  miTst  be  taken  into  the 
stomach  of  man  or  some  carnivorous  animal.  This  occurs  when  pork, 
beef,  or  fish  containing  cysticerci  is  eaten.  The  vesicle  Avail  is  now  dis- 
solved, and  the  head  passing  into  the  intestine  develops  into  the  mature 
tapeworm.     Several  varieties  of  tfenia  are  found  in  the  human  intestine  : 

Taenia  Saginata  or  Mediocanellata— Beef  Tapeworm  (Fig.  63).  This 
is  the  most  frequent  form  found  in  children,  all  others  being  rare.  In- 
fection results  from  eating  raw  or  partially  cooked  beef  containing  cys- 
ticerci. The  worm  is  from  twelve  to  twenty  feet  in  length,  and  has  a 
square  pigmented  head  without  hooks  but  provided  with  four  suckers. 
The  full-sized  segments  are  from  one  half  to  three  fourths  of  an  inch 
long  and  about  half  as  wide. 

Taenia  Solium — Pork  Tapeworm  (Fig.  64).  This  is  a  rare  form  in 
children,  and  comes  from  eating  raw  or  partially  cooked  pork  or  sausage. 
It  is  from  six  to  ten  feet  in  length,  the  segments  being  nearly  square. 


.   *i  ^i 


i 

Fig    0    — Iciiii.i  ~.a/mata,  head,  segment, 
and  egg.     (Jak&ch.) 


.uiijfe .  ^-f-  jT. r.^1 


Fig.  64. — Tfenia  solium  ;  head,  segment, 
and  egg.     (Jakseh.) 


The  head  is  about  the  size  of  a  mustard  seed  and  is  pigmented.  It  also  is 
provided  with  four  suckers  and  a  proboscis,  surrounding  which  is  a  circle 
of  about  twenty-six  hooks. 

Taenia  Cucnmerina  or  Elliptica  (Fig.  6.5).  The  larvfe  of  this  form 
develop  in  a  louse  found  on  the  skin  of  dogs  and  cats.  Children  who 
play  with  infected  animals  are  the  ones  affected,  the  parasite  being  con- 
veyed to  the  mouth  usually  by  means  of  the  hands;  it  may  thus  be 
found  even  in  young  infants.  JMost  of  the  tapeworms  in  infants  are  of 
this  variety.  This- form  of  taenia  is  much  smaller  than  either  of  the  pre- 
ceding varieties,  the  full  length  being  only  from  six  to  twelve  inches. 


INTESTINAL  WORMS. 


397 


Bothriocephalus  Latus  (Fig.  66).     This  is  a  rare  form  except  in  the 

sea  countries  of  northern  Europe  and  Switzerland,  where  it  is  said  to  be 


Fig.  65. — Head  and  segment  of  tania 
cucumerina.     (Jaksch.) 


Fig.  66. — Bothrioc«phalus  latus;  a,  J,  front 
and  side  views  of  head;  c,  segments; 
d,  eggs.     (Jakseh.) 


very  common.  The  larvae  are  harboured  by  certain  fish,  through  which 
they  are  introduced  into  the  body.  The  full-grown  worm  is  from  twenty- 
five  to  thirty  feet  in  length. 

Taenia  Nana  and  Taenia  Flava  Punctata.  These  are  two  rare  varieties 
that  have  been  found  in  children  in  a  few  instances. 

Usually  but  a  single  worm  is  present,  although  as  many  as  five  or  six 
have  been  found.  Earely  taeniae  have  been  associated  with  round  and  also 
with  threadworms. 

Symptoms. — The  only  positive  evidence  of  tapeworm  is  the  discharge 
of  tlie  separated  segments,  either  singly  or  in  groups.  Occasionally  worms 
pass  into  the  stomach  and  are  vomited.  Various  abdominal  symptoms 
may  be  associated  with  worms,  but  most  of  these  are  very  indefinite  in 
character  and  are  more  often  due  to  other  causes.  The  most  frequent 
symptoms  are  bad  breath,  various  annoying  sensations,  colicky  attacks,  in- 
ordinate or  capricions  appetite,  and  diarrha?a.  Usually,  if  the  jiatient  is 
in  good  health,  no  constitutional  symptoms  are  seen.  Sometimes,  particu- 
larly with  the  bothriocephalus  latus,  there  is  a  very  grave  degree  of  anemia. 
Many  cases  are  now  on  record,  some  of  them  in  children,  in  which  the 
symptoms  of  pernicious  anaemia  have  been  present  and  have  disappeared 
after  the  expulsion  of  the  tapeworm.  Nervous  symptoms  are  not  so  often 
seen  as  with  roundworms,  and  will  be  discussed  in  connection  with  them. 

Treatment. — Prophylaxis  requires  the  cooking  of  meat  to  a  sufticient 
degree  to  destroy  the  cysticerci.  There  is  especial  danger  in  eating  raw- 
pork  or  sausage;  that  from  rare  beef  is  much  less.  The  list  of  drugs 
used  for  the  expulsion  of  the  worm  is  a  long  one;  probably  the  most  sat- 
isfactory is  the  oleorcsin  of  male  fern,  which  should  be  given  in  capsule, 
in  TT[xv  doses  to  a  child  of  ten  years,  four  capsules  usually  being  adminis- 
tered at  hourly  intervals.  The  vermifuge  should  be  preceded  by  several 
hours'  fasting,  and  the  bowels  should  be  previously  opened  by  a  laxative. 


398 


DISEASES  OP   THE   DIGESTIVE   SYSTEM. 


The  following  plan  of  administration  has  been  found  satisfactory  :  A  light 
supper  of  milk,  and  in  the  morning  a  saline  laxative  on  rising,  but  no 
breakfast ;  after  the  saline  has  acted  freely  the  capsules  are  to  be  given, 
and  following  the  last  one,  half  an  ounce  of  castor  oil  or  some  other  active 
purge.  Only  milk  should  be  given  that  da}'.  The  fragments  passed 
should  be  carefully  examined  to  see  if  the  head  has  been  expelled,  as 
the  worm  is  very  likely  to  be  broken  at  the  neck.  If  this  occurs  it  will 
grow  again,  and  in  about  three  months  segments  will  appear  in  the  stools. 
Other  drugs  useful  for  tsenia  are  infusion  of  pomegranate  root,  turpentine, 
and  chloroform. 

Nematodes. — Two  varieties  are  found  in  the  intestinal  canal,  the  as- 
caris  lumhricoides  and  the  oxyuris  vermicnlaris. 

Ascaris  Lumbricoides — Roundworm. — This  worm  occupies  the  small 
intestine.  It  is  much  more  frequently  met  with  in  children  than  the  tape- 
worm. It  is  exceedingly  rare  in  infancy,  but 
is  usually  seen  between  the  third  and  tenth 
year.  In  over  one  thousand  autojDsies  upon 
infants  I  have  only  once  found  a  roundworm 
in  the  intestine. 

The  roundworm  is  from  five  to  ten  inches 
long,  the  female  being  longer  than  the  male. 
It  is  of  a  light  gray  colour  with  a  slightly 
pinkish  tint,  cylindrical,  and  tajDering  toward 
the  extremities  (Fig.  67).  The  eggs  are  oval 
in  form,  about  -^^-^  inch  in  diameter,  and  are 
numbered  by  millions.  These  worms  rarely 
exist  singly  ;  usually  from  two  to  ten  are  pres- 
ent, but  there  may  be  hundreds,  and  even 
thousands.  When  very  numerous  they  coil  up 
and  form  large  masses,  which  may  cause  intes- 
tinal obstruction. 

The  life  history  of  the  roundworm  is  not 
yet  perfectly  understood.  Epstein  culti- 
vated outside  of  the  body  eggs  taken  from  the  stools,  and  found  that 
under  favourable  conditions  of  sun  and  air  five  weeks  were  required  for 
the  development  of  the  embryo.  These  were  then  fed  to  children.  In 
three  months  the  ova  appeared  in  the  stools,  and  after  the  administration 
of  santonin  many  worms  were  discharged.  From  these  experiments  it 
would  appear  that  no  intermediate  host  is  required,  although  this  was  pre- 
viously supposed  to  be  the  case.  It  was  believed  that  the  ova  were  swal- 
lowed by  some  worm  or  insect,  and  in  this  form  were  taken  into  the  intes- 
tinal canal  with  green  vegetables,  fruit,  or  drinking  water. 

The  migration  of  these  worms  is  curious,  and  in  some  instances  truly 
remarkable.     They  frequently  enter  the  stomach  and  are  vomited.     Occa- 


FiG.  67. — Ascaris  lumbrieoides; 
a,  entire  worm  ;  6,  head  ;  c, 
eggs.    (Jaksch,) 


INTESTINAL   WORMS.  399 

sionally  one  may  appear  in  the  nose.  They  have  been  known  to  pass 
through  the  Eustachian  tube  into  the  middle  ear  and  to  appear  in  the  ex- 
ternal meatus.  Entering  the  larynx  they  have  produced  fatal  asphyxia. 
It  is  not  very  rare  for  them  to  enter  the  common  bile  duct  and  pro- 
duce jaundice.  They  may  even  enter  in  great  numbers  the  smaller  bile 
ducts  and  produce  hepatic  abscesses.  They  have  been  found  in  the  pan- 
creatic duct,  in  the  vermiform  appendix,  and  in  the  splenic  vein.  It 
has  long  been  known  that  they  would  perforate  an  intestine  which  was  the 
seat  of  ulceration,  but  well-authenticated  cases  have  been  reported  in  which 
they  have  perforated  an  intestine  previously  healthy,  setting  up  a  fatal 
peritonitis.  In  Archambault's  case  they  perforated  the  stomach.  In  cases 
of  a  persistent  Meckel's  diverticulum,  worms  have  been  discharged  from  an 
umbilical  fistula.  They  have  been  found  in  umbilical  abscesses.  Consid- 
ering, however,  the  frequency  of  roundworms,  migrations  are  rare. 

Symptoms. — The  symptoms  of  roundworms  are  of  the  most  indefinite 
kind.  Often  there  are  none  until  the  worm  is  discovered  in  the  stools. 
It  is  then  fair  to  assume  that  others  are  also  present.  The  most  frequent 
abdominal  symptoms  are  colic,  tympanites,  and  other  symptoms  of  indi- 
gestion, loss  of  appetite,  restless,  disturbed  sleep,  grinding  of  the  teeth  at 
night,  and  picking  the  nose.  These  symptoms  are  much  more  frequently 
due  to  other  causes  than  to  worms,  but  when  all  are  present  the  existence 
of  worms  should  be  suspected. 

A  great  variety  of  nervous  symptoms  may  be  associated  with  intestinal 
worms.  They  are  more  often  seen  with  lumbricoids  than  with  either  of 
the  other  varieties.  The  symptoms  may  be  of  the  most  puzzling  character, 
and  may  simulate  very  closely  those  of  serious  organic  disease.  There 
may  be  chills,  headache,  vertigo,  hallucinations,  hysterical  seizures,  epi- 
leptiform attacks,  convulsions,  tetany,  transient  paralyses  such  as  strabis- 
mus, and  even  hemiplegia  and  aphasia.  All  these  have  been  observed 
in  connection  with  intestinal  worms,  and  from  the  fact  that  the  symptoms 
disappeared  completely  after  the  worms  were  expelled  there  seems  to  be 
but  little  doubt  that  they  were  the  cause  of  the  symptoms.  As  in  the  case 
of  the  abdominal  symptoms,  however,  intestinal  worms  are  only  one  of  the 
causes  of  such  nervous  disturbances,  and  certainly  not  the  most  frequent ; 
but  the  possibility  that  they  may  depend  upon  worms  should  not  be 
overlooked. 

The  only  positive  evidence  of  the  existence  of  roundworms  is  the  dis- 
charge of  a  worm  from  the  body,  or  the  discovery  of  the  ova  in  the  stools. 
A  microscopic  examination  of  the  stools  is  a  valuable  means  of  diagnosis, 
and  one  that  is  too  infrequently  employed.  When  worms  are  present  the 
ova  may  be  found  in  great  numbers.  Their  continued  presence  after  the 
discharge  of  one  worm,  indicates  that  other  worms  remain. 

Treatment. — Altogether  the  most  efficient  agent  for   the  removal  of 

the  worms  is  santonin.     The  same  plan  of  administration  may  be  fol- 
27 


400 


DISEASES  OF   THE    DIGESTIVE   SYSTEM. 


lowed  as  in  the  case  of  the  tapeworm — viz.,  to  give  the  drug  on  an  empty 
stomach,  preceded  by  a  laxative.  Santonin  is  best  given  in  powdered 
form  mixed  with  sugar.  For  a  child  of  five  years  three  grains  are  usually 
required.  This  amount  should  be  given  in  three  doses  at  intervals  of  four 
hours,  followed  by  a  purge  of  calomel  or  castor  oil. 

Oxyuris  Vermicularis—Pinworm— Threadworm.  The  oxyuris  (Fig.  G8) 
resembles  a  short  piece  of  wnite  thread.  The  female  is  about  one  third 
of  an  inch  long,  the  male  about  one  half  that  length,  but  is  less  frequently 
seen.  The  worm  tapers  toward  the  tail.  The  ova  are  of  slightly  irregular 
size,  and  are  considerably  smaller  than  those  of  the  roundworm. 

The  oxyuris  inhabits  chiefly  the  rectum  and  lower  colon  ;  less  fre 
quently  it  may  be  found  as  high  as  the  caecum.     These  worms  have  been 
seen  in  the  stomach,  and  even  in  the  mouth.     If  present  they  are  usually 
discovered  by  separating  the  folds  of  the  anus.     The  number  of  worms 

is  usually  large.  The  irrita- 
tion to  which  they  give  rise, 
causes  a  great  production  of  mu- 
cus, and  frequently  leads  to  a 
chronic  catarrh  of  the  colon 
of  considerable  severity.  The 
worms  are  imbedded  in  the  mu- 
cus ;  often  they  form  with  it 
small  balls.  According  to  Leuck- 
art,  they  are  incapable  of  multi- 
plying in  situ.  For  develop- 
ment, the  ova  must  be  swallowed 
by  the  patient  or  some  other  in- 
dividual. They  as  well  as  the 
worms  are  passed  in  enor- 
mous numbers  wath  the  stool. 
They  attach  themselves  to  the 
folds  of  the  skin,  the  hairs  about 
the  anus,  and  even  to  the  genitals. 
The  patient  may,  through  lack  of  cleanliness  of  the  parts,  continu- 
ally re-infect  himself.  After  discharge  from  the  body,  the  ova  may  be 
carried  by  flies  and  deposited  upon  fruits,  vegetables,  or  in  drinking 
water. 

Symptoms. — The  principal  symptom  caused  by  the  oxyuris  is  itching 
of  tlie  anus  or  the  genitals.  This  is  caused  by  the  migration  of  the 
worms  from  the  bowel,  and  usually  comes  on  at  about  the  same  hour  at 
night,  generally  soon  after  the  patient  has  retired.  It  is  sometimes  so 
intense  as  to  be  almost  intolerable.  It  leads  to  frequent  micturition,  to 
incontinence  of  urine,  in  the  male  to  balanitis,  and  in  the  female  to  vagi- 
nitis or  vulvitis,  and  in  both,  but  especially  in  the  latter,  it  may  be  the  cause 


I 


e 


Fig.  68, 


— Pinworms.  a,  head ;  6,  female ;  c,  male ; 
«,  female  and  male,  natural  size ;  d,  ova. 
(Jaksch.) 


INTESTINAL   WORMS.  401 

of  masturbation.  Owing  to  the  catarrhal  colitis  which  is  excited,  there  is 
discharged  a  large  quantity  of  mucus.  The  irritation  may  lead  to  pro- 
lapsus aui.  Xervous  symptoms'  are  not  so  frequently  associated  as  with 
the  other  varieties  of  worms,  although  1  have  seen  at  least  one  case  of 
chorea  in  which  they  were  almost  certainly  the  cause.  They  have  been 
known  to  excite  convulsions. 

Treatment. — This  is  usually  spoken  of  as  a  very  simple  matter,  and  no 
doubt  in  recent  cases,  or  where  the  number  of  worms  is  small,  this  is  true; 
but  where  the  number  is  large,  and  considerable  catarrhal  inflammation  of 
the  colon  is  present,  it  is  often  a  matter  of  the  greatest  difficulty  to  rid  the 
bowel  of  these  parasites.  Cases  often  resist  the  most  approved  methods 
of  treatment  for  months,  even  though  carefully  and  thoroughly  applied. 
The  reason  for  this  difficulty  is,  that  the  whole  colon  is  doubtless  infected, 
and  that  the  upper  part  is  very  imperfectly  reached  by  injections.  While, 
therefore,  injections  are  important  and  indeed  invaluable,  they  can  not 
be  relied  upon  exclusively.  The  most  scrupulous  attention  to  cleanliness 
is  an  absolute  necessity  as  the  first  step  in  the  treatment  of  all  cases.  It 
is  well  to  bathe  the  parts  about  the  anus  after  each  stool,  and  even  two 
or  three  times  a  day,  with  a  bichloride  solution,  1  to  10,000.  Itching  is 
best  controlled  by  the  application  of  mercurial  ointment  to  the  folds  of 
the  anus  at  bedtime,  this  effectually  preventing  the  escape  of  the  worms 
from  the  bowel.  The  local  application  of  cold  will  sometimes  have  the 
same  effect.  The  most  efficient  of  the  injections  is  probably  the  bichlo- 
ride. The  colon  should  first  be  thoroughly  cleansed  by  an  injection  of 
lukewarm  water  containing  one  teaspoonful  of  borax  to  the  pint,  in  order 
to  remove  the  mucus.  When  this  has  been  discharged,  half  a  pint  of  the 
bichloride  solution  mentioned  should  be  injected  high  into  the  bowel 
through  a  catheter,  and  retained  as  long  as  possible.  This  should  be  re- 
peated every  second  or  third  night.  On  other  nights  a  simple  saline 
injection  may  be  employed.  The  infusion  of  quassia,  asafoetida,  aloes, 
and  garlic  are  also  useful. 

When  the  worms  are  high  in  the  colon,  drugs  by  the  mouth  must 
be  combined  with  injections.  The  worms  must  be  dislodged  by  the  use  of 
saline  cathartics,  and  simple  bitters,  especially  quassia  and  gentian,  should 
be  given  by  the  mouth.  I  have  known  one  case,  which  resisted  for  over 
two  years  everything  which  had  been  tried,  cured  in  two  or  three  weeks 
by  injections  of  a  decoction  of  garlic,  in  connection  with  which  garlic 
was  given  in  large  quantities  by  the  mouth. 


402  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

CHAPTER   XL 
DISEASES  OF   TEE  RECTUM. 

PROLAPSUS  ANI. 

Under  this  term  are  included  two  conditions.  In  the  first,  or  partial 
prolapse,  there  is  simply  an  eversion  of  the  mucous  membrane  which  pro- 
trudes beyond  the  sphincter.  In  the  second,  or  complete  prolapse,  there 
is  invagination  of  the  rectal  wall  for  a  variable  distance,  usually  two  or 
three  inches. 

Etiology. — Prolapse  is  most  common  in  children  during  the  second 
and  third  years.  Its  frequency  in  early  life  is  partly  due  to  the  lack  of 
support  furnished  by  the  levator-ani  muscles.  It  also  occurs  very  readily 
when  the  ischio-rectal  fat  is  scanty ;  it  is  therefore  often  seen  in  children 
suffering  from  marasmus.  The  exciting  cause  may  be  anything  which  pro- 
vokes severe  and  prolonged  straining.  This  may  be  either  the  tenesmus 
accompanying  inflammation  of  the  rectal  mucous  membrane  or  chronic 
constipation.  It  may  come  from  phimosis  or  stricture  of  the  urethra,  and 
it  is  a  very  frequent  symptom  of  stone  in  the  bladder. 

Symptoms. — Prolapse  usually  occurs  during  the  act  of  defecation.  It 
is  generally  easily  reduced,  but  shows  a  great  disposition  to  return  with 
every  stool.  In  obstinate  cases  the  bowel  comes  down  at  other  times. 
The  appearance  of  the  tumour  varies  with  its  size.  In  the  slighter  form 
there  is  simply  a  ring  composed  of  a  fold  of  mucous  membrane  surround- 
ing the  anus.  In  the  more  severe  form  there  is  a  flattened,  corrugated 
tumour,  usually  about  the  size  of  a  small  tomato  (Fig.  69).  The  mucous 
membrane  covering  the  tumour  is  of  a  deep  purplish-red  colour,  and 
bleeds  readily.  It  may  be  the  seat  of  catarrhal  or  membranous  inflamma- 
tion. The  diagnosis  in  most  cases  is  easy,  although  the  tumour  has  been 
confounded  with  polypus  and  intussusception. 

Treatment. — In  most  cases  reduction  is  easily  accomplished  by  laying 
the  child  upon  its  face  across  the  lap,  and  making  gentle  pressure  upon  the 
tumour  with  oiled  fingers.  The  application  of  cold,  either  by  means 
of  ice  or  cold  cloths,  is  of  assistance  in  cases  which  are  not  at  once  reduced 
by  pressure.  After  reduction,  in  the  milder  cases  the  child  should  be  kept 
upon  its  back  for  at  least  an  hour.  Where  the  tumour  tends  to  come 
down  with  every  stool,  special  attention  should  be  given  at  this  time.  If 
an  infant,  the  bowels  should  always  move  while  the  child  lies  upon  its 
back,  and  during  defecation  the  buttocks  should  be  pressed  together  by  a 
nurse.  Older  children  should  use  an  inclined  seat  placed  at  an  angle  of 
about  forty-five  degrees,  but  should  never  sit  upon  a  low  chair  or  assume 


PROLAPSUS  ANI.  4O3 

any  position  in  which  straining  is  easy.  After  defecation  the  patient 
should  lie  down  for  at  least  half  an  hour.  AVhere  there  is  constipation,  the 
bowels  should  be  kept  free  by  means  of  laxatives.     If  there  is  a  diarrhcea, 


i'lG.   ()'J.-    i'ii.»laj).-.u.>  alii. 

tenesmus  may  be  overcome  by  frequent  sponging  with  ice  water,  or  by 
the  use  of  small  injections  of  ice  water  and  tannic  acid,  in  the  proportion 
of  twenty  grains  to  the  ounce.  In  more  severe  cases  it  may  be  controlled 
by  the  use  of  suppositories  of  opium  or  cocaine.  Where  the  bowel  tends 
to  come  down  frequently,  this  may  be  prevented  by  the  use  of  an  adhesive 
strap  two  or  three  inches  wide,  placed  tightly  across  the  buttocks.  This 
is  better  in  the  milder  cases  than  a  T-bandage.  The  great  majority  of  the 
cases  are  cured  by  these  means  in  the  course  of  a  few  weeks. 

In  the  most  severe  cases  the  bowel  not  only  protrudes  during  defeca- 
tion, but  also  in  the  interval,  and  it  may  be  down  for  weeks  at  a  time. 
Such  cases  are  rarely  seen  except  in  infants  who  have  very  flabby  muscles, 
and  but  little  adipose  tissue  at  the  floor  of  the  pelvis.  Reduction  is  some- 
times difficult  in  cases  where  the  prolapse  has  lasted  a  long  time.  It 
is  often  facilitated  by  painting  the  protruding  part  with  a  4-per-cent  solu- 
tion of  cocaine,  and  then  dilating  the  sphincter  by  passing  the  finger  into 
the  central  opening  of  the  tumour.  After  reduction,  suppositories  con- 
taining from  one  fourth  to  one  grain  of  cocaine  may  be  inserted.  They 
are  more  efficient  than  those  containing  opium  or  belladonna.  A  firm  pad 
should  be  applied  over  the  anus,  held  in  position  by  a  T-bandage.  The 
tone  of  the  levator  and  sphincter-ani  muscles  is  often  greatly  improved  by 
local  injections  of  strychnia.  For  a  child  two  years  old  y^  grain  may  be 
used  twice  a  day.  Where  these  measures  fail,  the  protruding  part  may 
be  touched  with  the  Paquelin  cautery,  linear  markings  being  made  at  in- 
tervals of  an  inch.     Amputation  or  excision  is  not  required  in  children. 


404  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

FISSURE   OF   THE  ANUS. 

This  is  not  a  very  uncommou  condition  in  children.  The  most  fre- 
quent cause  is  the  passage  of  a  large,  hard,  faecal  mass.  Sometimes  it  re- 
sults from  traumatism  inflicted  with  the  nozzle  of  a  syringe  while  giving 
an  enema.  It  may  be  produced  by  the  scratching  excited  by  pinworms.  In 
the  beginning  there  is  a  simple  tear  at  the  margin  of  the  anus.  The 
laceration  which  is  produced  usually  heals  promptly  ;  but  if  the  cause  is 
.repeated,  healing  is  prevented,  and  there  is  finally  produced  a  linear  ulcer, 
or  a  true  fissure,  which  may  last  for  some  time  and  be  a  source  of  great 
annoyance. 

A  fresh  fissure  has  the  ai^pearance  of  any  other  tear  at  a  muco-cuta- 
neous  orifice.  One  of  longer  standing  has  a  gray  base,  slightly  indurated 
edges,  often  discharges  a  small  amount  of  pus,  and  bleeds  a  drop  or  two 
with  nearly  every  movement  of  the  bowels.  The  most  constant  symptom 
is  pain,  which  usually  occurs  with  the  act  of  defecation,  and  continues  for 
some  time  afterward.  It  is  most  severe  when  the  fissure  is  just  at  the 
margin  of  the  sphincter,  and  leads  the  child  to  resist  every  inclination  to 
have  the  bowels  move,  so  that  it  becomes  a  cause  of  chronic  constipation, 
which  condition  again  greatly  aggravates  the  fissure.  The  pain  is  often 
referred  to  other  parts  in  the  neighbourhood. 

The  treatment  is  simple  and  usually  efficient.  It  consists  in  clean- 
liness, overcoming  the  constipation,  and  touching  the  fissure  with  nitrate 
of  silver,  preferably  with  the  solid  stick.  If  the  case  is  not  speedily  re- 
lieved by  such  measures,  the  sphincter  should  be  stretched  as  in  adult 
patients. 

PROCTITIS. 

Proctitis,  or  inflammation  of  the  rectum,  usually  occurs  with  inflam- 
mation of  the  rest  of  the  large  intestine,  but  it  may  occur  alone.  It  ig 
to  the  cases  in  which  only  the  rectum  is  involved  that  the  term  is  gen- 
erally applied. 

The  causes  are  for  the  most  part  local.  A  frequent  one  in  infants 
is  the  use  of  irritating  injections  or  suppositories,  either  for  the  relief  of 
constipation  or  as  a  means  of  administering  certain  drugs.  I  have  seen 
one  obstinate  case  in  an  infant  a  year  old,  following  the  prolonged  use  of 
glycerin  suppositories.  It  is  sometimes  caused  by  traumatism,  especially 
by  the  careless  giving  of  an  enema.  It  accompanies  pinworms.  In 
certain  cases  it  may  result  from  direct  infection  through  the  anus.  This 
may  be  from  a  gonorrhoeal  inflammation  extending  from  the  vagina  or 
urethra,  or  from  an  infection  due  to  other  bacteria,  particularly  in  cases' 
of  measles,  scarlet  fever,  and  diphtheria ;  or  flnally,  it  may  be  due  to  syph- 
ilis. The  varieties  of  inflammation  are  the  same  as  in  the  rest  of  the  in- 
testine.    Proctitis  may  thus  be  catarrhal,  membranous,  or  ulcerative. 


PROCTITIS.  405 

Catarrhal  Proctitis. — The  pathological  conditions  are  the  same  as  in 
ordinary  catarrhal  inflammation  of  the  intestinal  mucous  membrane.  By 
the  introduction  of  a  specuhun,  or  by  simply  everting  the  mucous  mem- 
brane, it  is  seen  to  be  reddened,  swollen,  and  bleeds  easily.  There  is  a  co- 
pious secretion  of  mucus.  In  cases  of  long  standing  there  may  be  super- 
ficial ulceration  appearing  as  a  white  or  yellowish-white  surface,  usually 
just  inside  the  sphincter. 

The  symptoms  are  chiefly  local,  although  a  condition  of  general  irrita- 
bility may  result  from  the  local  condition.  There  is  heightened  reflex 
action,  so  that  the  stool,  often  comes  with  a  squirt.  There  is  pain  with 
defecation,  and  mucus  is  discharged,  usually  as  a  clear,  jelly-like  mass, 
and  sometimes  in  the  form  of  a  cast,  but  not  generally  mixed  with  the 
stool.  There  are  usually  traces  of  blood,  but  rarely  large  haemorrhages. 
In  the  most  acute  cases,  tenesmus  is  always  present  both  during  and  after 
the  stool.  There  may  be  prolapsus  ani.  The  skin  in  the  vicinity  is  irri- 
tated by  the  discharges,  most  frequently  so  in  infants.  If  the  cause  is  pin- 
worms,  there  may  be  intense  itching.  The  duration  of  the  disease  is 
indefinite,  depending  upon  the  cause.  It  may  be  a  few  days  or  many 
months.  The  inflammation  may  extend  from  the  rectum  to  neighbouring 
parts,  leading  to  ischio-rectal  abscess. 

Membranous  Proctitis. — It  has  been  customary  to  describe  this  as  a 
complication  of  diphtheria,  usually  occurring  with  diphtheria  of  the  exter- 
nal genitals.  As  very  few  of  these  cases  have  been  studied  bacteriolog- 
ically,  it  is  impossible  to  say  what  proportion  of  them,  if  any,  are  to  be 
regarded  as  true  diphtheria.  It  is  probable  that  the  great  majority  are 
due  to  infection  by  streptococci.  "When  the  infection  is  from  the  intestine 
above,  the  rectum  is  never  affected  alone.  When  it  is  from  below,  this 
may  be  the  case.  The  lesions  are  the  same  as  in  membranous  inflamma- 
tion occurring  higher  in  the  colon.  The  symptoms  resemble  those  of  the 
catarrhal  variety,  with  the  addition  that  the  stools  contain  pieces  of 
pseudo-membrane.  This  can  be  made  out  only  by  repeatedly  washing 
the  discharges  with  water.  If  accompanied  by  prola})se,  the  pseudo- 
membrane  may  be  seen.  Membranous  proctitis  may  be  complicated  by  a 
membranous  inflammation  of  the  genitals  or  the  perinaeum.  Although 
it  is  usually  acute,  it  may  last  for  weeks. 

Ulcerative  Proctitis. — Ulcers  of  the  rectum  may  be  the  result  of  a  ca- 
tarrhal inflammation  ;  these,  however,  are  usually  superficial,  affecting  the 
mucous  membrane  only,  and  in  most  cases  heal  rapidly.  Sometimes  they 
extend  more  deeply  into  the  submucous  or  even  the  muscular  coat.  They 
are  then  chronic,  often  very  obstinate,  and  may  last  indefinitely.  Follicu- 
lar ulcers  of  the  rectum  are  nearly  always  associated  with  the  same  con- 
dition in  the  sigmoid  flexure.  These  are  always  multiple  and  usually 
small,  rarely  being  more  than  a  quarter  of  an  inch  in  diameter.  Some- 
times the  small  ones  coalesce,  producing  much  larger  ulcers.    Membranous 


406  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

proctitis  is  rarely  followed  by  ulceration,  although  this  is  a  possible  result 
where  sloughing  has  occurred.  Single  ulcers  may  be  of  tuberculous  ori- 
gin. Steffen  reports  two  cases  of  tuberculous  ulcer  of  the  rectum  in 
children  of  seven  months  and  three  years  respectively.  I  have  seen  one 
in  a  young  infant,  which  was  fully  three  fourths  of  an  inch  in  diameter, 
and  was  not  associated  with  other  tuberculous  disease  of  the  large  intes- 
tine.    Syphilitic  ulcers  are  extremely  rare  in  children. 

The  symptoms  of  ulcer  of  the  rectum  are  mainly  two — pain  and  haem- 
orrhage. The  pain  is  of  variable  intensity,  and  may  be  referred  to  the 
coccyx,  or  to  any  of  the  neighbouring  parts.  The  amount  of  bleeding 
may  be  small,  the  blood  coming  in  clots,  or  it  may  be  fluid  and  in  so  large 
a  quantity  as  to  produce  general  symptoms.  It  usually  accompanies  every 
stool.  In  addition  the  stool  contains  more  or  less  pus,  particularly  in 
chronic  cases.  When  the  ulcer  is  low  down,  tenesmus  is  present  and  may 
be  a  prominent  symptom.  A  positive  diagnosis  of  ulcer  can  be  made  only 
by  examination  with  a  speculum. 

Treatment. — In  cases  of  acute  catarrhal  proctitis  injections  of  some 
bland  fluid  should  be  employed,  such  as  a  starch- water,  limewater,  a  mixture 
of  oil  and  limewater,  or  a  warm  one-per-cent  saline  solution.  The  local 
cause,  if  one  is  present,  should  be  removed.  Where  the  stools  are  excess- 
ively acid,  alkalies  may  be  given  by  the  mouth.  The  disordered  digestion^ 
when  present,  is  to  be  treated  according  to  its  special  symptoms.  In  the 
most  acute  cases  the  patient  should  be  kept  in  bed.  Where  the  tenesmus 
is  severe,  suppositories  of  opium  or  cocaine  may  be  used.  In  the  more 
chronic  cases  saline  injections  should  be  given,  and  followed  by  a  mild 
astringent  like  tannic  acid,  ten  grains  to  the  ounce,  or  a  one-per-cent  solu- 
tion of  hamamelis.  Cases  associated  with  pinworms  are  especially  obsti- 
nate. Here  the  treatment  is  first  to  be  directed  to  the  worms,  and  after- 
ward to  the  proctitis. 

In  the  membranous  cases  the  same  measures  are  to  be  employed,  and 
in  addition  the  injection  of  a  warm  boric-acid  solution  two  or  three 
times  a  day. 

Cases  of  ulcer  require  the  most  careful  treatment.  In  many  there  is 
but  little  tendency  to  spontaneous  recovery.  An  examination  with  the 
speculum  should  be  insisted  upon  in  all  cases  of  chronic  proctitis,  to 
make  sure  of  the  diagnosis.  Rest  in  bed  is  essential  to  a  rapid  improve- 
ment. The  patient  should  be  put  upon  a  bland  diet,  especially  of  milk, 
and  the  bowels  kept  freely  open  by  the  use  of  laxatives,  and  injections 
twice  a  day  of  a  saturated  boric-acid  solution.  Locally  there  should  be 
applied  a  solution  of  nitrate  of  silver,  one  grain  to  the  ounce,  the  bowel 
having  previously  been  washed  with  tepid  water.  If  a  stronger  solution 
than  this  is  used,  it  should  be  neutralized  after  half  a  minute  by  the 
injection  of  a  salt  solution. 


HJiIMORRHOIDS.  407 


ISCniO-RECTAL   ABSCESS. 

This  is  not  a  very  rare  condition  even  in  infancy.  Infection  from  the 
rectum,  usually  through  the  lymph  channels,  seems  to  be  the  most  com- 
mon cause,  although  sometimes  the  abscess  may  be  traced  directly  to  trau- 
matism. In  a  single  year  I  have  seen  six  cases.  All  but  two  were  small, 
circumscribed  abscesses  and  quite  superficial,  apparently  starting  as  an 
acute  inflammation  of  the  lymph  glands  of  the  region.  They  are  analo- 
gous to  a  similar  process  in  the  lymph  glands  of  the  neck,  seen  in  in- 
fancy. These  cases  healed  promptly  after  incision.  In  other  instances 
there  is  seen  a  disposition  to  burrow,  as  in  adults.  Only  once  have  I  met 
with  diffuse  suppuration  in  the  ischio-rectal  region,  terminating  in  slough- 
ing and  death,  and  this  was  in  an  infant  only  three  months  old. 

Essentially  the  same  varieties  of  inflammation  are  seen  in  early  life  as 
in  adults.  Most  of  these  cases  recover  promptly  after  simple  incision  and 
cleanliness,  fistula  being  a  rare  sequel. 

HEMORRHOIDS. 

These,  fortunately,  are  not  often  seen  in  children,  although  they  may 
occur  even  in  those  as  young  as  three  or  four  years.  The  principal  cause  is 
chronic  constipation.  The  tumours  are  generally  small  and  external,  the 
chief  symptom  complained  of  being  pain  on  defecation.  Bleeding  some- 
times accompanies  the  pain,  but  the  haemorrhages  are  usually  small. 
The  treatment  is  to  be  directed  toward  the  underlying  cause.  In  most 
of  the  cases  this  suffices  to  cure  the  condition.  I  have  never  yet  seen  in 
a  young  child  a  case  requiring  operation,  although  neglect  may  make  this 
procedure  necessary. 

INCONTINENCE  OF  PIECES. 

Inability  to  control  the  faecal  evacuations  is  seen  in  certain  cases  of 
paraplegia  due  to  myelitis,  in  injury  of  the  lumbar  portion  of  the  spinal 
cord,  and  in  spina  bifida.  It  is  also  seen  in  the  coma  of  meningitis,  and 
occasionally  in  the  typhoid  condition  and  in  extreme  adynamia,  no  matter 
in  the  course  of  what  diseases  they  develop.  In  all  these  conditions  in- 
continence of  faeces  is  a  symptom  giving  rise  to  much  annoyance  and 
needing  careful  attention.  Uncleanliness  with  reference  to  excreta,  seen 
in  idiocy,  can  hardly  be  classed  as  incontinence. 

Besides  these  familiar  forms,  the  condition  is  sometimes  seen  from 
causes  somewhat  resembling  those  of  incontinence  of  urine.  The  tone 
of  the  sphincter  becomes  so  feeble  that  it  does  not  resist  even  the  slightest 
impulse  to  evacuate  the  rectum.  The  discharge  may  take  place  with  but 
little  warning,  and  may  occur  either  by  day  or  night.  In  some  cases  a 
local  cause  exists,  such  as  stretching  of  the  sphincter  by  a  rectal  prolapse 


408 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


or  by  impaction  of  fseces ;  more  frequently,  however,  the  causes  relate  to 
the  general  nervous  condition  of  the  j^atieut.  Fowler  *  (New  York)  has 
reported  two  very  typical  cases  of  this  variety,  and  I  have  seen  one.  They 
are,  however,  very  rarely  met  with  in  practice.  Of  the  cases  reported  in 
literature,  the  majority  have  occurred  in  highly  nervous,  anaemic  children. 
Fowler's  cases  were  cured  by  the  use  of  ergot  given  by  the  mouth  and  by 
suppository.  In  cases  not  relieved  by  this  treatment,  strychnia  should  be 
injected  locally  as  described  under  Prolapsus  Ani.  In  all  cases  the  gen- 
eral condition  should  receive  careful  attention. 


CHAPTER  XII. 
DISEASES  OF  THE  LIVER. 

The  liver  is  not  often  the  seat  of  disease  in  infancy  and  early  child- 
hood. Nearly  all  the  forms  seen  in  adult  life  are  occasionally  met  with  in 
later  childhood,  although  even  then  they  are  quite  rare. ' 

Size  and  Position. — The  weight  of  the  liver  in  the  newly-born  child, 
from  one  hundred  and  seven  observations  of  Birch-Hirschfeld,  is  4-5  ounces 
(127  grammes),  or  about  4*2  per  cent  of  the  body  weight.  The  following 
table  gives  the  results  of  one  hundred  and  seventy-four  observations  upon 
the  liver  in  infancy  in  the  autopsy  room  of  the  New  York  Infant  Asylum : 


Weight  of  the  Liver  in  Infancy. 


AVERAGE. 

Agb. 

Ounces. 

Grammes. 

body  weight. 

3  months  

6-3 

7-5 

11-0 

14-0 

16-0 

180 
212 
311 
397 
453 

31 

6       •'       

3-0 

12       "       

3-40 

2  y6ars           

3-37 

3     " 

3-26 

In  adults,  according  to  Frerichs,  the  weight  of  the  liver  is  about  2*5 
per  cent  of  the  weight  of  the  body. 

The  upper  border  of  the  liver  is  best  made  out  by  percussion.  In  the 
child,  the  upper  limit  of  the  liver  dulness  in  the  mammary  line  is  found 
in  the  fifth  intercostal  space  ;  in  the  axillary  line,  in  the  seventh  space  ; 
posteriorly,  in  the  ninth  space.  The  lower  border  is  best  determined  by 
palpation.  This,  as  a  rvile,  in  the  mammary  line  is  found  about  one  half 
an  inch  below  the  free  border  of  the  ribs.  According  to  Steffen,  the  left 
lobe  is  relatively  larger  in  the  child  than  in  the  adult.     The  liver  may  be 


*  American  Journal  of  Obstetrics  and  Diseases  of  Children,  October,  1882. 


FUNCTIONAL   DISORDERS  OF   THE   LIVER.  409 

displaced  downward  by  contraction  of  the  chest,  as  in  rickets,  or  by  an 
accumulation  of  fluid  in  the  pleural  cavity.  It  is  frequently  found  lower 
than  normal  in  conditions  of  great  emaciation,  owing  to  relaxation  of  the 
abdominal  walls  and  its  ligamentous  supports.  Upward  displacement  is 
much  less  frequent,  and  depends  usually  upon  ascites  or  abdominal  tumours. 

Malformations  and  Malpositions. — Congenital  malformations  relate 
chiefly  to  the  bile  ducts.  These  have  been  considered  in  the  chapter  de- 
voted to  Icterus  in  the  Newly  Born  (page  76). 

The  liver  may  be  found  upon  the  left  side  in  cases  of  general  transpo- 
sition of  the  viscera.  In  fissure  of  the  diaphragm  it  has  been  found  in  the 
thoracic  cavity. 

ICTERUS. 

Icterus,  or  jaundice,  occurs  in  children,  as  in  adults,  from  two  general 
classes  of  causes.  The  first  includes  those  cases  in  which  there  is  some 
obstruction  of  the  flow  of  bile  from  the  liver  into  the  intestine,  or  obstruc- 
tive jaundice.  In  the  second  group,  in  which  the  jaundice  is  classed  as 
non-obstructive,  it  depends  upon  certain  changes  in  the  blood  itself.  This 
is  seen  in  the  physiological  jaundice  of  the  newly  born,  in  that  associated 
with  septic  conditions  and  as  the  result  of  certain  poisons. 

Obstructive  jaundice  from  pressure  upon  the  bile  ducts  is  extremely 
rare  in  children.  Obstruction  by  a  roundworm  entering  the  common 
duct  has  been  recorded,  but  is  also  very  rare.  The  principal  form  of  ob- 
structive jaundice  seen  in  early  life,  is  catarrhal.  This  has  already  been 
considered  in  connection  with  Gastro-duodenitis  (page  297). 

FUNCTIONAL   DISORDERS. 

Functional  derangements  of  the  liver  are  undoubtedly  exceedingly  com- 
mon in  childhood.  They  are  as  yet  but  little  understood,  and  it  is  almost 
impossible  to  separate  them  from  the  other  symptoms  of  intestinal  indiges- 
tion with  which  they  are  associated.  These  are  described  in  the  chapter 
upon  Chronic  Intestinal  Indigestion.  Some  of  these  symptoms  depend 
upon  a  diminution  in  the  quantity,  or  the  impoverished  quality  of  the 
biliary  secretion.  There  are  gray  or  white  stools,  flatulence,  and  other  evi- 
dences of  increased  intestinal  putrefaction.  These  in  all  probability  depend 
upon  imperfect  absorj)tion  in  consequence  of  the  absence  of  bile,  rather 
than  upon  the  absence  of  some  antiseptic  .projjerty,  as  recent  experiments 
seem  to  show  that  the  bile  is  not  an  intestinal  antiseptic.  The  other 
functional  disturbances  of  the  liver  relate  to  its  eifect  upon  the  proteid 
substances  which  undergo  destructive  metamorphosis  in  this  organ.  The 
nature  of  this  change,  and  the  symptoms  which  result  from  this  disturbance 
are  as  yet  but  imperfectly  understood.  It  is  quite  probable  that  many  of 
the  nervous  functional  disorders  of  children — for  example,  attacks  of 
migraine  or  of  cyclic  vomiting — may  depend  upon  such  a  cause. 


410  DISEASES  OP  THE   DIGESTIVE  SYSTEM. 


ACUTE   YELLOW  ATROPHY. 

This  form  of  hepatic  disease,  although  rare  in  adults,  is  still  more  rare 
in  children.  Greves*  has  reported  a  well-marked  case  in  an  infant  of 
twenty  months,  and  has  collected  seventeen  other  cases  under  ten  years  of 
age;  the  youngest  was  in  an  infant  three  months  old.  The  causes  are 
obscure.  The  symptoms  and  course  of  the  disease  are  essentially  the 
same  as  in  adults. 

CONGESTION  OP  THE   LIVER. 

This  occurs  from  the  same  cause  as  in  adults.  Acute  congestion  is  not 
often  seen.  It  may  result  from  a  malarial  fever  and  from  certain  poisons, 
particularly  phosphorus.  Chronic  congestion  is  more  common,  and  is  usu- 
ally secondary  to  general  venous  obstruction  dependent  upon  congenital 
or  acquired  heart  disease,  atelectasis,  or  other  pulmonary  conditions,  par- 
ticularly chronic  pleurisy,  chronic  interstitial  pneumonia,  and  emphysema. 
Chronic  congestion  of  the  liver  causes  no  characteristic  symptoms  except  a 
moderate  enlargement  of  the  organ.  The  disturbance  of  its  functions  is 
not  of  such  a  nature  as  to  be  diagnostic.  In  acute  congestion,  there  may 
be  in  addition  to  the  swelling  of  the  liver,  some  localized  pain  or  tender- 
ness. The  treatment  is  that  of  the  original  disease  upon  which  the  con- 
gestion depends. 

ABSCESS  OP  THE  LIVER— SUPPURATIVE   HEPATITIS. 

In  1890  Musser  f  found  but  thirty-four  recorded  cases  of  abscess  under 
thirteen  years.  Since  that  time  a  few  additional  cases  have  been  reported. 
This  suffices  to  show  how  rare  the  disease  is  in  early  life.  In  the  above 
collection,  there  have  not  been  included  cases  of  suppurative  hepatitis  oc- 
curring in  the  newly  born. 

As  in  adults,  abscess  of  the  liver  may  result  from  traumatism,  or  it 
may  be  secondary  to  suppurative  pylephlebitis,  which  depends  upon  a 
focus  of  infection  in  the  umbilical  vein,  or  in  some  part  of  the  abdomen 
from  which  the  branches  of  the  portal  vein  arise.  Pylephlebitis  may  fol- 
low appendicitis  (Bernard's  case),  it  may  follow  typhoid  fever  directly 
(Asch's  case),  or  be  due  to  suppuration  of  the  mesenteric  glands  or  peri- 
tonitis following  typhoid.  In  seven  of  the  cases  collected  by  Musser 
the  disease  was  due  to  migration  of  roundworms  from  the  intestine  into 
the  hepatic  ducts.  Menger  (Texas)  has  reported  one  case  following  dysen- 
tery, the  only  one,  I  think,  on  record  in  this  country.  In  quite  a  number 
of  cases  no  adequate  cause  can  be  found.     A  striking  example  of  this  was 

*  Liverpool  Medieo-Chirurgical  Journal,  July,  1884. 
f  Keating's  Cyclopaedia,  vol.  iii,  p.  466. 


ABSCESS  OF  THE   LIVER.  411 

reported  to  the  New  York  Pathological  Society  by  Swift,  in  1882,  where 
an  abscess  occupying  nearly  the  whole  right  lobe  occurred  in  a  child 
three  years  old. 

In  the  cases  occurring  in  pyaemia  and  in  those  associated  with  pyle- 
phlebitis there  are  usually  several  abscesses  ;  in  traumatic  cases  generally  but 
one.  The  abscesses  of  early  life  do  not  differ  very  much  from  those  of 
adults.  If  untreated,  the  majority  of  cases  prove  fatal  either  from  exhaus- 
tion or  from  rupture  into  the  pleura  or  peritonaeum.  In  Asch's  case  spon- 
taneous cure  took  place  by  rupture  into  the  intestine. 

Symptoms. — Occasionally  abscess  in  the  liver  is  latent,  but  in  most  of 
the  cases  the  symptoms  are  marked  and  sufficiently  characteristic  to  make 
the  diagnosis  a  matter  of  no  great  difficulty.  The  most  constant  general 
symptoms  are  chills,  which  may  be  single,  but  are  usually  repeated  ;  fever, 
which  is  commonly  of  the  hectic  variety  and  followed  by  sweating ;  pros- 
tration, vomiting,  diarrhoea,  and  cachexia.  Jaundice  is  present  in  less  than 
half  the  cases,  and  is  rarely  intense.  The  liver  is  almost  invariably  suffi- 
ciently enlarged  to  be  easily  made  out  by  palpation  or  by  percussion ;  the 
enlargement  in  most  cases  is  chiefly  downward.  Tumours  on  the  surface 
of  the  liver  are  often  present ;  these  may  be  recognised  as  abscesses  by  the 
presence  of  fluctuation.  Pain  is  quite  constant,  and  frequently  intense, 
but  not  always  in  the  region  of  the  liver.  It  may  be  in  the  epigastrium, 
at  the  umbilicus,  in  the  lower  part  of  the  abdomen,  and  occasionally 
in  the  right  shoulder.  Tenderness  over  the  liver  is  usually  present.  A 
positive  diagnosis  of  hepatic  abscess  is  to  be  made  only  by  aspiration  and 
the  withdrawal  of  a  fluid  having  the  characteristic^  known  as  "liver 
pus."  Pulmonary  symptoms  usually  exist  with  an  abscess  occupying  the 
convexity  of  the  right  lobe.  There  may  be  cough  and  dyspnoea  from 
pressure,  or  pleurisy  from  extension  of  the  inflammation  through  the 
diaphragm,  or  from  rupture  into  the  pleural  cavity.  The  usual  duration 
of  abscess  of  the  liver  after  the  beginning  of  the  symptoms  is  from  one  to 
two  months.  The  prognosis  will  depend  upon  the  cause  of  the  disease. 
The  pyajmic  cases  are  usually  fatal.  In  Musser's  collection,  the  proportion 
of  recoveries  was  about  thirty  per  cent.  At  the  present  time,  with  im- 
proved methods  of  treatment  and  earlier  diagnosis,  the  outlook  is  some- 
what better  than  this. 

Treatment. — This  is  purely  surgical.  Without  operation  the  chances 
of  recovery  are  very  slight.  A  small  number  of  cases  have  been  cured 
by  aspiration,  but  in  the  vast  majority  only  incision  and  drainage  are  to 
be  depended  upon,  and,  if  the  abscess  is  accessible,  should  be  resorted  to 
as  soon  as  the  diagnosis  is  established. 

CIRRHOSIS. 

This  is  exceedingly  rare  in  early  life,  although  quite  a  number  of  cases 
are  now  on  record  between  the  ages  of  seven  and  fourteen  years.     Sixty- 


412  DISEASES  OF   THE   DIGESTIVE  SYSTEM. 

five  have  been  collected  by  Howard*  and  fifty-three  by  Laure  and 
Honorat.f  Nearly  all  the  cases  in  these  collections  were  between  nine 
and  fifteen  years.  Cirrhosis  in  infancy  is  usually  of  syphilitic  origin. 
Two  thirds  of  those  in  Howard's  collection  were  males.  The  etiology  in 
most  of  the  cases  is  obscure ;  in  over  half  of  those  reported  no  cause  could 
be  discovered.  Fifteen  per  cent  of  Howard's  cases  were  traced  to  alco- 
holism, eleven  per  cent  to  syphilis,  and  eleven  per  cent  to  tuberculosis. 
Laure  and  Honorat  believe  that  the  eruptive  fevers  sometimes  play  an 
important  part  as  an  etiological  factor,  and  that  at  other  times  the  cause 
is  possibly  malaria. 

The  anatomical  features  of  cirrhosis  in  early  life  are  essentially  the 
same  as  in  adults.  The  liver  is  sometimes  enlarged,  but  usually  it  is 
smaller  than  normal.  The  connective  tissue  may  be  distributed  around 
the  lobules,  along  the  bile  ducts,  in  irregular  patches,  or  in  striations 
through  the  organ.  Associated  with  this  there  tre  atrophy  and  fatty  de- 
generation of  the  liver  cells.  In  some  of  the  cases  reported  there  has 
been  also  a  similar  increase  in  the  connective  tissue  of  the  spleen  and 
kidneys. 

Symptoms. — These  are  very  much  the  same  as  in  adult  life.  In  the 
beginning  there  are  the  indefinite  disturbances  referable  to  the  digestive 
organs,  and  the  liver  may  be  found  to  be  slightly  enlarged  ;  later  there  are 
ascites,  enlargement  of  the  spleen,  and  dilatation  of  the  abdominal  veins. 
Ascites  is  a  pretty  constant  symptom,  and  is  generally  marked.  Slight 
icterus  is  often  present,  but  a  marked  amount  is  rare.  There  may  be 
haemorrhages  from  the  stomach,  from  the  nose,  or  from  other  organs ;  in  a 
few  cases  there  is  slight  fever.  The  late  symptoms  are  a  small  liver, 
marked  ascites  with  the  consequent  embarrassment  of  respiration,  ca- 
chexia, and  sometimes  general  dropsy.  Diarrhoea  is  a  much  more  constant 
symptom  than  in  adults.  Death  usually  takes  place  from  exhaustion. 
The  course  of  cirrhosis  in  children  is  commonly  more  rapid  than  in 
adults,  and  the  progress  is  steadily  downward. 

Treatment. — Medicinal  treatment  is  of  avail  only  in  cases  which  are 
syphilitic.  These  should  be  put  upon  mercury  and  large  doses  of  the 
iodides.  The  treatment  in  other  respects  is  symptomatic  and  palliative. 
As  largely  as  possible  patients  should  be  kept  upon  a  milk  diet.  The 
ascites  may  require  aspiration  or  puncture,  as  in  adults. 

AMYLOID  DEGENERATION  (WAXY,  LARDACEOUS  LIVER). 

This  condition  results  from  prolonged  suppuration  in  connection  with 
chronic  bone  and  joint  disease,  especially  of  the  hip,  knee,  or  spine. 
More  rarely  it  is  seen  with  chronic  empyema,  tuberculosis,  or  hereditary 


*  American  Journal  of  the  Medical  Sciences,  1887,  p.  350. 

f  Revue  Mensuelle  des  Maladies  de  I'Enfance,  1887,  p.  97,  159. 


FATTY  LIVER.  413 

syphilis.  Amyloid  degeneration  of  the  liver  is  associated  with  similar 
changes  in  the  spleen  and  kidneys,  and  sometimes  in  the  villi  of  the  small 
intestine. 

The  liver  is  generally  very  much  enlarged ;  in  extreme  cases  a  weight 
of  six  or  seven  pounds  may  be  reached.  It  is  of  a  glistening,  waxy  colour, 
very  firm  and  hard.  With  a  solution  of  iodine,  a  mahogany-brown  reac- 
tion is  obtained.  The  amyloid  degeneration  affects  first  the  arterioles,  and 
finally  the  hepatic  cells. 

Amyloid  liver  per  se  produces  few  symptoms.  Ascites  is  rarely  pres- 
ent except  in  cases  in  which  the  liver  is  very  large,  and  jaundice  does  not 
occur.  In  addition  to  the  symptoms  of  the  original  disease  in  the  course 
of  which  the  amyloid  degeneration  occurs,  there  is  the  peculiar  waxy 
cachexia  which  is  seen  in  no  other  condition,  but  resembles  somewhat 
that  belonging  to  malignant  disease.  The  face  has  the  appearance  of  ala- 
baster, and  the  skin  has  a  singular  translucency.  The  liver  may  be  so 
large  as  to  form  a  tumoui-,  sometimes  nearly  filling  the  abdominal  cavity. 
Not  infrequently  it  extends  to  the  umbilicus,  and  even  to  the  crest  of  the 
ilium.  The  surface  is  smooth  and  hard,  and  the  edges  usually  sharp. 
There  is  no  localized  pain  or  tenderness.  The  spleen  is  invariably  en- 
larged. As  a  result  of  the  amyloid  degeneration  of  the  kidney,  there  may 
be  dropsy  and  albuminuria.  Dropsy  may  occur  from  pressure  of  the  large 
liver  upon  the  vena  cava,  apart  from  the  condition  of  the  kidney.  So 
many  complicating  conditions  are  usually  present  that  it  is  almost  im- 
possible to  say  which  of  the  other  symptoms  are  due  to  the  changes  in  the 
liver. 

Amyloid  changes  take  place  slowly,  the  whole  course  of  the  disease 
being  marked  by  years,  the  patient  dying  from  slow  asthenia,  from  ne- 
phritis, or  from  some  acute  intercurrent  disease.  As  a  rule,  cases  go  on 
steadily  from  bad  to  worse ;  but  sometimes,  after  the  disease  has  reached 
a  certain  point,  the  condition  is  stationary  for  a  long  time. 

The  prognosis  is  always  bad,  although  in  a  few  cases  improvement, 
and  even  cure,  are  stated  to  have  occurred  after  the  excision  of  the  diseased 
joints  upon  which  the  amyloid  degeneration  depended.  This,  however, 
is  a  result  which  is  not  often  met  with.  In  cases  of  amyloid  degeneration 
dependent  upon  syphilis,  the  usual  anti-syphilitic  remedies  should  be  given. 
In  other  cases,  no  treatment  is  of  any  avail  except  that  directed  toward  the 
removal  of  the  cause. 

FATTY   LIVER. 

This  consists  in  an  accumulation  of  fat  in  the  liver  cells.  It  is  gener- 
ally a  secondary  condition  in  childhood,  and  causes  no  symptoms  by  which 
it  can  be  positively  recognised. 

Fatty  liver  is  found  at  autopsy  chiefly  in  children  dying  of  marasmus, 
general  tuberculosis,  and  in  the  other  varieties  of  wasting  disease,  especially 


414  DISEASES   OP  THE   DIGESTIVE  SYSTEM. 

those  associated  with  the  digestive  tract.  In  such  patients  it  is  par- 
ticukirly  common,  but  under  other  conditions  it  is  quite  rare.  It  is 
found  in  children  of  all  ages,  being  frequent  in  infants. 

The  liver  is  moderately  enlarged,  smooth,  with  rounded  edges,  of  a 
yellowish-red  or  a  lemon-yellow  colour,  and  can  be  indented  with  the 
finger.  A  warm  knife  becomes  coated  with  oil  after  cutting.  Microscopic- 
ally there  is  seen  an  accumulation  of  fat  in  the  liver  cells,  usually  irregu- 
larly distributed. 

Jaundice,  ascites,  and  the  other  peculiar  symptoms  of  hepatic  disease, 
are  absent.  The  liver  is  moderately  increased  in  size  and  its  functions  are 
interfered  with,  but  not  in  such  a  way  as  to  be  recognised  by  the  symptoms. 

The  treatment  is  that  of  the  original  disease. 

HYDATIDS. 

Echinococcus  disease  of  the  liver,  while  rare  among  adults  in  this 
country,  is  almost  unknown  in  children.  I  have  been  able  to  find  but  two 
recorded  cases  in  America. 

From  twenty-two  European  cases  collected  by  Pontou  (Paris,  1867), 
it  appears  that  unilocular  cysts  are  especially  frequent  in  young  subjects. 
The  disease  may  be  latent  for  months  or  years.  The  earliest  symptoms 
are  localized  pain,  jaundice,  and  occasionally  fever.  Later  there  is  en- 
largement of  the  liver,  particularly  of  the  right  lobe.  If  the  upper  surface 
is  affected,  pulmonary  symptoms,  cough  and  dyspnoea,  are  usually  present ; 
if  the  under  surface  of  the  organ,  there  is  pressure  upon  the  portal  vein, 
the  vena  cava,  bile  ducts,  stomach,  and  intestines.  This  pressure  may 
cause  icterus,  dilatation  of  the  superficial  abdominal  veins,  and  sometimes 
ascites.  The  local  signs  are  enlargement  of  the  liver  with  a  tumour, 
which  is  easily  recognised  in  children  because  of  the  thin  abdominal 
walls.  The  hydatid  fremitus  is  usually  obtained.  By  aspiration  a  clear 
fluid  is  withdrawn,  showing  under  the  microscope  the  presence  of  the 
booklets,  which  establishes  the  diagnosis.  Occasionally  cure  may  take 
place  by  spontaneous  rupture  or  suppuration  of  the  cyst,  but  in  most 
cases,  when  left  to  itself,  the  disease  proves  fatal.  The  treatment  is  surgi- 
cal, and  consists  in  aspiration  or  in  incision,  and  the  evacuation  of  the  cyst. 

BILIARY   CALCULL 

Up  to  the  age  of  puberty  calculi  are  extremely  rare.  Walker*  has 
reported  a  case  in  a  child  dying  at  three  months,  who  had  symptoms  from 
the  age  of  one  month.  Parrot  has  put  on  record  one  case  in  an  infant 
twelve  days  old.  Frerichs  records  one  in  a  child  of  seven,  and  Simon  one 
at  six  years.  In  the  cases  reported  the  symptoms  have  been  like  those  of 
adults — colic  and  icterus,  and  finally  the  passage  of  the  stone  by  the  bowels. 


British  Medical  Journal,  1882. 


ACUTE  PEUITUNITIS. 


415 


CHAPTER   XIII. 
DISEASES  OF  THE  PERITONEUM. 

Inflammation  of  the  peritonanim  is  not  very  frequent  in  childhood, 
because  at  this  time  most  of  the  causes  which  are  operative  in  later  life 
either  do  not  exist  at  all  or  are  very  infrequent.  An  analysis  of  187  col- 
lected cases  of  peritonitis — not  including  those  associated  with  appendi- 
citis— gave  the  following  results,  which  are  of  some  interest  as  showing 
tlie  relative  frequency  of  the  different  forms  in  early  life : 


Acute. 

Chronic. 

Total. 

22 
22 

40 

IS 

10 
15 
IG 

88 

32- 

37 

Purulent 

62 
56 

Total 

108 

79 

187 

We  shall  consider  separately  acute,  chronic,  and  tuberculous  peritonitis. 


AC  LITE   PERITONITIS. 

Acute  peritonitis  may  occur  at  any  period  of  infancy  or  childhood. 
It  may  even  exist  in  intra-uterine  life.  In  the  newly  born,  peritonitis  is 
quite  frequent.  After  this  time  it  is  exceedingly  rare  during  infancy,  onlv 
four  cases,  including  all  varieties,  being  met  with  in  720  consecutive  au- 
topsies in  the  New  York  Infant  Asylum.  After  the  fifth  year  the  dis- 
ease is  relatively  much  more  common.  Of  the  187  cases  above  referred 
to,  25  per  cent  occurred  in  the  newly  born,  21  per  cent  between  one  and 
five  years,  and  54  per  cent  between  the  fifth  and  the  sixteenth  years. 

Etiology. — In  the  newly  born,  peritonitis  is  seen  as  one  of  the  most 
frequent  lesions  of  acute  pyogenic  infection  (page  81).  It  is  usually  due 
to  direct  infection  through  the  umbilical  vessels.  In  infancy  and  child- 
hood, peritonitis  occurs  both  as  a  primary  and  secondary  inflammation. 
The  primary  form  is  rare.  It  may  be  due  to  traumatism,  such  as  falls  or 
blows,  or  to  surgical  operations  upon  the  abdomen ;  it  has  occurred  after 
an  injection  for  the  cure  of  a  congenital  hydrocele.  In  a  very  small 
number  of  cases  the  inflammation  seems  to  have  been  excited  by  cold 
or  exposure,  and  it  may  follow  severe  burns. 

The  secondary  form  is  more  common.  The  most  frequent  of  all 
causes  is  appendicitis.  These  cases  are,  however,  considered  separately 
elsewhere.  Extension  of  inflammation  from  the  viscera  to  the  peritonaeum 
is  very  much  less  frequent  in  children  than  in  adults.  It  was  met  with  but 
once  in  my  autopsies  (about  130  in  number)  in  acute  intestinal  diseases. 
28 


416  DISEASES   OP   THE   DIGESTIVE  SYSTEM. 

It  is  also  rare  in  typhoid  fever,  being  noted  but  twice  among  my 
collected  cases.  It  is  occasionally  due  to  abscess  of  the  liver,  ulcer  of 
the  stomach,  acute  intestinal  obstruction  from  internal  strangulation, 
intussusception,  volvulus,  or  congenital  atresia.  It  may  extend  from  in- 
flammation of  the  pleura.  This  may  be  in  the  form  of  empyema  which 
burrows  through  the  diajDhragm,  or,  without  burrowing,  the  infection 
may  take  place  through  the  lymph  channels.  It  is  not  very  infre- 
quently due  to  infection  through  the  female  genital  tract,  especially  in 
gonorrhoeal  vulvo-vagiuitis  in  young  girls.  Extension  of  inflammation 
from  the  male  genital  organs  is  not  common.  In  one  case  at  the  New 
York  Infant  Asylum,  fatal  peritonitis  in  an  infant  originated  in  a  sup- 
purative inflammation  of  the  tunica  vaginalis  of  unknown  origin,  the 
infection  extending  into  the  peritonaeum  through  the  inguinal  canal. 
Any  abscess  in  the  neighbourhood  may  rupture  into  the  i^eritonreum 
and  excite  peritonitis.  The  most  frequent  in  children  are  those  con- 
nected with  Pott's  disease,  perinephritis,  and  cellulitis  of  the  abdominal 
wall. 

Of  the  acute  infectious  diseases,  peritonitis  is  most  frequently  seen  with 
pneumonia  and  scarlet  fever.  In  four  cases  occurring  in  the  New  York 
Infant  Asylum  the  disease  was  twice  secondary  to  pneumonia,  in  both 
complicated  by  extensive  pleurisy.  It  may  be  accompanied  by  pericar- 
ditis, and  even  by  meningitis. 

The  bacteria  most  frequently  associated  with  acute  peritonitis  in  chil- 
dren are :  the  streptococcus,  especially  in  the  newly  born  ;  the  micrococcus 
lanceolatus  (pneumococcus),  in  cases  complicating  pneumonia  or  empy- 
ema; and  the  bacterium  coli  commune  in  those  following  intestinal  per- 
foration. These  may  be  associated  with  other  pyogenic  bacteria,  or  less 
frequently  the  latter  may  occur  alone. 

Lesions. — In  the  fibrinous  form  we  have  changes  similar  to  those  oc- 
curring in  inflammation  of  the  pleura  and  the  other  serous  membranes. 
The  peritoneum  is  injected  and  lymph  is  thrown  out  in  considerable  quan- 
tity, usually  accompanied  by  a  small  amount  of  serum.  The  process  may 
be  localized  or  general.  It  is  more  frequently  general  in  the  child  than  in 
the  adult.  The  peritonseum  lining  the  abdominal  wall,  as  well  as  that 
covering  the  coils  of  intestine  and  the  solid  viscera,  is  covered  by  patches 
of  yellowish-gray  lymph,  causing  adhesions  between  the  various  viscera 
and  often  matting  the  intestines  together.  In  recent  cases  these  adhesions 
are  soft,  and  easily  broken  down ;  in  old  cases  they  are  quite  firm,  and 
they  may  result  in  the  formation  of  connective-tissue  bands  which  are  the 
source  of  subsequent  trouble. 

In  the  serous  form  there  is  a  moderate  amount  of  lymph,  generally 
less  than  in  the  plastic  variety,  and,  in  addition,  an  outpouring  of  serum 
in  considerable  quantity.  This  is  usually  clear,  but  may  be  turbid  from 
flakes  of  lymph,  or  it  may  even  be  bloody.     In  most  cases  the  amount  is 


ACUTE  PERITONITIS.  417 

not  very  large,  usually  varying  from  lialf  a  pint  to  two  pints.  In  cases 
going  on  to  recovery  the  serum  is  absorbed,  but  there  may  result  adhe- 
sions as  in  the  preceding  variety. 

In  the  purulent  form  the  products  are  serum,  lymph,  and  pus.  When 
peritonitis  results  from  perforation  it  is,  as  a  rule,  purulent  from  the  outset, 
and  the  pus  is  foul  and  stinking.  The  amount  of  pus  is  generally  larger 
than  in  adult  cases.  When  the  disease  proves  fatal  in  a  few  days  there  is 
found  an  extensive  exudation  of  plastic  lymph,  with  the  formation  of  small 
pockets  containing  pus  among  the  coils  of  intestine.  Occasionally  there 
may  be  larger  collections  of  pus  in  the  peritoneal  cavity.  In  cases  which 
have  lasted  a  longer  time — generally  those  of  localized  inflammation — the 
process  results  in  the  formation  of  a  peritoneal  abscess.  This  consists  in 
a  collection  of  pus  in  some  part  of  the  peritoneal  cavity,  the  situation  de- 
pending upon  the  cause,  but  it  is  usually  in  one  iliac  fossa  or  in  the  pelvis. 
The  abscess  is  shut  off  from  the  rest  of  the  peritoneal  cavity  by  a  thick 
wall  of  fibrin.  If  left  alone,  such  abscesses  may  open  into  the  rectum, 
vagina,  bladder,  pelvis  of  the  kidney,  or  externally,  usually  at  the  umbili- 
cus. After  the  discharge  of  pus  the  cavity  may  contract  and  fill  up  by 
granulations,  and  the  patient  recover. 

Inflammations  of  the  other  serous  membranes,  especially  the  pleura,  are 
often  associated  with  peritonitis. 

Symptoms. — The  symptoms  of  acute  peritonitis  in  older  children,  as  in 
adults,  are  usually  well  marked  and  suflficiently  characteristic  to  enable 
one  to  recognise  the  disease  easily ;  but  not  so  in  the  case  of  infants.  In 
them  the  symptoms  are  often  obscure,  and  the  disease  may  be  found  at 
autopsy  when  not  suspected  during  life.  The  onset  is  nearly  always 
abrupt,  with  fever  and  vomiting.  As  a  rule,  the  temperature  is  high — 
from  103°  to  105°  F.  Vomiting  may  be  only  at  the  onset,  but  it  often 
continues  throughout  the  disease.  Older  children  complain  of  pain, 
which  may  be  localized  or  general ;  and  in  younger  ones  this  is  indicated 
by  restlessness,  crying,  and  fretfulness.  The  abdomen  very  soon  becomes 
swollen  and  tympanitic,  this  being  one  of  the  most  constant  features 
of  the  disease.  The  distention  is  generally  uniform,  but  it  may  be  irregu- 
lar. It  is  very  rare  in  acute  cases  that  there  is  a  sufficient  amount  of  fluid 
present  to  give  the  sensation  of  fluctuation.  There  are  tenderness  on  pres- 
sure, and  usually  marked  rigidity  of  the  abdominal  walls.  The  position 
assumed  by  the  patient  is  generally  dorsal,  with  the  thighs  flexed.  The 
bowels  are  in  most  cases  constipated,  but  diarrhoea  is  by  no  means  rare. 
The  abdominal  distention  causes  dyspnunx  and  thoracic  breathing.  There 
may  be  retention  of  urine  or  frequent  micturition. 

The  general  symptoms  almost  from  the  beginning,  are  those  of  a  seri- 
ous disease.  The  pulse  is  small,  rapid,  and  compressible.  The  prostra- 
tion is  great,  from  the  very  outset.  The  face  is  pinched,  the  mouth  is 
drawn,  and  the  features  indicate  pain.     In  bad  cases  there  may  be  hie- 


418  DISEASES  OF   THE   DIGESTIVE  SYSTEM. 

cough,  cold  extremities,  clammy  perspiration,  and  collapse.     The  mind  is 
usually  clear. 

In  the  most  severe  forms  of  general  peritonitis  the  course  is  short  and 
intense,  and  the  disease  goes  on  rapidly  from  bad  to  worse  until  death 
occurs.  In  infants  this  is  often  on  the  second  or  third  day.  The  most 
severe  forms  of  general  peritonitis  in  older  children  run  the  same  rapid 
course.  In  other  cases  the  course  is  slower,  lasting  a  week  or  ten  days. 
If  the  patient  lives  longer  than  this  the  case  is  more  hopeful,  because  the 
process  is  more  apt  to  be  localized.  The  development  of  peritoneal  ab- 
scess is  indicated  by  the  continuance  of  the  temperature,  which  may 
assume  a  hectic  type,  and  be  accompanied  by  chills  and  sweating.  There 
are  the  local  signs  of  an  abdominal  tumour. 

Prognosis. — Acute  general  peritonitis,  whatever  its  cause,  is  a  very  seri- 
ous disease  in  childhood.  Of  eighty  cases  of  all  varieties  under  sixteen 
years  of  age,  sixty-nine  per  cent  died.  In  the  newly  born  and  in  infancy 
the  disease  is  almost  invariably  fatal.  In  older  children  the  outlook  is  not 
quite  so  hopeless,  and  depends  upon  the  exciting  cause.  It  is  better  in 
localized  than  in  general  inflammation  ;  also  in  the  fibrinous  than  in 
the  purulent  form ;  but  the  most  favourable  cases  are  those  with  a  sero- 
fibrinous exudation. 

Treatment. — The  treatment  of  acute  peritonitis  in  infants  and  young 
children  is  very  unsatisfactory,  since  it  is  almost  invariably  fatal.  In 
older  children  it  is  to  be  conducted  along  the  same  general  lines  as  in 
adults.  For  a  local  application,  cold  is  usually  to  be  preferred  if  it  is  well 
borne.  It  may  be  applied  either  by  an  ice-bag  or  by  Leiter's  coil.  Many 
children,  however,  rebel  against  cold  applications,  and  for  them  heat  must 
be  substituted.  The  most  satisfactory  way  of  applying  heat  is  by  spongio- 
piline,  which  is  wrung  out  of  very  hot  water  and  applied  over  the  whole 
abdomen.  It  may  be  sprinkled  with  spirits  of  turpentine  if  counter-irri- 
tation is  desired,  or  a  light  poultice  may  be  used.  Feeding  and  stimulation 
are  especially  difficult  on  account  of  vomiting.  The  diet  should  be  milk 
whenever  this  can  be  retained,  which  preferably  should  be  peptonized. 
Kumyss  may  be  tried  when  milk  is  rejected.  Brandy  with  ice  may  be 
used  as  a  stimulant,  or,  if  this  is  vomited,  champagne.  No  effort  should 
be  made  to  overcome  the  constipation  except  at  the  very  outset,  when 
a  saline  cathartic  may  possibly  be  admissible,  but  never  at  a  later  period. 
The  treatment  by  opium  is  the  only  one  upon  which  any  dependence  can 
be  placed  as  influencing  the  disease.  This  is  preferably  given  hypoder- 
mically,  on  account  of  the  vomiting.  The  dose  must  be  regulated  by  the 
condition  of  the  patient.  Enough  should  be  administered  to  control  pain 
and  peristalsis.  The  amount  required  must  be  determined  by  the  condi- 
tions in  each  case.  An  initial  hy2:)odermic  dose  of  morphine  for  a  child  of 
five  years  should  be  from  J^  to  -^^  grain.  This  will  ordinarily  need  to  be 
repeated  every  two  or  three  hours.     There  is  great  tolerance  of  opium  in 


CHRONIC  PERITONITIS.  4I9 

cases  of  peritonitis,  but  tliere  is  no  advantage  in  pushing  the  drug  further 
than  is  required  to  relieve  the  symptoms  mentioned.  There  are  com- 
paratively few  cases  in  children  in  which  the  question  of  operation  arises 
during  the  acute  stage,  except  in  those  depending  upon  appendicitis.  The 
cases  of  acute  perforative  peritonitis  are  almost  certain  to  die  under  any 
treatment.  Surgical  interference  is  always  indicated  in  peritoneal  abscesses 
wiiicli  have  passed  the  active  stage.  These  should  be  opened  and  drained 
in  accordance  with  general  surgical  principles.  Aspiration  is  not  to  be 
depended  ujjon,  and  should  be  used  only  as  a  means  of  diagnosis. 

CHRONIC   (NON-TUBERCULOUS)   PERITONITIS. 

Peritonitis  may  occur  in  foetal  life  with  the  production  of  extensive 
adhesions,  which  may  interfere  with  the  development  of  the  intestine  and 
result  in  various  malformations.  These  cases  have  been  ascribed  by  Sil- 
bermann  *  to  syphilis. 

Chronic  peritonitis  may  follow  the  acute  form,  in  which  there  are  left 
adhesions  which  slowly  increase  owing  to  the  production  of  new  connect- 
ive tissue.     Such  cases  are  sometimes  chronic  from  the  beginning. 

The  peritoneal  abscesses  which  follow  the  suppurative  form  may  run  a 
chronic  course.  Chronic  localized  peritonitis  may  occur  in  connection 
with  disease  of  any  of  the  organs  covered  by  the  peritonaeum.  This  is 
most  commonly  witli  the  si)leen,  liver,  and  kidney. 

Chronic  Peritonitis  with  Ascites. — In  most  cases  this  is  chronic  from 
the  outset  and  independent  of  the  above  causes.  By  far  the  most  frequent 
form  of  inflammation  is  that  due  to  tuberculosis,  and  by  some  writers  the 
opinion  is  still  held  that  this  form  is  always  tuberculous.  After  the  obser- 
vations reported  by  Henoch,  Vierordt,  Fiedler,  and  others,  there  seems  to 
be  no  longer  any  room  for  doubt  regarding  the  existence  of  a  chronic  non- 
tuberculous  form  of  peritonitis  with  ascites,  although  it  must  be  considered 
a  rare  disease.  In  its  pathological  and  clinical  aspects  it  is  to  be  compared 
to  subacute  or  chronic  pleurisy  with  effusion. 

Etiology. — Nearly  all  tiie  cases  thus  far  reported  have  occurred  in 
children  over  six  years.  Tiie  causes  are  for  the  most  part  obscure.  The 
disease  has  been  attributed  to  exposure,  rheumatism,  and  injury.  In 
a  few  instances  it  has  followed  measles.  It  may  be  associated  with  disease 
of  the  intestines  or  the  solid  viscera  of  the  abdomen,  especially  with  new 
growths  of  the  kidney,  liver,  etc. 

Lesions. — The  post-mortem  observations  thus  far  have  been  few.  In 
the  reported  cases  there  has  been  found  a  large  amount  of  greenish  serum 
in  the  general  peritoneal  cavity,  with  a  very  moderate  amount  of  fibrin  and 
adhesions,  which  are  sometimes  few  and  sometimes  very  numerous.  Chronic 
pleurisy  may  be  associated. 

*  Jahrbuch  fiir  Kinderh.,  Bd.  xviii,  420. 


420  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

Symptoms. — The  early  symptoms  are  of  a  very  indefinite  character, 
such  as  a  decline  in  the  general  health,  or  dyspeptic  symptoms ;  but  often 
nothing  whatever  is  noticed  until  the  swelling  of  the  abdomen  begins. 
The  enlargement  comes  on  rather  gradually  in  the  course  of  a  few  weeks. 
Pain  is  slight,  or  wanting  altogether.  There  may  be  some  abdominal  ten- 
derness, but  this  is  rarely  marked.  The  bowels  are  irregular ;  sometimes 
there  is  diarrhoea  and  sometimes  constipation.  The  abdomen  is  usually 
distended  with  fluid,  the  umbilicus  protruding,  and  the  superficial  veins 
prominent.  The  enlargement  is  generally  regular  and  symmetrical,  and 
the  wave  of  fluctuation  is  readily  obtained.  The  general  symptoms  are 
very  few.  In  some  cases  there  is  a  slight  evening  rise  of  temperature  of 
one  or  two  degrees.  There  may  be  general  weakness,  loss  of  appetite, 
and  moderate  anaemia. 

The  usual  course  of  the  disease  is  for  the  fluid  to  remain  for  a  time 
and  then  undergo  slow  absor2:>tion,  the  case  going  on  to  comjilete  recov- 
ery. Occasionally  relapses  are  seen.  The  results  are  not  always  so  favour- 
able, for  in  some  instances  there  is  no  tendency  to  absorption  of  the  fluid, 
the  general  health  is  gradually  undermined,  and  the  patients  die  from 
exhaustion  or  from  some  intercurrent  disease.  The  diagnosis  rests  upon 
the  presence  of  ascites,  developing  gradually  without  any  signs  or  symp- 
toms of  disease  in  the  heart,  liver,  or  other  organs.  The  points  which 
distinguish  it  from  tuberculous  peritonitis  are  considered  under  that  dis- 
ease. In  the  cases  which  recover,  the  fact  that  no  other  signs  of  tubercu- 
losis subsequently  develop  is  an  important  point  in  diagnosis.  The  prog- 
nosis is  in  most  cases  favourable,  but  must  be  guarded  on  account  of  the 
difficulty  in  making  a  positive  diagnosis  from  the  tuberculous  form.  Ee- 
covery  is  usually  complete  and  permanent. 

Treatment. — It  is  important  that  the  patient  should  be  kept  at  rest, 
preferably  confined  to  bed.  The  best  results  are  usually  obtained  by  the 
adoption  of  a  general  tonic  plan  of  treatment.  If  absorption  of  the 
fluid  does  not  begin  with  such  means,  saline  diuretics  should  be  given  and 
the  amount  of  fluid  allowed  the  patient  limited.  When  there  is  no  tend- 
ency to  absorption  after  a  thorough  trial  of  the  above  measures,  and 
especially  when  the  patient's  general  health  begins  to  siiffer,  the  fluid 
should  be  removed  by  aspiration.  If  it  continues  to  accumulate  after 
repeated  aspirations,  laparotomy  may  be  performed,  for  in  some  cases 
this  has  the  same  beneficial  effect  as  in  tuberculous  peritonitis. 

TUBERCULOUS   PERITONITIS. 

The  peritonaeum  is  quite  frequently  the  seat  of  tuberculous  inflamma- 
tion in  early  life;  but  not  so  often  in  infants  as  in  older  children.  Of 
56  collected  cases,  7  were  under  three  years  of  age,  26  from  three  to  eight 
years,  and  23  from  eight  to  sixteen  years.  In  119  autopsies  upon  tubercu- 
lous patients,  most  of  them  under  three  years  old,  of  which  I  have  records. 


TUBERCULOUS  PERITONITIS.  421 

the  peritonaeum  was  involved  in  8-5  per  cent.  In  105  autopsies,  for  the 
most  part  upon  older  tuberculous  children,  Ashby  found  the  peritoneum 
involved  in  3G  per  cent.  In  883  collected  autopsies  upon  tuberculous  chil- 
dren of  all  ages,  Biedert  *  found  the  peritonajum  involved  in  18'3  per  cent. 
These  figures  do  not  represent  the  number  of  cases  of  tuberculous  peri- 
tonitis, as  in  many  of  them  only  a  few  miliary  tubercles  were  present. 

It  is  no  doubt  possible  for  peritonitis  to  occur  as  the  primary  lesion  of 
tuberculosis,  but  in  the  great  majority  of  cases  it  is  secondary.  It  may, 
however,  appear  as  the  most  important  tuberculous  lesion  in  the  body. 
The  peritonaeum  may  be  infected  directly  from  the  intestine,  the  mesenteric 
glands  or  the  pleura,  or  from  more  distant  parts,  like  the  lungs,  the  bron- 
chial glands,  the  cervical,  or  other  external  glands.  In  a  small  number  of 
cases  some  local  exciting  cause  is  present,  such  as  a  fall  or  blow  upon  the 
abdomen.  It  may  follow  exposure,  or  occur  as  a  sequel  to  one  of  the 
exanthemata. 

Tuberculous  peritonitis  may  be  acute  or  chronic.  It  presents  several 
varieties  quite  distinct  from  one  another,  both  in  their  pathological  and 
clinical  features. 

1.  Miliary  Tuberculosis  of  the  Peritonaeum  accompanying  General  Tu- 
berculosis.— Tlie  peritonaeum  may  be  involved  as  one  of  the  lesions  in 
acute  or  subacute  general  miliary  tuberculosis.  This  is  the  most  common 
form  seen  in  infants.  The  lesions  consist  in  a  deposit  of  miliary  tuber- 
cles, which  are  generally  rather  sparsely  scattered  over  the  peritonaeum. 
The  evidences  of  inflammation  are  very  slight,  or  they  may  be  absent  alto- 
gether. These  cases  do  not  come  under  observation  as  cases  of  peritonitis, 
as  there  are  no  abdominal  symptoms. 

2.  Miliary  Tuberculosis  of  the  Peritonaeum  with  Ascites. — Although 
not  the  most  common  variety  in  children,  these  cases  form  an  important 
group.  The  peritonseum  is  thickly  sown  with  miliary  tubercles,  both  dis- 
crete and  in  conglomerate  masses.  They  are  found  in  the  omentum  and 
the  mesentery,  upon  the  surface  of  the  intestines  and  the  solid  viscera. 
The  peritonaeum  shows  in  varying  degrees  the  changes  of  acute  or  sub- 
acute inflammation.  There  is  congestion,  with  the  production  of  a  mod- 
erate amount  of  fibrin  and  a  large  amount  of  serum.  In  the  most  acute 
cases  the  fluid  is  in  the  general  peritoneal  cavity.  In  those  of  longer  du- 
ration it  may  be  sacculated.  The  fluid  is  usually  abundant,  but  not  excess- 
ive. It  is  most  commonly  an  olive-coloured  serum,  but  it  nuiy  be  sero- 
purulent,  and  even  bloody.  There  are  commonly  other  lesions  of  tubercu- 
losis in  the  body,  but  they  are  less  marked  than  those  of  the  peritoneum. 

Tiiese  ascitic  cases  generally  run  an  acute  or  subacute  course,  the  usual 
duration  being  from  four  to  eight  weeks.      Clinically  they  present  the 

*  Jahrbuch  fiir  Kinderh.,  xxi,  178 ;  see  also  Osier,  Johns  Hopkins  Hospital  Reports, 
vol.  ii. 


422  DISEASES  OF   THE   DIGESTIVE  SYSTEM. 

symptoms  of  a  moderate  grade  of  peritoneal  inflammation  with  ascites. 
The  onset  is  rather  gradual,  with  indefinite  general  symptoms.  There  is 
usually  some  fever— 100°  to  101-5°  F.  There  are  general  weakness,  pros- 
tration, and  loss  of  flesh,  but  not  rapid  emaciation.  Vomiting  is  not 
prominent,  and  pain  and  tenderness  are  rarely  very  marked.  There  may 
be  nothing  distinctive  until  distention  of  the  abdomen  is  seen.  This  at 
first  is  due  to  gas,  but  later  to  fluid,  which  may  accumulate  in  sufficient 
quantity  to  fill  the  general  peritoneal  cavity.  The  bowels  are  constipated, 
or  there  may  be  diarrhoea. 

The  usual  course,  when  untreated,  is  for  the  disease  to  go  on  to  a  fatal 
termination  from  exhaustion.  Less  frequently  the  fluid  is  absorbed,  and 
the  case  becomes  one  of  the  fibrous  type,  with  a  tendency  to  relapses; 
rarely  it  is  followed  by  the  ulcerative  form. 

3.  The  Fibrous  Form. — This,  in  its  general  characters,  may  be  com- 
pared to  the  fibroid  form  of  pulmonary  tuberculosis.  There  is  a  tuber- 
culous inflammation,  the  products  of  which  have  undergone  transfor- 
mation into  fibrous  tissue.  This  may  in  a  certain  sense  be  regarded  as 
a  method  of  cure.  The  essential  feature  of  the  lesion  in  these  cases  is  the 
production  of  extensive  organized  adhesions  between  the  intestinal  coils, 
and  between  the  intestines  and  the  abdominal  walls.  The  intestines  may 
be  compressed  against  the  spine  by  bands.  Ascites  may  be  present,  but  it 
is  frequently  absent  altogether.  If  there  is  fluid,  it  may  be  in  the  gen- 
eral peritoneal  cavity,  or  it  may  be  sacculated,  and  it  may  consist  either 
of  serum  or  of  sero-pus.  There  is  no  tendency  to  caseation  or  breaking 
down. 

Clinically  these  cases  are  distinguished  by  their  slow,  irregular  course. 
They  are  the  most  chronic  of  all  the  forms.  The  disease  may  be  chronic 
from  the  outset,  or  it  may  follow  the  variety  previously  mentioned.  The 
onset  is  generally  insidious;  fever  is  slight,  or  entirely  absent.  There 
is  rarely  vomiting.  The  bowels  may  be  constipated  or  loose.  For  a 
long  time  the  general  health  may  remain  good.  The  only  characteristic 
symptom  is  the  enlargement  of  the  abdomen.  In  the  early  part  of  the 
disease  this  is  chiefly  from  the  tympanites,  but  later  it  may  depend  wholly 
or  in  part  upon  an  accumulation  of  fluid.  Ascites  usually  develops  very 
slowly,  but  may  be  abundant.  The  adhesions  of  the  intestines  may  give 
rise  to  irregularities  in  the  outline  of  the  abdomen.  Ascites  may  be  pres- 
ent for  a  time  and  then  disappear  spontaneously,  and  the  general  health 
may  so  improve  that  the  patient  is  considered  quite  well.  There  may 
even  be  a  permanent  cure.  In  other  cases,  after  symptoms  have  been 
absent  for  some  time,  relapses  occur,  and  more  fluid  is  poured  out.  In 
addition  to  these  symptoms,  others  are  present  depending  upon  the  me- 
chanical effects  of  pressure  from  the  contracting  adhesions.  There  may 
be  more  or  less  constriction  of  the  intestine,  pressure  upon  the  vena  cava, 
the  renal  or  portal  veins,  the  thoracic  duct  or  its  branches,  or  upon  the 


TUBERCULOUS   PERITONITIS.  423 

stomach.     These  may  give  rise  to  dyspeptic  symptoms,  emaciation,  oedema 
of  the  lower  extremities,  and  albuminuria. 

In  some  cases  the  disease  is  entirely  latent,  and  it  is  discovered  at 
autopsy  when  there  have  been  either  no  abdominal  symptoms  during  life, 
or  only  colicky  pains  of  an  indefinite  character.  The  course  of  this  form 
is  slow  and  irregular ;  it  generally  lasts  for  from  three  to  twelve  months, 
although  with  intermissions  and  exacerbations  it  may  extend  over  several 
vears.  The  fatal  result  may  be  due  to  an  acute  exacerbation,  to  exhaus- 
tion, or  to  the  development  of  tuberculosis  elsewhere. 

4.  The  Ulcerative  Form. — This  is  an  inflammation  associated  with  large 
tuberculous  deposits  which  go  on  to  caseation  and  softening.  It  may  be 
compared  to  ulcerative  phthisis.  In  point  of  chronicity  it  is  midway  be- 
tween the  two  preceding  varieties.  It  is  one  of  tbe  most  frequent  forms 
seen  in  children,  and,  while  it  may  be  localized,  it  is  usually  general. 

There  is  commonly  a  very  abundant  fibrinous  exudate,  matting  the 
coils  of  intestine  together  and  causing  them  to  adhere  to  the  solid  viscera 
and  to  the  abdominal  walls.  In  this  exudate  there  are  seen  tuberculous 
deposits  consisting  of  small,  yellow  nodules  and  larger  caseous  masses, 
often  broken  down  at  the  centre.  These  caseous  deposits  are  also 
found  in  the  mesentery  and  in  the  omentum,  which  may  be  very  greatly 
thickened.  Pockets  are  formed  by  the  adhesions  which  sometimes  contain 
clear  serum,  but  more  frequently  pus  or  a  brownish  fluid.  The  tuber- 
culous deposits  are  found  upon  the  peritoneal  surface  of  the  intestine,  and 
infiltrate  the  intestinal  walls,  often  leading  to  perforation,  and  sometimes 
to  fistulous  communication  between  adherent  intestinal  coils.  There  may 
also  be  tuberculous  infiltration  of  the  abdominal  walls,  accompanied  by 
cellulitis,  resulting  in  abscesses,  which  open  externally,  usually  in  the 
neighbourhood  of  the  umbilicus. 

The  ulcerative  form  may  succeed  either  the  miliary  or  fibrous  form, 
or  the  inflammation  may  be  of  this  type  from  the  outset.  Tuberculous 
lesions  are  always  found  in  the  other  organs,  especially  in  the  lungs,  where 
they  are  usually  advanced. 

Clinically  the  ulcerative  cases  are  characterized  by  well-marked  consti- 
tutional symptoms,  which  are  due  partly  to  the  peritonitis  and  partly  to  the 
general  tuberculosis.  Fever  is  regularly  present,  the  temperature  usually 
ranging  from  99°  to  103°  F.  Sometimes  it  assumes  a  distinctly  hectic 
type.  There  are  progressive  emaciation,  ana?mia,  prostration,  and  sweating. 
Diarrhoea  is  frequent  and  the  intestinal  discharges  may  at  times  be  bloody. 
The  abdomen  is  large,  but  not  so  much  distended  as  in  some  of  the 
other  forms;  the  superficial  veins  are  often  prominent.  It  is  rare  that 
ascites  can  be  made  out  by  palpation,  although  fluid  can  usually  be  found 
•  by  puncture.  Areas  of  dulness  and  tympanitic  resonance  are  irregularly 
distributed  over  the  abdomen.  Nodular  masses  from  one  to  two  inches  in 
diameter  may  be  felt  on  palpation.     The  epigastric  and  umbilical  regions 


424  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

may  be  occupied  by  a  smootb,  hard,  and  board-like  tumour,  whicli  is  the 
thickened  omentum.  There  may  be  the  signs  of  phlegmonous  inflamma- 
tion of  the  abdominal  wall  iu  the  neighbourhood  of  the  umbilicus,  and 
even  an  abscess,  which,  after  opening,  may  leave  a  fistulous  communication 
with  the  peritoneum.  There  are  signs  of  disease  in  the  lungs,  and  the 
pulmonary  symptoms  may  mask  those  of  the  abdomen.  The  course  of 
the  disease  is  steady  and  progressive,  the  usual  duration  being  two  or 
three  months.  Death  results  from  the  pulmonary  disease,  from  tuberculous 
meningitis,  from  exhaustion,  and  occasionally  it  is  due  to  accidents  as- 
sociated with  perforation. 

5.  Peritonitis  associated  with  Tuberculosis  of  the  Mesenteric  Lymph 
Nodes. — These  nodes  may  be  tuberculous  in  any  of  the  preceding  varieties. 
In  certain  cases  this  is  the  principal  lesion,  and  it  is  accompanied  by  lo- 
calized peritonitis,  which  results  in  the  formation  of  a  large,  irregular, 
nodular  mass  lying  close  against  the  spine.  It  is  usually  associated  with 
tubercular  ulcers  of  the  intestine.  There  may  be  no  symptoms  except 
those  depending  upon  the  pressure  of  the  glandular  masses  upon  the  great 
vessels.  This  may  lead  to  oedema  or  to  thrombosis  of  the  vena  cava,  and 
may  give  rise  to  an  abdominal  tumour.  There  may  be  diarrhoea  due  to 
the  intestinal  lesions. 

Diagnosis  of  Tuberculous  Peritonitis. — In  children,  chronic  ascites  with 
fever  usually  means  tuberculous  jieritonitis.  If  the  abdominal  effusion  is 
sacculated  instead  of  diffuse,  the  probabilities  of  peritonitis  are  much  in- 
creased. If  there  are  added  the  physical  signs  and  symptoms  of  disease  of 
the  lungs,  the  diagnosis  is  almost  certain.  Cirrhosis  of  the  liver  is  much 
more  chronic  in  its  course,  and  is  very  rare  previous  to  the  ninth  year, 
being  almost  unknown  in  infancy  and  early  childhood.  In  it  there  is 
often  a  history  of  syphilis,  and  jaundice  may  be  present.  If  ascites  is  ab- 
sent, tuberculosis  of  the  peritonaeum  may  be  suspected  if  there  are  irreg- 
ular nodules  or  tumours  in  various  parts  of  the  abdomen,  with  tenderness, 
emaciation,  moderate  pain,  and  slight  fever.  Chronic  abscess  in  the  neigh- 
bourhood of  the  umbilicus  is  always  suspicious.  The  ulcerative  form  is 
almost  invariably  accompanied  by  evidences  of  advanced  disease  in  the 
lungs  and  other  organs,  and  is  easily  recognised.  The  fibroid  form  may 
be  suspected  if,  with  tuberculosis  of  other  organs,  there  are  irregular 
colicky  pains  and  abdominal  tenderness.  From  the  abdominal  symptoms 
alone  it  can  not  be  recognised  unless  there  is  ascites.  In  all  doubtful 
cases  an  exploratory  incision  should  be  made. 

Between  tuberculous  and  non-tuberculous  chronic  peritonitis  a  diag- 
nosis is  at  times  impossible.  If  there  is  a  good  family  history  ;  if  there  are 
no  signs  of  tuberculosis  in  the  lungs  or  elsewhere  ;  if  abdominal  tenderness 
is  slight  or  absent ;  if  there  are  no  nodular  tumours ;  if  fever  and  marked 
emaciation  are  wanting ;  and  if  the  amount  of  fluid  is  excessive,  the  prob- 
abilities are  in  favour  of  a  simple  inflammation.      There  are,  however. 


TUBERCULOUS  PERITONITIS.  425 

some  cases  in  which  the  diagnosis  can  be  made  only  by  an  exploratory  in- 
cision, and  sometimes  not  evon  then  without  an  examination  of  the  fibrous 
nodules  by  the  microscope  or  by  inoculation.  In  doubtful  cases  the 
chances  are  always  in  favour  of  tuberculous  inflammation  on  account  of  its 
greater  frequency. 

Prognosis. — This  depends  most  of  all  upon  the  form  of  the  disease. 
Cases  of  the  ulcerative  type  are  absolutely  hopeless.  In  the  ascitic  and 
fibrous  forms  the  prognosis  is  quite  good,  especially  since  the  general 
adoption  of  laparotomy  as  a  means  of  treatment.  Life  is  prolonged  in 
nearly  all  cases  by  the  operation,  and  a  considerable  number  are  perma- 
nently cured.  Exactly  in  what  proportion  a  permanent  cure  results,  it  is 
at  present  impossible  to  say,  for  most  of  the  reported  cases  were  not  under 
observation  long  enough  to  make  it  certain  that  relapses  did  not  occur. 

Treatment. — The  general  treatment  of  tuberculous  peritonitis  is  the 
same  as  that  of  tuberculosis  in  other  parts  of  the  body.  In  the  acute 
cases  the  local  symptoms  are  to  be  relieved  by  the  same  means  as  in  other 
forms  of  acute  peritonitis.  The  only  local  treatment  which  can  be  con- 
sidered in  any  way  curative  is  surgical.  Xothing  is  to  be  said  in  favour  of 
aspiration  except  for  purposes  of  diagnosis.  The  results  of  laparotomy  are 
so  satisfactory  that  the  question  of  operation  should  be  considered  in  every 
case.  The  most  favourable  cases  for  operation  are  those  of  the  ascitic 
variety.  Aldibert,*  in  his  monograph,  gives  the  indications  and  contra- 
indications for  ojDeration  as  follows :  Laparotomy  is  indicated  in  all  forms 
accompanied  by  ascites,  although  in  acute  cases  it  may  be  only  palliative ; 
in  suppurative  forms  which  are  diffuse,  or  with  a  unilocular  cyst;  in  all 
cases  of  intestinal  obstruction  in  the  course  of  tuberculous  peritonitis ;  and 
in  all  cases  of  doubtful  diagnosis.  Operation  is  contra-indicated  in  the 
fibrous  form  not  attended  by  pain,  this  usually  tending  to  spontaneous  re- 
covery; in  the  dry  ulcerative  form,  except  at  the  outset;  in  the  suppura- 
tive form  with  multilocular  cysts.  The  existence  of  other  foci  of  tuber- 
culosis does  not  contra-indicate  operation  except  when  these  are  chiefly 
intestinal,  or  when  there  is  general  tuberculosis  with  extensive  and  rapidly 
progressing  lesions. 

Aldibert  has  collected  statistics  of  fifty-two  operations  for  tuber- 
culous peritonitis  in  children,  with  seven  deaths  and  forty-five  recoveries. 
Nine  patients  were  reported  well  one  year  after  operation.  It  is  possible 
that  among  these  cases  some  of  simple  inflammation  have  been  included ; 
of  eighteen  cases,  however,  in  which  the  diagnosis  of  tuberculosis  was 
established  by  the  microscope  or  inoculation  experiments,  all  recovered,  and 
six  were  well  one  year  after  operation.  Why  it  is  that  the  operation  of 
opening  the  abdomen  and  draining  or  washing  out  the  peritoneal  cavity 
should  have  such  an  influence  in   arresting  the   disease,  has  not  yet 

*  De  la  Laparotomie  dans  la  Peritonite  Tuberculeuse  chez  I'Eiifant,  Paris,  1893. 


426  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 

been  satisfactorily  explained.     For  the  surgical  aspect  of  the  treatment 
the  reader  should  consult  works  upon  surgery. 

ASCITES. 

Ascites  consists  in  an  accumulation  of  fluid,  usually  clear  serum,  in  the 
general"  peritoneal  cavity.  It  is  a  symptom  of  the  various  forms  of  peri- 
tonitis, especially  the  chronic  varieties  described  in  the  preceding  pages. 
It  may  be  due  also  to  portal  obstruction  from  cirrhosis  of  the  liver,  or 
pressure  upon  the  portal  vein  by  peritoneal  adhesions  or  large  lymphatic 
glands.  It  is  occasionally  seen  in  all  forms  of  abdominal  tumours.  As- 
cites may  occur  in  general  dropsy  from  cardiac  disease,  chronic  pleurisy, 
or  interstitial  pneumonia,  and  from  any  condition  causing  pressure  upon 
the  vena  cava.  It  is  also  seen  in  the  general  dropsy  of  renal  disease.  A 
moderate  amount  of  ascites  is  often  met  with  in  extreme  anemia  or 
leucsemia^ 

Small  accumulations  of  fluid  in  the  peritoneal  cavity  are  difficult  of 
detection.  Large  amounts  are  generally  easily  made  out.  There  is  a  uni- 
form smooth  distention  of  the  abdomen  and  dilatation  of  the  superficial 
veins,  especially  about  the  umbilicus.  On  palpation,  the  wave  of  fluctu- 
ation can  be  obtained  by  placing  one  hand  against  the  abdomen  upon  one 
side  and  giving  the  opposite  side  a  sharp  tap.  A  similar  wave  may  be  felt 
when  there  is  tympanitic  distention.  The  two  are,  however,  readily  dis- 
tinguished by  having  an  assistant  make  pressure  with  the  edge  of  the  hand 
along  the  linea  alba  while  the  test  is  being  made  ;  this  obstructs  the  wave 
transmitted  through  the  abdominal  wall,  but  does  not  affect  that  through 
the  fluid.  On  percussion  in  the  sitting  posture,  there  are  dulness  below 
and  resonance  above.  When  the  patient  is  recumbent,  there  are  resonance 
in  the  median  line  and  dulness  or  flatness  in  the  lateral  portion  of  the 
abdomen. 

The  prognosis  and  treatment  of  ascites  will  depend  upon  its  cause. 

Chylous  Ascites. — This  term  is  applied  to  certain  cases  in  wliich  the 
abdominal  fluid  contains  fat.  The  colour  may  be  milky- white  or  light 
brown,  and  the  fluid,  after  standing,  may  have  at  its  surface  a  thick, 
creamy  layer.  The  amount  of  fat  present  has  been  as  high  as  five  per  cent. 
This  condition  is  rare  in  childhood.  In  1884,  Letulle*  could  find  but 
seven  cases  on  record.  The  exact  pathology  is  as  yet  not  well  understood. 
In  the  cases  which  have  thus  far  come  to  autopsy  there  has  usually 
been  found  chronic  peritonitis,  sometimes  simple,  sometimes  tuberculous. 
The  lymph  vessels  in  some  of  the  cases  have  been  empty,  and  often  no 
obstruction  of  the  lymph  circulation  could  be  discovered.  The  fat  is 
believed  by  some  to  be  derived  from  fatty  degeneration  of  the  products  of 
chronic  inflammation,  but  this  seems  hardly  sufficient  to  explain  the  large 

*  Revue  de  Medeciiie,  1884,  No.  9. 


SUBPHRENIC   ABSCESS. 


427 


amount  of  fat  sometimes  found.  In  some  of  the  cases  it  has  been  due 
to  a  wound  of  the  thoracic  duct.  The  amount  of  fluid  is  frequently  very 
large.  The  prognosis  is  usually  bad,  although  Pounds  has  reported  (Brit- 
ish Medical  Journal,  1892)  a  case  in  a  girl  of  ten  years,  where  recovery 
followed  laparotomy.     Tuberculous  peritonitis  was  present. 

SUBPHRENIC   ABSCESS. 

In  the  group  of  cases  of  localized  peritonitis  or  peritoneal  abscess  must 
be  included  subphrenic  abscess.  This  is  a  rare  condition  in  childhood, 
and  consists  in  an  accumulation  of  pus  just  beneath  the  diaphragm  and 
above  the  liver.  Its  cause  may  be  either  in  the  thorax  or  in  the  abdomen. 
It  may  complicate  acute  pneumonia,  usually  of  the  right  lower  lobe,  by  a 
direct  extension  of  infection  through  the  lymph  channels.  Sometimes 
it  has  been  associated  with  phthisical  cavities.  In  the  abdomen  it  may  be 
associated  with  disease  of  the  liver.  The  accumulation  of  pus  is  some- 
times very  great,  so  that  the  diaphragm  is  crowded  high  into  the  thorax. 

The  symptoms  and  j^hysical  signs  closely  resemble  those  of  empvema, 
and  most  of  the  cases  have  been  operated  upon  with  the  belief  that  the 
surgeon  was  dealing  witli  empyema.  Meltzer*  has  reported  a  case  in  a 
child  of  two  years  which  followed  pneumonia  of  the  right  base.  At  the 
operation  only  a  few  drops  of  pus  were  found  in  the  pleural  cavity  ;  but 
there  was  discovered  a  pinhole  opening  in  the  diaphragm,  from  which  the 
pus  had  escaped  from  a  large  subplirenic  abscess.  This  was  evacuated, 
and  the  patient  recovered  perfectly.  Subphrenic  abscesses  may  contain 
air ;  they  are  then  likely  to  be  mistaken  for  pneumothorax.  These  ab- 
scesses require  incision  and  drainage  like  other  forms  of  peritoneal  abscess. 

*  New  York  Medical  Journal,  June  24,  1893.     In  this  article  will  be  found  refer- 
ences to  the  recent  literature. 


SECTION  IV. 
DISEASES  OF  THE  EESPIRATORY  SYSTEM. 

CHAPTER   I. 

NASAL   CAVITIES. 

ACUTE  NASAL   CATARRH— CORYZA. 

Although  the  symptoms  of  this  disease  are  nasal,  the  principal  seat 
of  the  pathological  process  is  the  rhino-pharynx. 

Etiology. — Certain  children  are  predisposed  to  attacks  of  acute  nasal 
catarrh.  This  predisposition,  as  it  sometimes  extends  to  entire  families, 
may  be  inherited;  but  more  frequently  it  is  acquired,  and  usually  by  the 
following  mode  of  life :  It  is  seen  in  children  who  get  very  little  fresh  air, 
because  they  are  kept  indoors  unless  the  weather  is  perfect ;  Avho  live  in 
houses  always  overheated ;  whose  sleeping  rooms  are  kej)t  carefully  closed 
at  night  for  fear  they  may  take  cold ;  Avho  are  for  the  same  reason  so  over- 
loaded with  clothing  that  they  can  not  engage  in  any  active  play  without 
being  thrown  into  a  profuse  perspiration.  This  condition  after  a  time 
results  in  a  great  sensitiveness  of  all  the  mucous  membranes,  but  especially 
those  of  the  nose  and  pharynx.  A  small  adenoid  growth  is  very  often 
present.  Infants  under  three  months  old,  and  those  who  are  rachitic,  are 
frequent  sufferers  from  acute  nasal  catarrh.  It  may  be  seen  as  a  compli- 
cation of  dentition.  Attacks  are  often  brought  on  by  insufficient  covering 
for  the  head,  by  wetting  the  feet,  by  cold  and  exposure,  especially  to  the 
raw  winds  of  spring,  accompanied  by  the  dampness  which  occurs  with 
melting  snow.  In  susceptible  children  the  exciting  cause  is  often  a  very 
trivial  one.  A  draught  of  cold  air  for  a  few  minutes  may  be  sufficient  to 
excite  sneezing  and  a  nasal  discharge.  Atmospheric  conditions  are  prob- 
ably not  the  only  cause  of  acute  nasal  catarrh.  Micro-organisms  certainly 
play  an  important  part,  particularly  in  the  purulent  variety.  Although 
pyogenic  germs  are  always  present  in  the  nose,  they  do  not  excite  an 
attack  of  acute  catarrh  without  the  vascular  changes  which  are  produced 
by  other  causes.  Acute  catarrh  may  be  sporadic  or  epidemic  ;  it  is  prob- 
ably contagious,  being  communicated  by  children  ^^sing  the  same  hand- 
kerchief or  occupying  the  same  bed. 

Acute  nasal  catarrh  may  be  a  symptom  of  measles,  nasal  diphtheria,  or 
influenza,  and  it  may  accompany  erysipelas  of  the  face. 

428 


ACUTE  NASAL  CATARRH.  429 

Symptoms. — The  changes  in  the  mucous  membrane  of  the  nose  are  not 
great,  and  are  usually  secondary  to  those  of  the  rhino-pharynx,  being  in  a 
large  measure  due  to  the  discharge.  There  are  redness  and  slight  swell- 
ing. The  nasal  passages  may  be  for  the  time  quite  occluded  by  the  dis- 
charge, which  is  usually  profuse,  at  first  sero-mucous,  and  finally,  if  the 
attack  is  severe,  muco-purulent.  The  symptoms  may  be  very  transient, 
sometimes  passing  away  in  a  few  hours,  in  which  cases  there  is  only  a  vaso- 
motor disturbance;  or  they  may  continue  and  develop  into  a  true  inflam- 
mation. The  discharge  excoriates  the  nostrils  and  the  upper  lip.  At  the 
onset  there  is  usually  sneezing,  and  in  infants  often  a  slight  fever.  In 
older  children  there  is  no  rise  of  temperature  except  in  the  most  severe 
cases.  The  obstruction  to  nasal  respiration  causes  mouth-breathing,  and  the 
dryness  and  discomfort  which  result  from  it  produce  disturbed  sleep,  snuf- 
fling and  difficulty  in  nursing,  this  being  in  severe  cases  almost  impossible. 
The  inflammation  may  extend  to  the  lachrymal  duct,  involving  the  eyes  in 
a  mild  conjunctivitis.  There  may  be  closure  of  the  Eustachian  tubes, 
causing  deafness  and  otalgia.  There  may  also  be  secondary  otitis.  The 
process  often  extends  to  the  larynx  and  bronchi,  with  hoarseness  and  cough. 

In  infants,  severe  cases  may  be  followed  by  inflammation  of  the  lymph 
glands  of  the  neck  or  of  the  retro-pharyngeal  region  ;  in  either  it  may  ter- 
minate in  abscess.  Less  frequently  these  catarrhal  colds  are  accompanied 
by  disturbances  of  the  digestive  tract,  and  there  is  vomiting,  or  diarrhoea 
with  large  mucous  stools. 

Attacks  of  acute  nasal  catarrh  are  stated  by  some  writers  to  cause 
death  in  young  infants  by  interfering  with  respiration.  I  have  never 
seen  dangerous  symptoms,  and  believe  them  to  be  exceedingly  rare,  if,  in- 
deed, they  ever  occur  as  a  result  of  a  simple  coryza.  In  the  mild  form 
the  attack  lasts  from  two  to  three  days ;  in  the  severe  form  from  one 
to  two  weeks.  Repeated  attacks  are  frequently  followed  by  the  develop- 
ment of  the  chronic  form  of  the  disease. 

Diagnosis. — It  is  important  to  distinguish  between  a  simple  acute  ca- 
tarrh and  one  due  to  measles,  influenza,  nasal  diphtheria,  or  hereditary 
syphilis.  Measles  and  influenza  cause  more  fever  and  general  constitu- 
tional disturbance  than  does  simple  catarrh.  Nasal  diphtheria  is  charac- 
terized by  the  appearance  of  membrane  in  the  anterior  nares  and  by 
patches  upon  the  tonsils.  These  may  be  wanting,  however,  and  there  may 
be  only  a  very  profuse  discharge  tinged  with  blood.  When  persisting  for 
two  or  three  weeks  this  is  always  to  be  regarded  with  suspicion,  even  though 
the  constitutional  symptoms  may  be  very  slight.  The  only  positive  means 
of  excluding  diphtheria  is  by  cultures.  A  persistent  acute  nasal  catarrh  in 
a  youTig  infant  should  always  suggest  syphilis,  and  the  patient  should  be 
carefully  watched  for  tlie  development  of  other  symptoms. 

Treatment. — A  child  suffering  from  acute  coryza  should  always  be  kept 
indoors  in  a  room  with  an  even  temperature  of  about  70°  F.,  the  bowels 


430  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

freely  opened,  and  the  amount  of  food  somewhat  reduced.  The  only  drug 
which  seems  to  have  much  influence  upon  the  secretion  is  belladonna. 
This  may  be  given  in  the  form  of  atropine,  gr.  -g^-g-  every  hour  to  a  child 
of  six  months.  For  older  children  a  good  combination  is  that  known  as  the 
"  rhinitis  "  tablet  (camphor  gr.  i,  quinine  gr.  i,  fluid  extract  of  belladonna 
in,  1) ;  one  half  a  tablet  may  be  given  every  hour  to  a  child  of  five  years. 

Locally,  either  plain  sweet  oil  or  albolene  may  be  ajjplied  by  means  of 
a  medicine  dropper,  a  brush,  or  a  spray  (page  55),  an  alkaline  spray  (page 
56)  having  been  first  used  to  clear  away  the  secretion.  If  the  nasal  ob- 
struction causes  great  interference  with  nursing,  a  two-per-cent  solution 
of  cocaine  may  be  applied  with  a  brush,  or  with  a  probe  and  cotton,  or 
dropped  into  the  nostril  just  before  each  nursing.  This  is  not  to  be  ad- 
vised unless  the  symptoms  are  severe,  as  infants  are  quite  susceptible 
to  cocaine.  In  all  cases  the  upper  lip  and  nostrils  should  be  protected  by 
vaseline  or  some  simple  ointment.  Under  no  circumstances  should  irri- 
tating or  astringent  injections  be  given.  In  older  children  inhalations  of 
spirits  of  camphor  or  fumes  of  carbolic  acid  may  be  used  with  advantage. 

Prophylaxis  consists  in  solving  the  perplexing  question,  so  often  put  to 
the  physician,  of  how  to  prevent  children  from  "  taking  cold."  This  is  a 
matter  of  the  utmost  importance,  and  follows  what  has  been  previously 
said  under  the  head  of  Etiology.  No  amount  of  cod-liver  oil  and  iron 
will  remove  this  tendency  to  catarrh  so  long  as  bad  hygienic  conditions 
continue.  Sleeping  rooms  should  be  large  and  well  ventilated,  and  a 
window  should  be  kept  open  at  night,  except  in  very  severe  weather  or 
during  acute  attacks.  The  temperature  of  the  house  during  the  day  should 
be  from  68°  to  70°  F.,  but  never  above  this.  Children  should  be  accus- 
tomed to  go  out  of  doors  unless  the  weather  is  especially  bad.  So  firmly 
rooted  in  the  minds  of  the  laity  is  the  idea  that  acute  catarrhs  come  from 
cold,  that  the  habit  of  coddling  delicate  children  is  alwa3's  likely  to  be 
carried  to  an  extreme. 

With  every  delicate  and  "  catarrhal "  child  one  should  begin  in  the 
summer  by  having  him  live  in  the  open  air  as  much  as  possible,  sleeping 
in  a  room  with  free  ventilation,  with  moderate  covering,  and  continuing 
the  same  practice  into  the  fall  and  early  winter.  If  begun  gradually  in 
this  way  there  is  little  difficulty  in  continuing  throughout  the  winter. 

The  next  point  to  be  insisted  on  is  cold  sponging  immediately  upon 
rising  in  the  morning,  especially  about  the  chest,  throat,  and  spine  (page 
55).  The  use  of  chest  protectors,  cotton  pads,  and  extremely  thick  cloth- 
ing should  be  prohibited.  Flannel  underclothing  should  be  worn  upon 
the  chest  throughout  the  year,  and  upon  the  legs  also  in  winter ;  the  very 
lightest  in  summer,  and  only  a  medium  weight  in  winter. 

Frequently  repeated  attacks  point  to  the  presence  of  adenoid  vegeta- 
tions in  the  pharynx,  and  no  measures  are  of  much  avail  until  these  are 
removed. 


CHRONIC   XASAL   CATARRH.  431 


CHRONIC   NASAL   CATARRH. 

This  term  is  rather  loosely  used  to  designate  a  chronic  nasal  discharge. 
Such  a  discharge  is  frequent  both  in  infancy  and  childhood.  It  is  a  con- 
dition much  neglected  by  the  general  practitioner.  Patients  are  too  often 
subjected  to  routine  constitutional  treatment  by  cod-liver  oil  and  prep- 
arations of  iodine,  with  the  idea  that  such  cases  are  "scrofulous,"  while 
local  treatment  is  either  neglected  altogether,  or  consists  only  of  the  use  of 
the  nasal  douche  or  syringing  with  a  saline  solution.  Sometimes,  when 
suggested  by  parents,  local  treatment  is  opposed  by  the  physician  in  the 
case  of  young  children,  and  a  great  amount  of  harm  follows.  Permanent 
damage  to  the  organs  of  hearing,  smell,  speech,  and  respiration  may  result 
from  neglecting  or  ignoring  chronic  nasal  catarrh  iq,childhood. 

Chronic  nasal  catarrh  is  not  to  be  regarded  as  a  disease,  but  onlv  as 
a  symptom  which  may  be  due  to  any  one  of  a  variety  of  pathological  con- 
ditions, each  of  which  requires  very  different  treatment — viz.,  adenoid 
growths  of  the  pharynx,  foreign  bodies  in  the  nose,  polypi,  deviation 
of  the  septum  or  any  other  congenital  deformity  of  the  nasal  passages, 
the  various  forms  of  chronic  rhinitis,  and  syphilis,  which  causes  a  form  of 
rhinitis  peculiar  to  itself. 

Adenoid  Growths  of  the  Pharynx. — These  are  more  fully  discussed 
elsewhere  (page  263).  They  are  by  far  the  most  frequent  cause  of  chronic 
nasal  discharge  in  infants  and  young  children,  and  should  be  the  first 
cause  suspected.  Every  general  practitioner  may  easily  familiarize  him- 
self with  the  method  of  digital  exploration  of  the  rhino-pharynx,  by 
which  means  these  growths  can  in  most  cases  be  easily  recognised.  The 
nasal  discharge  accompanying  adenoid  growths  is  due  to  a  chronic  rhino- 
pharyngitis. Treatment  is  without  avail  unless  the  growths  are  removed. 
After  this  is  done  the  nasal  discharge  usually  disappears  quite  promptly. 

Foreign  Bodies  in  the  Nose. — This  condition  should  be  suspected 
whenever  there  is  an  abundant  muco-purulent  discharge  limited  to  one 
nostril.  Foreign  bodies  in  the  nose  are  quite  frequent  in  young  children. 
Peas,  beans,  beads,  or  shoe  buttons  are  most  frequently  lodged  there.  The 
efforts  at  removal  on  the  part  of  the  child,  or  even  of  the  mother,  gener- 
ally result  in  pushing  the  body  farther  into  the  nose.  It. first  sets  up  a 
mechanical  irritation,  accompanied  by  pain,  swelling,  sneezing,  and  some- 
times haemorrhage.  This  is  followed  by  a  catarrhal  inflammation,  which 
in  the  course  of  a  few  days  becomes  purulent,  and  may  last  indefinitely. 
The  discharge  is  generally  quite  abundant.  The  symptoms  point  to  an 
obstruction  of  one  nostril,  and  an  examination  with  the  probe  readily  de- 
tects the  presence  of  the  foreign  body. 

In  recent  cases  the  removal  of  the  foreign  body  may  sometimes  be  ac- 
complished by  compressing  the  empty  nostril  and  having  the  child  blow 
his  nose  strongly.  Often  the  sneezing  which  the  body  excites  is  sufficient 
29 


432  DISEASES  OP  THE  RESPIRATORY  SYSTEM. 

to  remove  it.  Before  any  attempt  is  made  to  seize  the  body  with  forceps 
cocaine  should  be  used,  not  only  for  the  purpose  of  preventing  pain,  but 
in  order  to  shrink  the  mucous  membrane  so  as  to  allow  better  manipula- 
tion. In  many  cases  chloroform  is  necessary.  In  most  circumstances 
ordinary  foreign  bodies  can  with  proper  forceps  be  extracted  without  diffi- 
culty. No  subsequent  treatment  is  required,  except  to  keep  the  nose 
clean  for  a  few  days,  as  the  inflammation  quickly  subsides  after  the  re- 
moval of  the  cause. 

Nasal  Polypi. — These  are  among  the  infrequent  causes  of  chronic 
nasal  discharge  in  childhood.  They  are  especially  rare  before  the  seventh 
year,  but  both  mucous  and  fibrous  polypi  are  seen.  The  symptoms  are 
those  of  a  chronic  nasal  catarrh  with  partial  or  complete  obstruction  of 
one  or  both  sides.  Polypi  increase  in  size  with  the  occurrence  of  every 
acute  coryza,  and  are  always  especially  troublesome  in  damp  weather. 
They  may  be  accompanied  by  reflex  symptoms,  such  as  cough,  sneezing, 
and  even  by  attacks  of  asthma.  There  may  be  headache,  and  sometimes  dis- 
turbances of  smell,  taste,  and  hearing.  The  symptoms  are  of  much  longer 
duration  than  in  the  case  of  obstruction  from  a  foreign  body,  the  discharge 
is  not  so  abundant,  and  is  not  purulent.  The  diagnosis  is  made  only  by 
examining  the  nose  with  the  mirror  and  nasal  speculum. 

Polypi  may  be  removed  with  the  forceps,  but  this  is  best  accomplished 
by  the  use  of  the  wire  snare.  When  they  have  been  present  for  a  long 
time  the  accompanying  chronic  rhinitis  may  require  subsequent  treat- 
ment. 

Deviation  of  the  nasal  septum,  and  other  congenital  deformities  which 
cause  narrowing  of  the  nasal  respiratory  tract,  are  conditions  which  belong 
to  the  specialist. 

CHRONIC   RHINITIS. 

Three  forms  of  chronic  rhinitis  are  recognised — simple,  hypertrophic, 
and  atrophic. 

Simple  Chronic  Rhinitis. — Simple  chronic  rhinitis  existing  alone  is  of 
very  doubtful  occurrence  in  young  children.  In  the  cases  so  classed  the 
symptoms  are  due  to  rhino-pharyngitis,  which  almost  invariably  depends 
upon  an  adenoid  growth. 

The  growth  may  be  a  small  one,  so  that  the  symptoms  of  obstruction 
are  slight  or  absent.  A  frequent  complication  is  chronic  enlargement  of 
the  cervical  lymph  glands. 

The  only  constant  symptom  is  an  excessive  nasal  discharge,  which  is 
usually  mucous,  but  which  may  be  muco-purulent.  It  is  easily  removed 
by  blowing  the  nose,  if  the  child  is  old  enough  to  be  taught  to  do  this. 
Children  too  young  to  clear  the  nose  in  this  way,  suffer  from  almost  con- 
stant discomfort.  The  amount  of  discharge  depends  upon  the  severity  of 
the  case.     It  frequently  causes  irritation  of  the  upper  lip,  which  may  ho 


CHRONIC   REINITIS.  j.oo 


tO<J 


the  seat  of  eczema  or  impetigo,  especially  in  infants.  The  lip  may  be 
swollen  and  prominent.  The  condition  of  the  external  parts  is  aggravated 
by  the  constant  disposition  to  pick  the  nose,  which  may  be  overcome  by 
the  application  of  a  short  anterior  splint  to  each  elbow.  This  condition  is 
often  the  cause  of  epistaxis.  The  duration  is  indefinite  ;  it  may  last  for 
months  or  even  for  years,  the  symptoms  in  summer  being  insignificant, 
but  returning  every  cold  season.  It  may  terminate  in  recovery,  or  in  chil- 
dren with  flabby  tissues  and  delicate  constitution,  it  may  be  followed  in 
later  childhood  by  hypertrophic  rhinitis. 

Treatment. — Prophylaxis  is  very  important.  The  main  purpose  should 
be  to  prevent  attacks  of  acute  nasal  catarrh  by  the  measures  mentioned  in 
the  discussion  of  that  disease.  The  general  treatment  should  not  be 
routine,  but  directed  according  to  the  indications  of  each  case.  There 
should  be  careful  attention  to  diet  and  to  the  condition  of  the  bowels. 
Iron  and  arsenic  are  needed  when  there  is  ana?mia.  A  general  tonic  treat- 
ment is  required  in  most  cases.  Cod-liver  oil  and  the  syrup  of  the  iodide 
of  iron  are  both  useful,  but  are  not  specifics,  and  must  be  intelligently 
combined  with  other  measures. 

Local  treatment  consists  first  in  cleanliness,  and,  secondly,  in  the  use 
of  astringents  in  the  form  of  powder  or  solution.  For  cleansing,  a  solu- 
tion which  is  both  alkaline  and  antiseptic  is  desirable.  This  may  be  used 
in  the  form  of  a  spray,  after  which  the  nose  is  cleared  by  blowing ;  or  in 
infants,  if  the  discharge  is  abundant,  the  only  efficient  method  of  getting 
rid  of  it  is  by  nasal  syringing.  This  is  attended  by  some  risk  of  forcing 
materials  into  the  middle  ear ;  but  if  carefully  done,  the  danger  seems 
to  me  to  be  less  than  that  of  allowing  the  discharge  to  remain.  Syring- 
ing should  always  be  done  with  the  mouth  open  and  the  head  inclined 
forward.  All  solutions  are  to  be  made  with  sterilized  water  and  used 
warm.  But  little  force  should  be  employed,  and  it  may  be  well  to  have 
a  syringe  the  nozzle  of  which  does  not  completely  fill  the  nostril.  Either 
Dobell's  or  Seller's  solution  (page  56)  may  be  employed,  diluted  with  an 
equal  amount  of  water.     As  a  spray  the  following  may  be  used : 

5  Listerine  * 5  ^s. 

Sodii  bicarVi., 

Sodii  biborat aii  3  ss. 

Aqua'  1  iv. 

If  this  is  to  be  used  with  a  syringe,  twice  as  much  water  should  be  added. 
Ordinarily,  the  nose  must  be  cleansed  thoroughly  twice  a  day,  more  fre- 
quently in  very  severe  cases.  Once  a  day,  after  the  nose  has  been  cleansed, 
an  astringent  solution  or  powder  should  be  applied.     One  of  the  best  solu- 

*  Listerine  is  a  combination  containing  the  essential  oils  of  thyme,  eucalyptus,  bap- 
tisia,  gaulthcria,  and  mentha  arvensis. 


434  DISEASES   OF  THE  EESPIRATORY  SYSTEM. 

tions  is  sulpho-carbolate  of  zinc  (gr.  v  to  Avater  §  j).  This  may  be  used 
as  a  spray,  or,  better,  dropped  into  the  nostril  with  a  medicine  dropper, 
the  head  being  held  far  back.  A  good  powder  is  a  combination  of  salicylic 
acid  gr.  iij,  tannic  acid,  gr.  xxx,  and  stearate  of  zinc  3  j,  which  may  be 
used  with  an  insufflator  once  daily. 

Hypertrophic  Rhinitis. — This  is  a  chronic  inflammation  of  the  nasal 
mucous  membrane,  accompanied  by  a  marked  hypertrophy  of  all  its  nor- 
mal structures,  particularly  its  blood-vessels.  The  parts  chiefly  affected 
are  those  covering  the  inferior  turbinated  bones.  The  mucous  membrane 
and  submucous  tissue  are  so  thickened  and  relaxed  that  they  may  greatly 
encroach  upon  the  nasal  respiratory  space,  and  when  these  venous  sinuses 
are  filled  with  blood,  may  entirely  occlude  the  passage.  There  is  usually 
associated  with  this  condition  some  degree  of  hypertrophy  of  the  adenoid 
tissue  at  the  pharyngeal  vault. 

In  young  children  hypertrophic  rhinitis  is  a  very  infrequent  disease,  if, 
indeed,  it  ever  occurs.  It  is  fairly  common  in  moderate  degree  in  older 
children,  although  its  severe  forms  are  rare.  It  usually  follows  repeated 
attacks  of  acute  nasal  catarrh  in  children  who  have  the  diathesis  "  lympha- 
tism."     A  frequent  local  cause  is  a  deflected  nasal  septum. 

The  syinptofns  are  those  of  nasal  catarrh  with  bilateral  nasal  stenosis. 
The  discharge  is  usually  abundant,  thick,  and  tenacious,  being  increased  by 
dust  and  dampness.  All  the  symptoms  of  nasal  obstruction  are  present  in 
varying  intensity — the  "  wooden  "  voice,  mouth-breathing,  disturbed  sleep, 
etc.  There  may  be  reflex  cough,  catarrh  of  the  larynx  or  bronchi,  accom- 
panied by  muscular  or  vaso-motor  spasm,  giving  rise  to  spasmodic  croup  or 
asthma.  Rhinoscopic  examination  shows  the  large  pendulous  masses  of 
mucous  membrane,  usually  red  and  irregular,  more  or  less  completely 
blocking  the  nasal  passage.  It  is  only  by  this  examination  that  the  dis- 
ease is  differentiated  from  adenoids  of  the  pharynx,  with  Avhich,  however, 
it  is  frequently  associated.  In  infants  and  young  children  the  adenoid 
growth  is  much  the  more  frequent,  and  throughout  childhood  generally 
the  more  important  factor  in  producing  these  symptoms. 

The  treatment  of  these  cases  falls  largely  to  the  specialist,  although 
very  much  can  be  done  by  the  general  practitioner  if  he  Avill  learn  to  use 
intelligently  a  few  remedial  agents.  Constitutional  treatment  is  indicated 
as  in  simple  rhinitis,  but  if  employed  alone  it  accomplishes  little  or  noth- 
ing. The  purpose  of  local  treatment  is  the  reduction  of  the  hypertrophied 
tissue  by  cauterization  under  cocaine  anaesthesia,  by  glacial-acetic  or  chro- 
mic acid,  or  by  the  gal \'ano- cautery.  Each  has  its  advantages  and  its  ad- 
vocates. If  the  hypertrophied  tissue  forms  pendulous  tumours,  it  may  be 
removed  by  the  wire  snare.  Both  nostrils  should  not  be  operated  upon  at 
the  same  time.  In  most  cases  cauterization  must  be  repeated  several  times 
at  intervals  of  a  few  weeks.  In  the  meantime  one  of  the  cleansing  solu- 
tions mentioned  on  page  56  may  be  employed. 


CHRONIC   RHINITIS.  435 

The  following  formula  of  Lefferts  is  an  excellent  one  for  a  spray  to 
be  used  in  this  condition  : 

5   lodi gr.  iv 

Potass,  iodidi gi".  x 

Zinei  iodidi, 

Zinei  sulpho-carbolat aa  gr.  xx 

Listerine |  j 

Aqufe §  iv 

To  be  used  as  a  spray  once  daily. 

Atrophic  Rhinitis  {Fetid  Catarrh). — This  is  unknown  in  young  chil- 
dren, and  only  occasionally  seen  in  those  over  twelve  years  old.  It  is  char- 
acterized by  the  formation  of  crusts  in  the  nose,  which  decompose  and 
produce  the  horribly  fetid  odour.  By  some  writers  the  term  ozcena  is  ap- 
plied to  this  disease,  but  usually  this  term  is  limited  to  rhinitis  associ- 
ated with  disease  of  the  bones.  Atrophic  rhinitis  has  been  regarded  by 
some  as  the  late  stage  of  the  hypertrophic  form.  This  view,  however,  is 
strongly  combatted  by  Bosworth,  who  considers  it  the  result  of  a  puru- 
lent form  of  acute  rhinitis.  The  changes  consist  in  an  atrophy  of  the 
mucous  membrane  and  the  destruction  of  many  of  the  secreting  glands. 
The  nasal  fossae  are  large  and  roomy.  The  voice  is  not  affected,  but  the 
sense  of  smell  may  be  much  impaired.  There  are  no  symptoms  of  ob- 
struction. The  discharge  is  scanty,  and  tends  to  accumulate  between  the 
bones,  forming  large  crusts,  Avhicli  are  expelled  with  difficulty  by  blowing 
the  nose. 

In  the  severe  cases  the  treatment  is  only  palliative,  yet  this  is  of  the 
utmost  importance  for  the  comfort  of  the  patient  and  those  about  him. 
The  object  of  treatment  is  to  prevent  as  much  as  possible  the  forma- 
tion of  crusts  by  the  frequent  use  of  an  oil  spray,  such  as  albolene,  in 
order  to  coat  the  dry  mucous  membrane.  For  the  removal  of  crusts  they 
must  first  be  macerated  by  a  prolonged  nasal  douche  as  hot  as  can  be 
borne.  This  should  be  thoroughly  used  morning  and  evening  as  a  part 
of  the  patient's  toilet.  In  employing  the  douche,  a  bag  containing  from 
one  to  two  pints  should  be  suspended  a  few  inches  above  the  patient's 
head.  One  of  the  alkaline  and  antiseptic  fluids  mentioned  on  page  56 
may  be  added  to  the  douche.  The  head  should  be  slightly  inclined  for- 
ward and  the  mouth  kept  open  during  the  douche.  The  mechanical 
removal  of  the  crusts  may  be  necessary  if  they  are  large,  hard,  and  im- 
pacted. Benefit  may  be  derived  in  some  cases  from  the  daily  use  of  a 
stimulating  spray  containing  ten  grains  of  menthol  to  one  ounce  of  albo- 
lene. One  of  the  very  best  deodorizers  for  general  use  is  listerine,  which, 
diluted  with  two  or  three  parts  of  water,  may  be  employed  as  a  spray  sev- 
eral times  a  day,  in  addition  to  the  other  measures  mentioned. 

Syphilitic  Ehinitis. — Ehinitis  is  seen  both  in  early  and  late  hereditary 
syphilis.      Coryza,  or  snuffles,  is  one  of  its  earliest  and  most  constant 


436  DISEASES  OF  THE   RESPIRATORY  SYSTEM. 

symptoms.  It  usually  begins  between  the  third  and  sixth  weeks  of 
life,  rarely  after  the  third  month.  The  pathological  condition  is  a  sub- 
acute catarrhal  rhinitis,  sometimes  with  the  formation  of  superficial 
ulcers  or  mucous  patches.  The  disease  is  attended  by  a  profuse  discharge 
of  sero-mucus  or  muco-pus,  occasionally  tinged  with  blood.  It  may  con- 
tinue from  a  few  weeks  to  two  or  three  months.  It  usually  requires  only 
constitutional  treatment,  and  j^rotection  of  the  nostrils  and  lips  by  the  use 
of  the  ointment  of  the  yellow  oxide  of  mercury  diluted  with  four  parts  of 
vaseline.  This  may  be  introduced  with  the  finger  or  brush  for  some  dis- 
tance into  the  nostrils.  When  the  discharge  is  very  abundant,  any  one 
of  the  cleansing  solutions  previously  mentioned  may  be  used  as  a  spray. 

The  rhinitis  of  late  hereditary  syphilis  is  a  very  different  patholog- 
ical condition.  There  are  here  gummatous  deposits  which  break  down, 
and  form  ulcers  of  the  mucous  membrane  and  deeper  tissues.  There  is 
also  periostitis,  with  extension  of  the  disease  to  the  cartilages  and  bones 
of  the  nasal  fossse,  particularly  of  the  septum.  There  may  be  perforation 
of  the  triangular  cartilage,  necrosis  of  the  vomer  or  nasal  bones,  perfora- 
tion of  the  hard  or  soft  palate,  and  at  times  extensive  ulceration  of  the  ala? 
nasi  and  the  face.  This  may  be  followed  by  cicatrization,  causing  stenosis 
of  the  nostril.  These  lesions  in  the  nose  are  generally  accompanied  by 
deep  ulceration  of  the  pharynx  and  soft  palate.  They  usually  occur  in 
children  who  have  presented  the  early  symptoms  of  hereditary  syphilis, 
but  are  occasionally  seen  when  no  such  history  can  be  obtained.  Such  was 
the  case  in, a  patient  recently  under  observation  in  the  Babies'  Hospital, 
who  had  perforation  of  the  nasal  septum  and  of  the  floor  of  the  nasal 
fosste,  causing  a  free  communication  with  the  mouth.  These  are  cases  of 
true  oztena.  The  odour  from  the  discharge  is  at  times  almost  intolerable. 
When  neglected,  these  cases  go  on  from  bad  to  worse,  and  may  continue 
for  years,  producing  unsightly  deformities. 

The  treatment  is,  to  bring  the  patient  fully  under  the  influence  of 
mercury,  first  by  means  of  the  mercurial  ointment  or  by  small  doses  of 
calomel — i.  e.,  one  tenth  grain  four  or  five  times  a  day.  Later  the  bin- 
iodide  or  the  bichloride  should  be  substituted,  and  iodide  of  potassium 
given  in  doses  of  ten  to  twenty  grains  three  times  a  day.  Tonics  are 
needed  in  most  cases,  as  the  general  health  is  frequently  undermined  and 
the  patients  are  usually  ansemic. 

Locally  there  may  be  used  a  spray  of  one  of  the  cleansing  solutions 
already  mentioned,  or  black  wash,  or  a  solution  of  bichloride,  1  to  10,000. 
For  purposes  of  deodorization,  listerine  is  one  of  the  best  remedies. 
Although  improvement  may  take  place  quite  promptly,  the  results  of 
treatment  are  often  unsatisfactory,  as  the  disease  has  usually  progressed 
so  far  before  treatment  is  begun  that  some  deformity  of  the  nose  results, 
usually  a  sinking  in  of  the  bridge  and  flattening  of  the  alse,  giving  rise  to 
the  so-called  "  saddle-back  "  deformitv. 


MEMBRANOUS   RHINITIS.  437 


MEMBRx\NOUS   RHINITIS. 

The  results  of  bacteriological  examinations  have  shown  that  these 
cases,  whose  etiology  was  formerly  the  subject  of  considerable  controversy, 
are  nearly  always  due  to  the  Loeffler  bacillus,  and  hence  are  to  be  regarded 
as  true  nasal  diphtheria.  It  has  been  difficult,  from  clinical  features 
alone,  to  establish  this  relationship,  as  the  disease  differs  in  several  impor- 
tant particulars  from  diphtheria  of  the  pharynx  and  rhino-pharynx — viz., 
its  prolonged  course,  the  absence  of  glandular  enlargements,  and  the  pres- 
ence of  very  mild  constitutional  symptoms,  which  are  sometimes  alto- 
gether wanting.  These  peculiarities  are  due  to  the  very  slight  absorption 
which  takes  place  from  the  nose,  which  is  in  striking  contrast  with  that 
from  the  rhino-jiharynx.  The  importance  of  recognising  such  cases  as 
true  diphtheria  can  not  be  overestimated,  as  they  have  often  been  the 
means  of  spreading  infection  in  schools  and  institutions  before  their  true 
nature  was  determined.  The  possibility  of  membranous  inilammation  of 
the  nose  arising  from  other  micro-organisms  than  the  Loeffler  bacillus  is 
not  to  be  denied,  but  such  cases  are  extremely  rare. 

The  most  striking  clinical  feature  of  primary  nasal  diphtheria  is  a 
nasal  discharge  of  serum  or  sero-mucus,  frequently  streaked  with  blood. 
It  is  sometimes  very  abundant,  at  other  times  slight.  There  are  also  the 
symptoms  of  moderate  nasal  obstruction.  The  false  membrane  can  in 
most  cases  be  seen  in  the  anterior  nares  as  a  gray  or  whitish  exudation. 
It  may  cover  the  whole  inner  surface  of  the  nose.  It  often  remains  for 
two  or  three  weeks,  when  it  may  loosen  and  come  away  e7i  masse,  some- 
times forming  an  entire  cast  of  the  nose.  After  forcible  removal  it  may 
reform.  The  disease  in  very  many  cases  remains  limited  to  the  nose,  but 
it  may  at  any  time  extend  to  the  rhino-pharynx  or  to  the  larynx.  When 
such  an  extension  takes  place  it  is  accompanied  by  an  increase  in  the  con- 
stitutional symptoms,  glandular  swellings,  etc.  A  positive  diagnosis  can 
be  made  only  by  means  of  cultures. 

In  addition  to  the  general  treatment  for  diphtheria,  the  nose  in  these 
cases  should  be  syringed  frequently  with  a  warm  saturated  solution  of 
boric  acid,  or  bichloride  1  to  10,000,  with  5  per  cent  of  glycerin.  Such 
cases  must  be  isolated,  like  ordinary  cases  of  diphtheria. 

EPISTAXIS. 

The  hgemorrhage  may  come  from  any  part  of  the  nasal  fossa,  biit  it 
is  generally  from  the  anterior  nares,  and  most  frequently  from  the  ves- 
sels of  the  septum.  Epistaxis  is  a  rare  symptom  in  the  haemorrhages 
of  the  newly  born,  and  when  present  indicates  syphilis.  It-is  infrequent 
throughout  infancy,  but  in  childhood  it  is  quite  common,  occurring  in 
boys  more  frequently  than  in  girls.     In  the  latter  it  is  especially  common 


438  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

about  the  time  of  puberty.  Children  who  are  kept  much  indoors  in  over- 
heated apartments,  and  who  have  susceptible  mucous  membranes  and 
flabby  tissues,  are  particularly  prone  to  it.  The  exciting  cause  may  be  a 
local  one,  like  a  fall  or  blow;  it  may  be  due  to  picking  the  nose,  or  to 
any  kind  of  mechanical  irritation ;  it  may  be  associated  with  nasal  ca- 
tarrh ;  and  it  is  often  caused  by  an  erosion  upon  the  septum.  An  attack  of 
bleeding  may  be  brought  on  by  mental  or  physical  excitement.  It  occurs 
as  an  occasional,  often  an  early  symptom,  in  typhoid  or  malarial  fever,  in 
measles,  or  during  severe  paroxysms  of  pertussis.  It  is  seen  in  the  hem- 
orrhagic form  of  all  the  eruptive  fevers,  in  certain  cases  of  diphtheria, 
most  commonly  late  in  the  disease,  in  hsemophilia  and  scorbutus,  in  grave 
ausemia,  leucaemia,  and  in  diseases  of  the  heart  and  blood-vessels. 

Symptoms. — Epistaxis  is  frequently  preceded  by  a  sense  of  fulness  or 
pain  in  the  head,  which  is  relieved  by  the  bleeding.  The  blood  is  usu- 
ally from  one  nostril,  and  comes  slowly  by  drops.  The  amount  lost  is 
generally  small,  but  it  may  be  large  enough,  when  repeated,  to  produce  a 
serious  grade  of  anfemia  even  in  strong  children,  and  it  has  been  the 
cause  of  death.  Epistaxis  may  be  overlooked  if  the  blood  finds  its  way 
into  the  pharynx  and  is  swallowed.  In  most  of  the  cases  the  hsemor- 
rhage  ceases  spontaneously  in  from  ten  to  twenty  minutes,  recurring  at 
longer  or  shorter  intervals,  according  to  the  nature  of  the  cause.  Hasm- 
orrhage  from  adenoid  growths  of  the  pharynx  may  closely  resemble  that 
from  the  nose,  but  otherwise  there  can  rarely  be  any  difficulty  in  recog- 
nising epistaxis.  In  doubtful  cases  an  inspection  of  the  pharynx  reveals 
the  presence  of  blood-clots. 

Prognosis. — This  depends  upon  the  cause.  In  the  great  majority  of 
the  so-called  idiopathic  cases  it  is  not  serious.  Occurring  early  in  the 
course  of  the  infectious  diseases  it  does  not  ordinarily  affect  the  prognosis 
unless  it  is  very  severe.  When  it  occurs  late,  however,  it  is  always  a  bad 
sign,  and  particularly  so  in  diphtheria.  It  may  be  serious  in  any  of  the 
hemorrhagic  diseases  or  in  diseases  of  the  blood,  where  it  is  not  infre- 
quently a  cause  of  death. 

Treatment.— To  remove  the  predisposition,  a  child  should  receive 
general  tonic  treatment,  especially  plenty  of  outdoor  exercise,  and  every 
means  should  be  taken,  by  the  use  of  cold  baths,  friction,  and  proper  food, 
to  tone  up  the  vascular  system. 

An  efficient  means  of  arresting  the  hemorrhage  is  compression  of  the 
nose  between  the  thumb  and  finger.  This  may  be  combined  with  the 
application  of  ice  over  the  root  of  the  nose,  and  sometimes  small  pieces  of 
ice  may  be  introduced  into  the  nostrils.  The  application  of  cold  to  the 
back  of  the  neck  or  its  use  in  the  mouth  may  be  of  service  by  exciting 
reflex  contraction  of  the  capillary  vessels.  All  tight  clothing  or  bands 
about  the  neck  should  be  loosened,  and  the  patient  kept  quiet  in  the  sit- 
ting posture.    After  the  hemorrhage  has  ceased  the  child  should  not  blow 


CATARRHAL   SPASM   OF   THE   LARYNX.  439 

his  nose  for  some  time.  The  use  of  the  compound  tincture  of  benzoin  or 
lemon  juice,  dihited,  or  a  weak  astringent  solution,  like  alum  or  tannic 
acid,  will  sometimes  arrest  haemorrhage  which  does  not  yield  to  cold  or 
pressure.  The  insufflation  of  astringent  powders  often  increases  the  haem- 
orrhage because  of  the  sneezing  excited.  If  bleeding  continues  in  spite 
of  all  the  above  measures,  the  anterior  nares  should  be  plugged  with 
styptic  cotton,  and  if  this  does  not  control  it,  the  posterior  nares  should 
be  plugged.  Usually  very  little  effect  is  seen  from  drugs  given  internally, 
although  in  frequently  recurring  haemorrhages  where  no  local  cause  can 
be  discovered  ergot  should  be  given  a  trial  in  full  doses. 

In  severe  cases  of  nasal  haemorrhage  recurring  at  short  intervals  with- 
out any  apparent  cause,  ulcer  of  the  septum  should  be  suspected,  and,  if 
present,  should  be  touched  with  chromic  acid. 


CHAPTER   II. 

DISEASES  OF  THE  LARYNX. 

The  characteristic  feature  of  laryngeal  disease  in  infants  and  young 
children  is  the  association  of  muscular  spasm  with  all  forms  of  the  inflam- 
mation. Often  it  is  the  laryngeal  spasm,  rather  than  the  inflammation, 
which  gives  rise  to  the  principal  symptoms.  This  spasm  is  only  one 
expression  of  the  great  reflex  irritability  of  young  children. 

CATARRHAL  SPASM  OP  THE  LARYNX. 

Synonyms  :  Spasmodic  laryngitis,  spasmodic  croup,  catarrhal  croup  (sometimes 
improperly  called  laryngismus  stridulus). 

The  term  catarrhal  spasm,  first  suggested,  I  think,  by  Goodhart,  is 
fairly  descriptive  of  this  disease,  which  is  characterized  by  a  very  mild 
degree  of  catarrhal  inflammation  associated  with  marked  laryngeal  spasm. 

Etiology. — It  is  not  often  seen  during  the  first  six  months,  but  is  fre- 
quent from  this  time  up  to  the  third  year.  After  five  years  it  is  rare.  It 
occurs  in  children  who  are  well  nourished,  as  well  as  in  those  who  are 
cachectic.  Certain  children  have  a  predisposition  to  such  attacks  ;  those 
who  have  had  one  attack  are  likely  to  have  others.  Heredity  seems  to 
have  some  influence  in  producing  this  susceptibility.  Catarrhal  spasm  of 
the  larynx  is  frequently  associated  with  enlarged  tonsils  and  adenoids  of 
the  pharynx,  sometimes  with  elongated  uvula.  The  exciting  cause  may 
be  exposure  to  cold,  an  attack  of  indigestion,  or  constipation. 

Lesions. — The  catarrhal  inflammation  of  the  larynx  affects  chiefly  the 
parts  above  the  cords;  there  is  congestion  and  dryness,  and  later  increased 
secretion  of  mucus.     To  this  there  is  added  a  spasm  of  the  muscles  of  the 


440  DISEASES  OP  THE  RESPIRATORY  SYSTEM. 

larynx,  especially  the  adductors.  There  is  no  submucous  infiltration,  and 
no  tendency  to  oedema  glottidis. 

Symptoms. — The  attack  may  be  preceded  for  several  hours  by  slight 
hoarseness,  or  by  a  nasal  discharge.  During  the  day  the  child  may 
have  appeared  perfectly  well.  Usually  there  is  heard  during  the  evening  a 
hollow,  barking  cough,  at  first  infrequent  and  not  severe.  About  midnight 
this  is  apt  to  increase  in  severity,  and  there  is  now  difficulty  in  breathing. 
As  soon  as  this  becomes  marked  the  child  wakes,  and  presents  the  char- 
acteristic symptoms  of  an  attack.  In  the  mildest  cases  the  dyspnoea  is 
not  sufficient  to  waken  the  child.  In  severe  cases  there  is  marked  dyspncea, 
especially  on  inspiration,  and  a  loud  stridor  as  the  air  is  drawn  through 
the  narrowed  opening  of  the  glottis.  This  may  often  be  heard  even  in  an 
adjoining  room.  There  is  seen  on  inspiration  deep  recession  of  the  supra- 
sternal fossa,  the  supraclavicular  spaces,  and  the  epigastrium  ;  also  depres- 
sion of  the  intercostal  spaces,  and  even  of  the  walls  of  the  chest.  The 
terror  of  the  child  or  any  excitement  increases  the  spasm  and  aggravates 
the  dyspncsa.  The  distress  is  very  great ;  the  breathing  usually  slow  and 
laboured  ;  the  voice  hoarse,  but  rarely  lost ;  the  cough  stridulous,  hoarse, 
and  metallic  ;  the  pulse  rapid  ;  the  temperature  normal  or  slightly  ele- 
vated, rarely  over  101°  F.  The  child  sits  up  and  struggles  for  breath,  its 
forehead  covered  with  perspiration.  There  may  be  slight  lividity  of  the 
finger-tips  and  of  the  lips,  and  sometimes  considerable  prostration.  In 
the  course  of  three  or  four  hours  the  attack  slowly  wears  away  and  the 
child  falls  asleep.  During  the  following  day,  aside  from  slight  hoarse- 
ness and  occasional  cough,  the  child  is  apparently  well.  Most  of  the  cases 
are  not  so  severe  as  this  ;  there  are  the  croupy  cough,  hoarseness,  and  gen- 
eral discomfort,  but  not  marked  dyspnoea.  On  the  second  night  there  is  a 
repetition  of  the  experience  of  the  first,  usually  quite  as  severe  unless  af- 
fected by  treatment ;  and  on  the  third  day  a  remission  similar  to  that  of 
the  day  previous.  On  the  third  night  the  attack,  if  it  occurs  at  all,  is 
generally  a  mild  one.  Slight  hoarseness  persists  for  several  da3^s,  but 
otherwise  the  child  is  apparently  well.  Many  children  have  such  attacks 
every  few  weeks  in  the  course  of  the  cold  season,  the  slightest  exposure  or 
an  indiscretion  in  diet  being  sufficient  to  induce  one. 

Prognosis. — This  is  good,  the  disease  never,  I  think,  proving  fatal,  al- 
thougli  nothing  is  more  alarming,  at  least  to  parents,  than  to  witness  for 
the  first  time  one  of  these  severe  attacks  of  catarrhal  croup. 

Diagnosis. — Catarrhal  spasm  may  be  confounded  with  laryngismus 
stridulus  and  with  membranous  croup.  Laryngismus  stridulus  is  a  rare 
disease,  and  occurs  only  in  infancy.  In  it  we  have  not  simply  stridulous 
breathing,  but  periods  of  complete  cessation  of  respiration.  These  may 
be  repeated  many  times  during  the  day,  and  may  continue  for  weeks, 
being  often  complicated  by  carpo-pedal  spasm,  sometimes  by  general  con- 
vulsions. 


CATARRHAL  SPASM   OF  THE   LARYNX.  44I 

From  membranous  laryngitis,  catarrhal  spasm  is  distinguished  by  its 
sudden  onset,  the  mildness  of  the  symptoms  of  inflammation,  the  spas- 
modic character  of  the  dyspnoea,  and  the  daily  remissions,  ^he  history 
of  previous  attacks  will  often  aid  in  diagnosis.  In  case  of  doubt,  a  posi- 
tive diagnosis  can  often  be  made  by  allowing  the  child  to  inhale  a  little 
chloroform.  This  at  once  relieves  dyspnoea  due  to  spasm,  while  it  has 
scarcely  any  effect  upon  that  due  to  membrane. 

Treatment. — The  purpose  of  treatment  during  the  attack  is  to  pro- 
duce relaxation  of  the  laryngeal  spasm.  This  is  accomplished  by  the  use 
of  emetics,  steam,  and  hot  fomentations  over  the  larynx.  A  favourite 
emetic  is  a  tablet  triturate  of  antimony  and  ipecac,  gr.  jJ^  each.  To  a 
child  of  two  years,  one  tablet  may  be  given  every  ten  or  fifteen  minutes, 
until  free  vomiting  occurs  ;  or  a  teaspoonful  of  the  syrup  of  ipecac  and 
fifteen  drops  of  the  wine  of  antimony  at  the  same  interval.  When  chil- 
dren do  not  vomit  after  two  or  three  doses  the  antimony  should  not  be  re- 
peated, as  it  may  produce  serious  depression. 

Emetics  have  a  double  value  if  the  attack  is  due  to  indigestion.  If 
there  is  constipation,  an  enema  should  be  given.  Following  the  free 
vomiting  there  is  generally  some  improvement  in  the  symptoms,  but  there 
may  be  a  recurrence  of  the  spasm  unless  other  means  are  employed.  To 
prevent  this,  antipyrine  is  one  of  the  most  useful  drugs.  Three  grains  may 
be  given  in  divided  doses  to  a  child  two  years  old.  This  may  be  repeated 
in  four  or  five  hours  if  necessary.  Quite  as  much  relief  as  that  obtained 
from  the  drugs  mentioned  is  seen  from  the  use  of  steam  inhalations.  For 
this  purpose  the  child  should  be  placed  in  a  closed  tent,  and  steam  intro- 
duced from  a  croup  kettle  (page  58).  This  may  be  used  in  conjunction 
with  other  measures,  and  continued  as  long  as  necessary.  Poultices  or  hot 
fomentations  over  the  larynx  are  often  useful.  In  one  case  in  which  se- 
vere spasm  had  recurred  for  eight  successive  nights  in  spite  of  everything 
that  was  tried,  the  child  being  in  great  distress  from  the  d3'spncea,  I  per- 
formed intubation,  which  gave  instant  relief.  Tracheotomy,  however, 
would  scarcely  be  advisable. 

During  the  day  following  the  first  night  attack,  it  is  well  to  continue 
the  antimony  and  ipecac  in  doses  too  sm.all  to  produce  vomiting — e.  g., 
gr.  j^  each,  every  four  hours.  After  6  p.  m.  the  doses  should  be 
doubled,  and  at  bedtime  two  grains  of  antipyrine  given.  If  so  treated, 
the  symptoms  may  not  recur  upon  the  second  night,  or  there  may  be 
only  the  cough  without  the  severe  dyspnoea.  The  child  should  be  con- 
fined to  the  house  for  two  or  three  days  after  one  of  these  attacks,  the 
drugs  being  gradually  reduced ;  but  the  antipyrine  should  be  given  at 
bedtime  for  three  or  four  successive  nights. 

To  prevent  a  repetition  of  the  attacks  and  remove  the  tendency  to 
them,  it  is  most  important  that  the  child  should  have  plenty  of  fresh  air 
and  cold  bathing,  especially  cold  sponging  about  the   neck   and  chest. 


442  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Everything  which  experience  has  sliown  to  bring  on  the  attack  should  be 
carefully  avoided.  Local  causes,  such  as  adenoid  growths,  hypertrophied 
tonsils,  elongated  uvula,  etc.,  should  receive  appropriate  treatment.  Gen- 
erally it  is  not  necessary  to  exclude  fresh  air  from  the  sleeping  room. 
Although  an  open  window  for  a  single  night  may  sometimes  excite  the 
attack,  a  persistence  in  this  direction  tends  rather  to  diminish  the  sus- 
ceptibility. If  the  child's  condition  is  poor,  general  tonic  treatment  is  to 
be  employed. 

ACUTE  CATARRHAL  LARYNGITIS. 

This  is  not  nearly  so  frequent  as  the  disease  just  described,  although 
it  is  much  more  severe,  and  may  even  be  fatal.  It  occurs  especially  in 
children  from  one  to  five  years  of  age,  usually  in  the  cold  season.  Pre- 
disposition to  attacks  is  induced  by  the  same  conditions  as  in  the  case  of 
acute  rhinitis.  Catarrhal  laryngitis  may  be  primary,  when  it  is  usually 
excited  by  cold  or  exposure,*  or  it  may  be  secondary  to  measles,  influenza, 
scarlet  fever,  or  other  infectious  diseases.  It  may  also  be  of  traumatic 
origin,  from  the  inhalation  of  steam  or  irritating  gases. 

Lesions. — There  is  a  moderately  intense  congestion  of  the  laryngeal 
mucous  membrane,  sometimes  general  and  sometimes  localized.  This  may 
be  seen  with  the  laryngoscope,  but  is  not  always  visible  after  death.  With 
the  congestion  there  are  swelling  and  dryness,  followed  by  increased  secre- 
tion. In  the  milder  cases  the  process  is  limited  to  the  mucosa.  In  the 
more  severe  cases  it  involves  the  submucosa  also,  which  is  congested, 
cedematous,  and  may  be  infiltrated  with  cells.  The  changes  are  especially 
marked  in  the  lymphoid  tissue  of  the  subglottic  region.  The  swelling 
may  be  sufficient  to  produce  a  very  marked  degree  of  laryngeal  stenosis. 
In  many  mild  and  in  all  the  severe  cases  there  is  associated  catarrhal 
inflammation  of  the  trachea,  and  often  of  the  larger  bronchi.  In  young 
children  there  is  very  little  tendency  to  oedema  glottidis,  so  frequent  a 
complication  in  adults. 

Symptoms. — In  the  mild  form,  such  as  that  which  is  usually  seen  in 
older  children,  there  are  hoarseness,  or  even  loss  of  voice,  and  a  laryngeal 
cough  which  is  sometimes  hard  and  teasing,  always  worse  at  night.  There 
may  be  pain  and  soreness  over  the  larynx.  Constitutional  symptoms 
are  mild  or  absent,  the  patient  not  usually  being  sick  enough  to  go  to  bed, 
and  often  rebelling  even  at  being  kept  indoors.     Tlie  duration  of  the  dis- 

*  The  following  case  is  a  good  illustration  of  a  severe  attack  excited  by  cold :  A 
rather  delicate  infant,  eight  months  old,  an  inmate  of  the  New  York  Infant  Asylum, 
was  taken  out  on  a  raw  December  day  with  very  slight  covering.  In  a  few  hours 
hoarseness  and  stridor  were  noticed,  and  the  temperature  was  101°  F. ;  three  hours 
later  it  was  103°,  and  in  spite  of  the  usual  remedies  which  were  employed  the  dyspnoea 
had  reached  such  a  degree  as  to  require  intubation.  The  tube  was  worn  only  three 
days  and  the  case  made  a  prompt  recovery. 


ACUTE   CATARRHAL    LARYNGITIS.  443 

ease  is  from  four  to  ten  days,  with  a  strong  tendency  to  relapses  from 
slight  causes. 

The  severe  form  of  catarrhal  laryngitis  is  sometimes  preceded  by  acute 
coryza,  or  there  may  be  mild  laryngeal  symptoms  for  a  few  days  before  the 
development  of  the  more  severe  ones.  In  other  cases  the  disease  develops 
raj)idly  and  severe  symptoms  are  present  within  a  few  hours  from  the  onset. 

When  the  case  is  fully  developed  the  voice  is  metallic  and  hoarse, 
and  occasionally  but  not  usually  lost.  There  is  a  hoarse,  dry,  barking 
cough,  which  is  very  distressing,  and  sometimes  almost  constant.  The 
cough,  like  the  voice,  is  stridulous,  and  more  or  less  stridor  is  present  on 
inspiration.  There  is  a  slight  amount  of  constant  dyspnoea,  but  this  is 
scarcely  noticeable  unless  the  chest  is  bared.  Severe  dyspnoea  occurs  in 
paroxysms,  usually  at  night.  Then,  we  may  get  the  signs  of  obstructive 
dyspnoea  similar  to  those  mentioned  in  severe  attacks  of  catarrhal  spasm. 
This  dysjjncea  is  chiefly  inspiratory,  but  in  some  cases  it  increases  steadily 
from  the  beginning  of  the  attack,  and  may  be  indistinguishable  from  that 
due  to  membrane.  Constitutional  symptoms  are  usually  present  and 
may  be  severe.  The  temperature  ranges  in  most  cases  from  101"^  to 
103°  F.,  but  may  go  to  104°  or  105°.  The  pulse  is  rapid  and  full  and  res- 
piration is  accelerated.  Older  children  sometimes  complain  of  pain  in 
the  larynx  and  trachea,  increased  by  coughing.  The  symptoms  are  severe 
for  two  or  even  three  days,  the  fever  continuing  with  moderate  prostra- 
tion and  paroxysms  of  dyspnoea,  sometimes  even  attacks  of  suffocation  and 
cyanosis.  Usually  after  two  or  three  days  there  is  a  gradual  subsidence 
of  the  dyspnoea  and  inflammatory  symptoms,  and  the  case  goes  on  to  re- 
covery. At  other  times  the  inflammation  extends  downward  to  the  large 
and  then  to  the  small  bronchi,  and  finally  results  in  broncho-pneumonia. 
The  attack  may  prove  fatal  from  laryngeal  obstruction  due  to  swelling 
and  spasm. 

Diagnosis. — This  disease  is  chiefly  to  be  distinguished  from  membra- 
nous laryngitis.  The  onset  of  the  two  diseases  may  be  very  similar,  and 
for  the  first  twelve  hours  we  have  no  absolute  means  of  distinguishing 
between  them,  except  possibly  by  the  use  of  the  laryngoscope,  which  is 
often  conclusive  in  older  children  but  not  usually  so  in  infants.  All  cases, 
therefore,  should  be  looked  upon  with  a  degree  of  apprehension.  The 
temperature  in  the  catarrhal  is  usually  higher  than  in  the  membranous 
form.  The  dyspnoea  is  mainly  paroxysmal,  with  daily  remissions  and 
nightly  exacerbations,  and  is  chiefly  inspiratory,  while  that  of  membra- 
nous laryngitis  is  constant,  steadily  and  often  rapidly  increasing,  and  is 
present  both  on  inspiration  and  expiration.  In  catarrhal  laryngitis  the 
voice  is  not  usually  lost,  but  in  the  membranous  form  this  is  the  rule. 
There  can  be  little  room  for  doubt  when  there  are  enlarged  glands,  mem- 
branous patches  on  the  tonsils,  nasal  discharge,  and  albumin  in  the  urine. 
Very  often,  however,  all  these  evidences  of  diphtheria  are  wanting,  the 


444  DISEASES  OP  THE  RESPIRATORY   SYSTExM. 

really  difficult  cases  being  those  in  which  the  process  begins  in  the  larynx. 
The  prevalence  of  diphtheria  and  a  known  exposure  count  for  something 
in  favour  of  membranous  laryngitis.  If  cultures  from  the  pharynx  show 
the  presence  of  Loeffler  bacilli,  diphtheria  of  the  larynx  is  highly  prob- 
able ;  but  no  conclusion  can  be  drawn  when  cultures  give  negative  results. 
In  catarrhal  as  well  as  in  membranous  laryngitis  there  may  be  extreme 
dyspnoea,  cyanosis,  pallor,  prostration,  and  even  death. 

Prognosis. — This  depends  somewhat  upon  the  cause  of  the  disease  and 
also  upon  the  age  of  the  patient.  It  is  much  worse  when  it  is  secondary 
to  measles  or  scarlet  fever.  It  is  better  in  children  over  three  years  of  age 
than  in  infants,  also  when  the  general  condition  of  the  child  is  good.  The 
prognosis  in  severe  catarrhal  laryngitis  should  always  be  guarded,  not  only 
on  its  own  account,  but  also  because  it  is  impossible  to  be  certain  that 
the  case  may  not  be  one  of  membranous  laryngitis. 

Treatment. — In  all  cases  children  affected  are  to  be  kept  in  bed  ;  and 
the  temperature  of  the  room  should  be  between  70°  and  72°  F.'  The  diet 
should  be  light  and  fluid,  and  the  bowels  should  be  freely  opened  by  calomel 
or  a  saline.  A  hot  mustard  foot  bath  should  be  given  at  the  outset ;  also, 
benefit  may  sometimes  be  derived  from  aconite,  given  in  one-quarter- 
minim  doses  every  fifteen  minutes  for  the  first  five  or  six  hours.  An- 
tipyrine  (two  grains  every  four  hours:  to  a  child  two  years  old)  is  useful  if 
there  is  much  spasmodic  dyspnoea.  For  this  symptom  emetics  are  bene- 
ficial, given  as  in  catarrhal  spasm.  The  use  of  ipecac  and  squills  in  smaller 
doses  than  is  required  for  emesis  (five  drops  each  of  the  syrups  of  ipecac 
and  squills  every  two  hours)  may  give  relief,  especially  in  the  early  stage, 
when  the  cough  is  dry,  hard,  and  severe. 

All  the  remedies  mentioned  are  to  be  regarded  as  accessories  to  the 
essential  treatment,  which  consists  in  the  use  of  inhalations.  The  child 
should  be  placed  in  a  tent  (page  58)  into  which  steam  is  introduced  from 
a  croup  kettle  or  vapourizer.  Simple  steam  may  be  used,  or  turpen- 
tine, limewater,  or  creosote  may  be  added.  In  moderately  severe  cases 
inhalations  should  be  used  for  fifteen  minutes  every  two  hours ;  in  very 
severe  ones  they  should  be  continued  the  greater  part  of  the  time.  Poul- 
tices or  hot  fomentations  may  be  applied  over  the  larynx.  Eelief  is  some- 
times obtained  by  using  counter-irritation  by  a  mustard  paste,  but  blister- 
ing should  never  be  allowed.  In  my  experience  the  local  use  of  cold  is 
very  unsatisfactory,  on  account  of  the  difficulty  of  applying  it  properly,  and 
the  objection  to  it  on  the  part  of  young  children.  Stimulants  may  be  re- 
quired late  in  the  disease,  the  amount  of  prostration  being  the  guide  to 
their  use. 

In  cases  of  extreme  dyspnoea  operative  interference  may  be  needed.  It 
is  required  more  often  in  infants  and  young  children  than  in  those  who 
are  older,  and  especially  in  the  subglottic  form  of  the  disease.  Opinions 
will  of  course  differ  as  to  when  the  dyspnoea  has  reached  the  danger  point. 


MEMBRANOUS  LARYNGITIS.  445 

One  should  not  wiiit  for  general  cyanosis.  If  pallor,  marked  prostration, 
and  steadily  increasing  dyspna-a  are  present  the  case  should  not  be  allowed 
to  go  on  without  interference.  Intubation  has,  to  my  mind,  every  advantage 
over  tracheotomy,  and  is  always  to  be  preferred  in  these  cases.  One  should 
not  hesitate  to  operate,  even  though  he  may  be  perfectly  sure  that  the  case 
is  one  of  catarrhal  inflammation  only.  The  severity  of  the  dyspnoea  is  the 
only  guide,  and  more  than  once  I  have  seen  cases  shown  at  autopsy  to  be 
catarrhal,  which  were  regarded  during  life  as  undoubtedly  membranous. 
If  intubation  is  done,  the  tube  can  usually  be  dispensed  with  in  two  or 
three  days.  Convalescence  is  usually  rapid,  but  there  is  danger  of  recur- 
ring attacks  during  the  remainder  of  the  cold  season. 

MEMBRANOUS    LARYNGITIS. 
Synonyms:    Membranous  croup,  true  croup,  laryngeal  diphtheria. 

Bacteriology  has  settled  many  questions  long  debated  with  reference  to 
this  disease.  For  nearly  half  a  century  the  identity  of  membranous  croup 
and  laryngeal  diphtheria  has  been  contended  for  by  some  observers,  and 
denied  by  others  equally  good.  The  extensive  bacteriological  researches 
made  since  1890,  both  in  this  country  and  in  Europe,  have  yielded  results 
sufficiently  uniform  to  warrant  the  following  statements  : 

1.  Membranous  inflammation  beginning  in  the  larynx  is  almost  invari- 
ably true  diphtheria — i.  e.,  it  is  due  to  the  Loeffler  bacillus. 

3.  Membranous  laryngitis  following  a  primary  membranous  inflam- 
mation of  the  tonsils,  pharynx,  or  nose,  is,  in  the  great  majority  of  cases, 
due  to  the  Loeffler  bacillus. 

3.  Membranous  laryngitis  following  membranous  inflammation  of  the 
tonsils,  nose,  or  pharynx,  occurring  as  a  complication  of  measles,  scarlet 
fever,  or  influenza,  is  more  frequently  due  to  another  kind  of  infection 
(usually  the  streptococcus)  than  to  the  Loeffler  bacillus. 

The  etiology,  lesions,  pathological  relations,  and  bacteriological  diag- 
nosis of  membranous  laryngitis  are  considered  in  the  chapter  devoted  to 
iJiphtheria.  In  the  present  chapter  there  will  be  considered  only  the 
clinical  aspect  of  the  cases,  especially  of  those  in  which  the  disease  begins 
in  the  larynx  ;  for  even  if  the  cause  is  in  most  cases  diphtheria,  the  clin- 
ical picture  is  laryngitis. 

In  cases  of  primary  laryngeal  diphtheria  there  are  wanting  most  of  the 
characteristic  clinical  features  which  distinguish  diphtheria  of  the  pharynx. 
There  are  two  reasons  for  this  :  one  is  the  relatively  rapid  course  of  the 
disease,  often  producing  death  from  local  causes  before  the  constitutional 
symptoms  resulting  from  the  absorption  of  the  toxine  have  developed  ;  the 
second  reason  is,  that  absorption  of  the  poison  by  the  laryngeal  mucous 
membrane  is  very  slow  and  feeble  as  compared  with  that  which  takes  place 
from  the  pharynx.     Hence  it  follows  that  glandular  enlargements,  albumi- 


446  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

nuria,  and  asthenic  symptoms  are  geuerally  wanting;  also,  that  in  the  cases 
which  come  to  autopsy  early,  the  parenchymatous  degenerations  in  the 
heart,  kidney,  and  other  organs  are  seldom  found,  but  instead  only  such 
lesions  as  are  connected  with  the  laryngeal  disease.  The  feeble  contagion 
is  due  to  the  fact  that  the  course  is  much  shorter,  and  that  the  discharge 
from  the  nose  and  mouth  is  slight,  or  absent  altogether. 

Symptoms. — In  its  onset,  membranous  inflammation  of  the  larynx  is 
indistinguishable  from  the  catarrhal  form.  It  is  perhaps  a  trifle  less 
abrupt,  and  apparently  not  quite  so  severe  for  the  first  twelve  hours  or 
even  for  a  longer  time.  We  have  the  same  hoarse  cough  and  voice,  with  a 
slight  stridor,  gradually  increasing.  The  constitutional  symptoms  are 
usually  not  quite  so  marked,  the  temperature  ranging  from  99°  to  101° 
F.  The  pulse  is  accelerated,  but  not  weak  or  intermittent.  It  is  the 
progress  of  the  disease  which  indicates  its  character,  usually  during  the 
first  twenty-four  hours.  A  child  beginning  in  the  morning  with  such 
symptoms  as  have  been  described,  may  by  evening  show  a  decided  change 
for  the  worse,  or  the  symptoms  may  increase  with  great  rapidity  during  the 
night.  At  first  the  voice  is  hoarse ;  later  it  is  entirely  lost.  Dyspnoea  in 
the  beginning  is  scarcely  noticeable,  but  steadily  increases  hour  by  hour. 
At  times  of  excitement  it  may  be  very  great,  but  as  the  spasm  subsides  it 
diminishes.  During  the  second  twenty-four  hours  all  the  symptoms  are 
usually  well  developed.  The  respiration  is  often  somewhat  accelerated, 
but  it  may  be  slower  than  normal.  The  face  is  pale  and  anxious.  The 
alae  nasi  dilate  with  each  inspiration.  The  loud,  "  sawing,"  stridulous 
breathing  is  present.  As  the  dyspnoea  increases,  all  the  accessory  muscles 
of  respiration  are  brought  into  action.  There  is  now  with  every  inspi- 
ration deep  recession  of  the  suprasternal  fossa,  the  supraclavicular  re- 
gions, and  the  epigastrium.  The  child  tosses  uneasily  from  side  to  side  in 
its  crib,  at  times  struggling  violently  to  get  more  air  into  the  lungs.  The 
pulse  grows  rapid  and  weaker.  There  is  slight  blueness  of  the  finger  nails 
and  the  lips ;  the  face  is  usually  pale ;  but  later  this  too  may  be  cyanotic. 
The  skin  is  covered  with  clammy  perspiration.  On  auscultating  the 
chest,  very  rude  respiratory  sounds  are  heard,  but  no  vesicular  murmur. 
As  the  symptoms  increase  in  severity  the  temperature  usually  rises  gradu- 
ally, in  some  very  severe  cases  at  the  rate  of  a  degree  an  hour,  until  shortly 
before  death  it  reaches  104°  or  even  10G°  F.  Late  in  the  disease  the  in- 
tellect becomes  dull,  the  violent  struggles  for  air  cease,  and  the  child  passes 
into  a  condition  of  semi-stupor  which  gradually  deepens  until  death  occurs, 
which  may  be  preceded  by  convulsions. 

Such  is  the  usual  course  of  the  disease  when  unrelieved  by  treatment. 
Its  progress  is  most  raj^id  in  infants,  in  whom  death  usually  takes  place  in 
from  thirty-six  to  forty-eight  hours  from  the  first  symptoms.  In  older 
children  the  course  is  rather  slower,  and  the  attack  may  last  from  two 
days  to  a  week,  death  occurring  more  frequently  from  bronchial  croup  or 


MEMBRANOUS  LARYNGITIS.  447 

pneumonia.     These  are  indicated  by  continued  high  temperature,  rapid 
respiration,  cyanosis,  and  increased  prostration. 

The  course  of  the  disease  is  not  always  so  regular.  Occasionally  for  a 
week  or  more  the  symptoms  are  precisely  like  those  of  catarrhal  laryngitis 
of  moderate  severity — hoarseness,  laryngeal  cough,  little  or  no  fever,  and 
slight  or  occasional  dyspnoea.  Then  there  may  be  the  sudden  develop- 
ment of  very  severe  symptoms,  and  death  in  a  few  hours.  Great  improve- 
ment may  follow  the  dislodgment  of  the  membrane  by  vomiting  or  cough- 
ing, although  in  most  cases  it  forms  again. 

Prognosis. — The  issue  of  every  case  of  membranous  laryngitis  is  doubt- 
ful. The  prognosis  depends  upon  the  age  of  the  patient,  the  character  of 
the  epidemic,  but  most  of  all  upon  the  treatment.  The  latest  results  with 
antitoxine  show  a  mortality  of  less  than  25  per  cent. 

Diagnosis. — The  points  by  which  membranous  laryngitis  is  distin- 
guished from  the  catarrhal  form  have  been  considered  in  connection  with 
the  latter  disease.  It  may  be  further  confounded  with  retro-pharyngeal 
abscess,  a  foreign  body  in  the  larynx,  and  even  with  broncho-pneumonia. 
Inspection,  or,  better,  digital  exploration  of  the  pharynx,  usually  makes 
the  recognition  of  retro-pharyngeal  abscess  an  easy  matter.  The  mistake 
generally  made  is  that  of  trusting  entirely  to  the  patient's  objective  symp- 
toms for  a  diagnosis.  "With  a  foreign  body  there  is  usually  a  history  of  a 
very  sudden  onset  and  violent  paroxysmal  dyspnoea,  without  fever.  Bron- 
cho-pneumonia is  easily  distinguished  by  its  higher  temperature,  its  phys- 
ical signs,  and  the  difference  in  the  character  of  the  dyspnoea.  A  mistake 
is  hardly  possible  except  when  there  is  also  present  some  degree  of  catar- 
rhal laryngitis.  In  any  of  these  conditions,  if  time  is  taken  to  obtain  a 
careful  history  and  to  make  even  a  moderately  thorough  examination  of 
the  throat  and  lungs,  no  mistake  need  be  made.  Yet  such  cases  have  often 
been  operated  upon  by  physicians  anxious  to  give  immediate  relief  to  what 
they  had  hastily  diagnosticated  as  membranous  laryngitis. 

Treatment. — All  cases  of  membranous  laryngitis  should  be  isolated  like 
those  of  diphtheria  of  the  pharynx.  Every  case  of  membranous  laryngitis 
should  receive  an  injection  of  antitoxine  upon  a  clinical  diagnosis  without 
waiting  for  this  to  be  confirmed  by  a  bacteriological  examination.  No- 
where else  are  the  beneficial  effects  from  antitoxine  so  evident  and  so 
striking  as  in  these  cases.  That  the  serum,  when  properly  used  in  the 
great  majority  of  cases,  prevents  the  spreading  of  diphtheritic  membrane 
from  the  larynx  to  the  lower  air  passages  is  now  well  established.  For 
dosage  and  other  details  regarding  the  use  of  antitoxine  the"  reader  is 
referred  to  the  article  on  Diphtheria. 

Emetics,  inhalations  of  steam,  and  solvents  for  the  membrane,  although 
they  all  sometimes  give  relief,  are  now  little  used,  and  are  never  to  be 
relied  upon  alone.     In  fact,  leaving  out  antitoxine  and  surgical  opera- 
tion, the  only  therapeutic  measure  that  can  be  said  to  be  of  much  avail  is 
30 


448 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


calomel  fumigation.  This  is  in  no  sense  a  substitute  for  antitoxine,  but 
may  be  employed  where  circumstances  make  the  use  of  antitoxine  im- 
possible, and  in  the  few  cases  of  membranous  laryngitis  due  to  strep- 
tococci. 

Calomel  fumigations. — These  were  first  advocated  by  Corbin,  of  Brook- 
lyn, in  1881,  although  they  did  not  come  into  general  use  until  about 
1891.  The  method  consists  in  the  vapourization  of  calomel  in  a  confined 
space,  the  patient  inhaling  the  fumes.  For  this  purpose  the  child  should 
be  placed  in  a  close  tent  (page  58),  either  sitting  or  lying  down.  A  very 
simple  arrangement  for  the  purjjose,  and  one  that  can  be  extemporized 
readily,  is  the  following :  A  strip  of  tin,  or  any  sheet  metal  two  inches 
wide  and  ten  or  twelve  inches  long,  is  bent  and  placed  across  the  top  of  a 
pot-de-chamh^e ;  upon  this  is  placed  the  calomel,  and  beneath  it,  so  that 

the  flame  will  come  close  to  the  tin,  an  alco- 
hol lamp.  The  lamp  is  then  lighted  and 
the  apparatus  placed  beneath  the  tent.  It 
should  always  be  steadied  by  the  hand  of 
an  attendant,  otherwise  there  is  danger  of 
fire,  as  the  lamp  might  be  accidentally  over- 
turned by  the  child's  struggles.  In  Fig.  70 
is  shown  an  apparatus  which  can  be  used 
with  greater  safety,  as  it  is  suspended  by  a 
wire.  In  a  few  moments  the  tent,  which 
should  be  kept  closed,  is  filled  with  the 
white  fumes  of  the  mercury.  From  ten  to 
twenty  minutes  are  required  to  vapourize 
the  ordinary  amount  used,  depending  upon 
the  size  of  the  flame.  It  is  well  to  have 
the  child  somewhat  accustomed  to  the  tent 
before  the  fumigation  is  begun ;  also  to 
cover  the  body,  except  the  face,  so  as  to 
prevent  any  unnecessary  exposure  to  the 
calomel  fumes.  The  usual  amount  vapoui'- 
ized  at  once  is  ten  or  fifteen  grains,  and  this  is  repeated  every  one,  two,  or 
three  hours,  according  to  the  severity  of  the  case.  This  amount  is  calcu- 
lated for  a  tent  which  covers  a  child's  crib.  If  a  much  larger  one  is  used 
more  calomel  will  of  course  be  required.  h\  extreme  cases  as  much  as 
twenty  grains  every  hour  have  been  used  for  days.  After  the  calomel  has 
all  been  vapourized  the  tent  should  be  opened  and  the  room  thoroughly 
aired. 

At  times  so  much  irritation  is  produced  by  the  fumes  that  it  may 
have  the  effect  of  increasing  the  dyspnoea.  This  may  be  due  either  to  the 
fact  that  the  calomel  contains  impurities,  or  that  the  vapour  is  too  con- 
centrated.    The  concentration  of  the  vapour  depends  on  the  size  of  the 


Fig.  70. — Ermold'S  apparatus  for  cal- 
omel fumigation. 

a,  alcohol  lamp;  d,  plate  on  which 
calomel  is  placed ;  e,  wire  loop  for 
suspension. 


MEMBRANOUS   LARYNGITIS.  449 

tent  and  the  rapidity  of  the  process  of  vapourization.  It  is  rare  that  any 
unpleasant  symptoms  occur.  Nurses  should  always  be  warned  against 
the  danger  of  fire.  I  have  several  times  known  serious  accidents  from 
carelessness.  Salivation  in  a  jiatient  is  rare,  but  care  is  always  neces- 
sary to  prevent  it  on  the  part  of  the  attendants.  They  should  not  put 
their  heads  beneath  the  tent ;  the  room  should  be  kept  as  clean  as  pos- 
sible, and  thoroughly  aired  after  each  fumigation.  The  mouth,  gums, 
and  teeth  of  the  patient  should  be  kept  clean  with  a  wash  of  chlorate  of 
potash. 

The  improvement  is  often  very  marked  even  after  the  first  fumiga- 
tion, and  nearly  always  after  the  second  or  third.  Fumigations  should  be 
begun  as  soon  as  the  diagnosis  of  membranous  laryngitis  is  made,  without 
waiting  for  even  a  moderate  amount  of  dyspncea.  This  applies  both  to 
cases  beginning  in  the  larynx  and  where  the  disease  is  secondary  to  phar- 
yngeal diphtheria. 

Operative  measures. — Opinions  will  always  differ  as  to  the  time  when 
operative  interference  is  called  for.  One  should  never  wait  for  general 
cyanosis,  for  often  this  does  not  occur  until  just  before  death.  It  is  better 
to  operate  too  early  than  too  late.  After  a  fair  trial  has  been  made  of 
other  measures,  and  if,  in  spite  of  all,  the  dyspnoea  increases  steadily  and 
the  temperature  begins  to  rise,  operation  should  not  be  deferred  longer. 
When  this  has  been  decided  upon,  the  physician  has  the  choice  between 
intubation  and  tracheotomy.  During  the  last  ten  years  intubation  has 
grown  steadily  in  favour,  and,  since  the  introduction  of  autitoxine,  trache- 
otomy has  been  practically  abandoned  as  a  primary  operation  for  the  re- 
lief of  membranous  laryngitis,  it  being  resorted  to  only  in  rare  cases,  after 
intubation  has  failed  to  give  relief. 

The  general  treatment  of  the  child  is  important,  and  should  not  be 
overlooked.  It  includes  careful  feeding,  and  the  use  of  alcoholic  stimu- 
lants according  to  the  amount  of  prostration  present.  All  patients  with 
membranous  laryngitis  should  be  closely  watched,  for  marked  changes 
may  take  place  in  the  course  of  a  few  hours. 

Results  without  antitoxine. — In  November,  1892,  McNaughton  and 
Maddren  (Brooklyn),  in  response  to  a  circular  letter,  collected  statistics 
of  8,383  cases  of  membranous  laryngitis,  occurring  in  the  practice  of 
242  physicians.  The  following  results  were  reported  :  Tracheotomy,  2,417 
cases ;  recoveries,  58G,  or  24'2  per  cent.  Intubation,  5,546  cases ;  recov- 
eries, 1,G91,  or  30-5  per  cent. 

In  1893,  Ranke  (Munich)  published  reports  of  1,445  cases  of  intuba- 
tion, collected  from  various  German  hospitals,  with  553  recoveries,  or  38 
per  cent.  Bokai  (Buda-Pesth),  in  500  operations,  reports  180  recoveries, 
or  36  per  cent.  In  all  the  different  series  of  cases  above  referred  to,  the 
percentage  of  recoveries  has  ranged  from  30  to  40.  Combining  them,  we 
have  7,491  cases  of  intubation  for  membranous  larvngitis,  with  2,424  re- 


450  DISEASES  OF   THE   RESPIRATORY   SYSTEM. 

coveries,  an  average  of  32-3  per  cent.  These  figures  may  be  taken  to  rep- 
resent, as  accurately  as  statistics  can,  the  results  from  intubation  prior  to 
the  use  of  calomel  fumigations  and  before  the  introduction  of  antitoxine. 

With  the  introduction  of  calomel  fumigations  the  statistics  of  the  opera- 
tion from  1891  to  1895  were  materially  improved.  Of  the  cases  of  intuba- 
tion collected  by  McXaughton  and  Maddren,  only  85  had  received  calomel 
fumigations,  with  35-3  per  cent  recoveries.  Although  no  large  collection 
of  cases  so  treated  has  been  made,  the  experience  of  Dillon  Brown  may  be 
taken  as  fairly  representing  the  improvement  in  the  results  of  intubation 
by  the  addition  of  calomel.  Up  to  June,  1894,  he  reports  his  personal 
experience  as  follows  :  490  intubations  without  calomel  fumigations  with 
34-8  per  cent  recoveries ;  279  operations  with  calomel  fumigations  with 
49-4  per  cent  recoveries.  Nearly  all  of  the  cases  in  both  series  were 
from  private  practice.  In  addition  to  this  reduction  of  mortality  in  cases 
operated  upon,  it  was  a  matter  of  common  observation  in  Xew  York  and 
Brooklyn,  that  during  the  period  mentioned  a  much  larger  number  of 
cases  than  ever  before  recovered  without  operation. 

Such  were  the  results  in  laryngeal  diphtheria  prior  to  the  introduction 
of  antitoxine  in  1895.  They  have  been  fully  given,  that  they  may  be  com- 
pared with  those  obtained  since  that  date  with  the  addition  of  antitoxine. 
The  latter  figures  are  given  in  the  general  article  on  Diphtheria. 

INTUBATION. 

Intubation  is  the  introduction  of  a  tube  through  the  mouth  into  the 
larynx  for  the  relief  of  laryngeal  dyspnoea.  For  the  operation  as  now 
performed  the  world  is  indebted  to  Dr.  Joseph  O'Dwyer,  of  New  York. 

A  set  of  O'Dwyer's  instruments  (Fig.  71)  consists  of  six  gold- 
plated  tubes,  an  iutroductor,  an  extractor,  a  mouth-gag,  and  a  gauge.  In 
his  latest  tubes  the  lower  extremity  is  made  somewhat  bulbous,  and  not 
straight,  as  appears  in  the  illustration.  The  operation  is  not  very  difficult, 
provided  one  has  had  previous  practice  on  the  cadaver.  Without  this  it 
should  not  be  attempted.  The  tube  is  selected  according  to  the  age  of  the 
patient,  the  length  for  the  different  years  being  indicated  upon  the  gauge. 
The  age  is  not  the  only  guide,  for  a  very  large  child  will  often  require  a 
tube  of  larger  size  than  its  age  would  indicate. 

Tlie  introduction  of  the  tube. — Two  assistants  are  required,  neither  of 
whom  need  be  skilled.  The  child  is  taken  from  the  bed,  wrapped  in  a 
large  blanket,  and  held  in  a  sitting  position  upon  the  lap  of  the  first  assist- 
ant, its  head  being  inclined  neither  backward  nor  forward.  The  arms 
may  be  confined  by  the  blanket  or  held  by  the  assistant.  The  second  as- 
sistant, standing  behind  the  child,  steadies  the  head,  and  with  one  finger 
holds  the  loop  of  braided  silk  with  whicli  the  tube  should  be  threaded. 
The  tube  is  attached  to  the  introductor,  and  the  gag  is  inserted  into  the 
left  angle  of  the  mouth  and  opened  as  widely  as  possible.     The  slipping. 


INTUBATION. 


451 


of  the  gag  and  laceration  of  the  mouth  may  be  prevented  by  using  a  piece 
of  rubber  tubing  to  cover  each  arm  of  the  gag  where  it  comes  in  contact 


Fig.  71.— O'Dwyer's  intubation  set. 
1,  introductor;  2,  gag;  3,  extractor;  4,  gauge;  5,  tube. 

with  the  gum.  The  attempts  at  introduction  must  be  made  quickly, 
for  during  them  respiration  is  practically  arrested.  Several  short  attempts 
are  always  better  than  a  single  prolonged  one.  Very  little  force  is  ordi- 
narily required  in  introducing  the  tube,  that  used  in  passing  a  catheter 
being  a  good  general  guide.  In  cases  of  subglottic  stenosis,  however,  quite 
a  little  force  may  be  necessary  (Brown). 

The  index  finger  of  the  left  hand  is  used  as  a  guide  in  introduction. 
This  is  passed  well  back  into  the  pharynx,  then  brought  forward  until  a 
hard  nodule — the  upper  border  of  the  cricoid  cartilage — is  encountered. 
This  is  the  best  of  all  landmarks,  since  the  soft  parts  are  often  distorted 
by  swelling.  Directly  in  front  of  the  cricoid  cartilage  may  be  felt  the 
epiglottis  and  the  opening  of  the  larynx,  which  are  readily  recognised 
after  the  touch  has  become  somewhat  educated.  The  tube  is  passed  along 
the  palmar  surface  of  the  left  index  finger,  by  which  it  is  guided  into  the 
hu'ynx ;  it  is  then  pushed  off  the  introductor  by  a  thumb-piece  attached 
to  its  handle.  When  it  is  certain  that  the  tube  is  in  position,  and  the  pa- 
tient breathes  properly,  the  loop  of  silk  attached  to  the  head  of  the  tube 
is  cut  off  and  pulled  through,  the  removal  of  the  tube  being  prevented 
by  placing  the  left  forefinger  upon  its  head.     The  silk  should  not  be  left 


452  DISEASES  OP  THE  RESPIRATORY  SYSTEM. 

attached  unless  there  is  evidence  of  loose  membrane  below  the  tube.  It 
may  then  be  fastened  to  the  cheek  by  a  piece  of  adhesive  plaster.  The 
tube  is  known  to  be  in  place,  first,  by  the  hissing  breathing  sounds, 
somewhat  similar  to  what  is  heard  when  the  trachea  is  opened  ;  secondly, 
by  a  severe  paroxysm  of  coughing,  which  is  usually  excited  by  a  tube 
in  the  larynx  ;  thirdly,  by  the  relief  of  the  dyspnoea.  If  this  relief  is  not 
very  apparent  the  physician  may  still  be  in  doubt  as  to  whether  the  tube 
is  in  the  larynx  or  the  oesophagus.  If  in  the  former,  it  can  not  be  pushed 
down  by  the  finger  without  depressing  the  larynx  with  it ;  and  by  intro- 
ducing the  finger  into  the  pharynx,  the  posterior  wall  of  the  larynx  can 
be  felt  between  the  finger  and  the  tube.  The  most  common  mistake 
made  is  to  pass  the  tube  into  the  oesophagus.  This  sometimes  happens 
because  the  position  of  the  child's  head  is  improper— too  far  forward  or 
too  far  backward — but  more  often  because  the  operator  has  not  been  quite 
sure  of  his  landmarks.  If  this  has  occurred,  there  is  no  relief  to  the  dysp- 
noea, no  hissing  sound,  and  the  tube  can  be  pushed  down  indefinitely. 
When  this  condition  is  recognised,  the  tube  is  withdrawn  by  the  loop  of 
silk  and  after  a  few  moments  a  second  attempt  made. 

False  passages  in  the  larynx  are  most  frequently  made  because  the 
operator  has  worked  at  the  angle  of  the  mouth  instead  of  keeping  in  the 
median  line.  The  tube  usually  goes  into  one  of  the  ventricles,  and  may 
be  pushed  quite  through  the  larynx  into  the  cellular  tissue.  This  is  not 
likely  to  happen  unless  undue  force  has  been  used.  The  production  of 
a  false  passage  is  recognised  by  the  fact  that,  although  the  tip  of  the  tube 
can  be  felt  to  enter  the  larynx,  it  does  not  descend,  but  projects  above 
the  epiglottis. 

False  membrane  which  has  become  loosened  is  sometimes  crowded 
down  by  the  tube  and  obstructs  the  larynx  just  below  it.  This  is  one  of 
the  most  serious  accidents  that  may  occur,  but  fortunately  it  is  not  a 
frequent  one.  It  is  more  liable  to  happen  where  the  disease  has  existed 
for  several  days  than  in  recent  cases.  The  tube  may  be  in  place  in  the 
larynx  as  shown  by  all  the  signs  above  mentioned,  except  relief  of  the 
asphyxia.  In  such  a  case  the  immediate  withdrawal  of  the  tube  is  neces- 
sary ;  it  being  often  followed  by  the  discharge  of  masses  of  loose  mem- 
brane. This  is  aided  by  the  administration  of  a  teaspoonful  of  pure  whis- 
ky or  brandy  to  excite  a  strong  cough.  Artificial  respiration  may  be 
required,  and  if  there  is  no  relief  by  any  of  these  means  tracheotomy  is 
indicated.  Asphyxia  is  sometimes  produced  by  prolonged  and  injudicious 
attempts  at  introduction. 

After-treatment. — So  far  as  the  tube  itself  is  concerned  no  treatment 
is  required.  The  original  disease  is  to  be  treated  as  before.  The  operation 
has  removed  only  one  danger  from  the  patient,  viz.,  that  of  asphyxia  from 
mechanical  obstruction  of  the  larynx.  A  good  expulsive  cough  should 
occur  after  the  tube  is  in  place.     This  is  necessary  to  clear  the  tube  of 


INTUBATION.  453 

mucus,  as  the  pharynx  and  larynx  are  generally  filled  with  it  as  a  result 
of  the  manipulation. 

The  child  should  not  be  allowed  to  lie  upon  its  face,  nor  should  it  be 
held  over  the  nurse's  shoulder  face  downward,  for  in  either  position  a  slight 
cough  is  enough  to  expel  the  tube.  Nursing  infants  may  continue  at  the 
breast  after  the  operation  ;  ordinarily  they  have  but  little  difficulty  in  swal- 
lowing. Older  children  often  experience  considerable  trouble  in  taking 
liquids.  This  may  be  overcome  by  the  device  suggested  by  Casselberry 
(Chicago),  of  having  the  patient's  head  lower  than  his  body  while  he  drinks. 
If  there  is  still  trouble  in  taking  fluids,  semi-solid  articles,  such  as  con- 
densed milk,  wine  jelly,  corn  starch,  or  scrambled  eggs,  may  be  tried. 
Feeding  is  always  easier  after  the  first  day  or  two,  and  patients  who  wear 
a  tube  for  chronic  disease  soon  experience  no  trouble  whatever,  showing 
that  the  difficulty  depends  more  upon  the  inability  to  co-ordinate  the  move- 
ments of  the  muscles  of  deglutition  when  the  tube  is  in  place  than  upon 
mechanical  causes,  for  the  head  of  the  tube  is  effectually  covered  by  the 
epiglottis. 

It  sometimes  happens  that  the  tube  is  coughed  out  soon  after  its 
introduction,  because  too  small  a  size  has  been  used.  In  some  cases 
this  occurs  repeatedly.  It  happened  in  a  case  of  my  own  twenty- 
eight  times  during  four  days.  Such  cases  are  probably  due  to  paralysis 
of  the  laryngeal  muscles.  The  dyspnoea  does  not  usually  return  for 
two  or  three  hours  after  the  tube  has  been  coughed  out,  so  there  is 
ample  time  to  notify  the  physician.  It  may  happen  that  the  tube  is 
coughed  up  and  not  seen  by  the  nurse,  or  it  may  be  coughed  up  and 
swallowed  by  the  child.  When  called  because  of  dyspnoea  after  operation, 
the  physician  should  make  a  digital  examination  of  the  pharynx  to  be  sure 
that  the  tube  is  still  in  place.  Swallowing  the  tube  generally  causes  no 
harm  to  the  child,  for  tubes  have  repeatedly  passed  through  the  intes- 
tines. 

The  entrance  of  food  into  the  bronchi  through  the  tube  is  a  danger 
that  does  not  exist,  as  has  been  shown  by  the  extensive  post-mortem  obser- 
vations of  Xorthrup  in  the  New  York  Foundling  Asylum.  My  own  expe- 
rience in  the  New  York  Infant  Asylum  coincides  in  every  particular  with 
his  statement,  that  the  broncho-pneumonia  following  intubation  docs  not 
depend  upon  the  entrance  of  food  into  the  bronchi. 

Ulceration  at  the  head  of  the  tube  very  rarely  occurs,  provided  properly 
made  tubes  are  employed.*  The  tube  rests  not  upon  the  vocal  cords,  but 
upon  the  inferior  ventricular  bands.  When  ulceration  occurs,  it  is  usually 
of  the  anterior  wall  of  the  trachea,  at  the  lower  end  of  the  tube,  and 


*  This  and  many  other  bad  results  obtained  after  intubation  are  duo  to  improperly 
constructed  instruments.  Those  made  by  George  Ermold,  312  East  Twenty-second 
Street,  New  York,  are  perhaps  the  most  reliable. 


454  DISEASES  OP  THE  RESPIRATORY  SYSTEM. 

appears  to  be  produced  by  the  movements  of  the  tube  during  deglutition. 
With  O'Dvvyer's  latest  tubes  there  is  much  less  liability  of  this  occurring. 
The  ulcers  are  usually  small  and  superficial.  Deep  ulcers  extending  to 
the  tracheal  rings  may  be  seen  in  ill-conditioned  children,  usually  in  con- 
nection with  other  complications  severe  enough  to  cause  death. 

Spontaneous  descent  of  the  tube  into  the  larynx  is  impossible,  and  it 
can  not  be  crowded  down  without  using  considerable  force  and  severely 
lacerating  the  larynx. 

Sudden  blocking  of  the  lower  end  of  the  tube  by  membrane  loosened 
from  the  trachea  or  bronchi  is  an  infrequent  accident.  The  usual  result 
of  this  is  the  immediate  expulsion  of  the  tube  by  coughing,  the  discharge 
of  the  loose  membrane  following.  This  condition  is  one  of  the  safety  valves 
of  the  operation.  One  of  the  strong  points  in  favour  of  intubation  is  that 
the  forcible  cough  which  the  patient  is  able  to  make  on  account  of  the 
narrow  opening  of  the  tube,  often  enables  him  to  expel  large  accumula- 
tions of  mucus,  and  even  membrane,  more  readily  than  through  a  much 
larger  tracheal  opening. 

In  membranous  laryngitis  the  tube  is  usually  left  in  place  from  four  to 
seven  days,  longer  in  very  young  children.  Should  the  tube  be  coughed 
out  at  any  time,  its  introduction  should  be  delayed  until  dyspnoea  returns. 
If  this  happens  on  the  third  or  fourth  day,  a  second  introduction  is  often 
unnecessary. 

Tlie  removal  of  the  tube. — This  is  rather  more  difficult  than  its  intro- 
duction. The  general  arrangement  of  the  patient  and  assistants  is  the 
same  as  for  introduction.  The  left  index  finger  is  placed  upon  the  head 
of  the  tube,  which  is  steadied  externally  by  the  thumb  of  the  same 
hand.  The  beak  of  the  extractor  is  introduced  within  the  opening  of  the 
tube,  its  Jaws  are  then  separated  by  pressure  upon  the  lever  at  the  han- 
dle, and  the  instrument  withdrawn,  very  slight  force  being  required. 

The  tube  is  first  removed  tentatively,  the  physician  waiting  to  see  if 
ayspncea  returns.  It  is  well  to  give  an  opiate  an  hour  before  the  removal 
of  the  tube,  since  the  contact  with  the  air  almost  invariably  excites  a 
marked  degree  of  laryngeal  spasm  which  lasts  for  ten  or  fifteen  minutes. 
To  avoid  the  production  of  vomiting  and  the  entrance  of  food  into  the 
larynx,  food  should  not  be  given  for  two  hours  previously.  If  dyspnoea 
does  not  return  in  the  course  of  three  or  four  hours,  the  probabilities  are 
that  the  tube  will  no  longer  be  required.  It  is  very  exceptional  that  the 
patient  has  great  difficulty  in  dispensing  with  the  tube,  as  so  often  hap- 
pens after  tracheotomy. 

The  advantages  over  tracheotomy.  — -  The  advantages  claimed  by 
O'Dvvyer  for  this  operation  over  tracheotomy  are  conceded  by  most  of 
those  who  have  had  any  considerable  experience  in  the  operation,  viz.  : 
(1)  It  is  quicker,  simpler,  and  adds  no  danger  to  the  original  disease  ;  (2) 
there  is  no  shock  or  haemorrhage  ;  (3)  no  anaesthetic  is  required  ;  (4)  no 


SUBMUCOUS  LARYNGITIS.  455 

fresh  wound  is  made  which  may  prove  an  avenue  of  infection  ;  (5)  it  gives 
an  opportunity  for  a  better  expulsive  cough,  which  is  of  great  value  in 
dislodging  false  membrane  and  mucus;  (6)  there  are  usually  no  objections 
on  the  part  of  the  parents  to  be  overcome — a  point  of  great  impor- 
tance ;  (7)  the  air  is  warmed  and  moistened  as  it  is  normally,  by  passing 
over  the  nasal  and  buccal  mucous  membranes ;  (8)  no  skilled  after-treat- 
ment is  required  :  as  the  largest  proportion  of  the  cases  of  diphtheria 
are  among  the  very  poor,  living  under  conditions  in  which  the  careful 
after-treatment  required  in  tracheotomy  is  difficult  or  impossible  to  ob- 
tain, this  is  an  important  point;  (0)  in  infancy,  all  who  have  had  experi- 
ence with  both  operations  admit  the  great  superiority  of  intubation  ;  (10) 
the  intubation  tube  can  be  dispensed  with  earlier  than  the  tracheal  can- 
ula,  and  also  with  much  less  difficulty  ;  (11)  if  tracheotomy  is  subse- 
quently required,  the  operation  may  be  done  upon  the  tube  as  a  guide. 

The  only  objection  of  much  force  urged  against  intubation  is  that 
asphyxia  may  be  produced  by  crowding  down  loose  membrane  into  the 
larynx.  This  is  a  very  infrequent  accident ;  should  it  happen,  and  the 
asphyxia  not  be  relieved  by  coughing  up  the  membrane,  tracheotomy  may 
be  performed. 

Experience  has  clearly  proved  that  intubation  relieves  the  dyspnoea 
due  to  laryngeal  stenosis  promptly,  efficiently,  certainly;  it  does  this  with- 
out many  of  the  dangers  and  objectionable  features  of  tracheotomy,  while 
at  the  same  time  it  does  not  deprive  the  patient  of  any  essential  advantage 
which  tracheotomy  affords. 

The  use  of  antitoxine  in  the  treatment  of  diphtheria  has  so  shortened 
the  period  of  stenosis  that  tracheotomy  as  a  routine  operation  is  hardly 
justifiable.  The  great  superiority  of  intubation  is  now  generally  admitted 
not  only  in  America,  but  all  over  the  continent  of  Europe,  where  it  has 
practically  displaced  the  older  operation. 

SUBMUCOUS  LARYNGITIS— CEDEMA   OF  THE   GLOTTIS. 

These  two  conditions  are  not  quite  identical,  although  they  are  close- 
ly associated  and  may  be  conveniently  considered  together.  They  are 
both  rare  in  early  life.  In  true  oedema  of  the  glottis  there  is  simply  a 
dropsical  effusion  into  the  submucous  cellular  tissue  of  the  aryteno-epi- 
glottic  folds,  causing  them  to  project  as  large  rounded  swellings  on  either 
side  of  the  superior  isthmus  of  the  larynx.  They  may  be  of  sufficient  size 
to  cause  serious  or  even  fatal  obstruction  to  respiration.  With  the  laryn- 
goscope they  appear  as  pale  red  tumours,  lying  usually  in  contact  near 
tlie  base  of  the  tongue.  By  the  finger  their  presence  can  be  quite  as 
readily  distinguished.  (Edema  of  tlie  glottis  occurs  principally  in  the 
late  stages  of  nephritis. 

In  the  inflammatory  form  of  oedema,  or  true  submucous  laryngitis, 
there  is  the  same  sort  of  swelling  of  these  structures,  but  in  this  case  it  is 


456  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

due  to  some  active  inflammation  in  the  neighbourhood.  The  swelling  is 
partly  from  the  oedema  and  partly  from  cell  infiltration.  Usually  all  the 
parts  surrounding  the  upper  opening  of  the  larynx  are  in  a  state  of  acute 
inflammation.  The  epiglottis  may  be  swollen  to  the  thickness  of  a  finger, 
and  easily  seen  by  depressing  the  tongue. 

The  exciting  causes  may  be  the  mechanical  irritation  of  foreign  bodies, 
the  inhalation  of  steam  or  irritating  gases,  erysipelas  of  the  neck,  primary 
catarrhal  laryngitis,  or  retro-pharyngeal  abscess. 

The  symptoms  in  both  cases  consist  in  great  inspiratory  dyspnoea 
with  attacks  of  suffocation,  while  expiration  may  be  quite  easy.  In  true 
oedema  there  are  in  addition  the  symptoms  of  the  original  disease.  In 
the  inflammatory  form  there  are  the  evidences  of  local  inflammation — 
hoarseness,  cough,  pain,  and  difficulty  in  swallowing.  A  positive  diag- 
nosis may  be  made  by  a  digital  examination.  The  symptoms  develoi^  with 
great  rapidity  in  either  variety,  and  frequently  prove  fatal  in  a  few  hours. 

The  treatment  of  true  oedema  consists  in  scarification  or  multiple 
puncture,  the  application  of  ice  externally,  and  even  the  swallowing  of 
ice  ;  in  the  inflammatory  form,  in  addition,  local  blood-letting  by  leeches 
and,  as  a  last  resort,  tracheotomy.     Intubation  is  useless  in  either  form. 

CHRONIC  LARYNGITIS. 

The  following  varieties  are  seen  :  (1)  a  simple  form  usually  associated 
with  adenoid  vegetations  of  the  pharynx  ;  (2)  tuberculous ;  (3)  syphilitic  ; 
(4)  that  associated  with  new  growths. 

1.  With  Adenoid  Vegetations  of  the  Pharynx. — This  is  not  very  uncom- 
mon. The  larynx  is  kept  in  a  state  of  chronic  congestion  by  the  adenoid 
growth,  and  there  finally  develops  a  sight  superficial  catarrhal  inflamma- 
tion. The  symptoms  may  continue  for  many  months.  These  cases  are 
often  treated  for  a  long  time  unsuccessfully  by  the  use  of  sprays,  inhala- 
tions, etc.,  but  the  symptoms  disappear  rapidly  after  the  removal  of  the 
adenoid  growth.  Similar  symptoms  may  be  associated  with  hypertrophic 
rhinitis.  In  this  also  the  treatment  should  be  directed  to  the  primary 
condition. 

2.  Tuberculous  Laryngitis. — This  belongs  to  later  childhood,  and  is  rare 
even  then.  In  infancy  it  is  almost;  unknown.  Eheindorf  *  has  reported 
a  case  in  a  child  of  thirteen  months,  Avhich  was  regarded  during  life  as 
syphilitic,  but  was  shown  by  autopsy  to  be  tuberculous.  Of  sixteen  cases 
in  children,  reported  by  Rilliet  and  Barthez,  none  occurred  during  the 
first  three  years,  and  only  four  before  the  seventh  year.  The  larynx  alone 
may  be  affected,  or  the  larynx  and  trachea,  or  the  larynx,  trachea,  and 
lungs.     Pulmonary  tuberculosis  is  usually  found  to  be  present  at  autopsy, 

*  Jahrbuch  fiir  Kinderh.,  Bd.  xxxiii,  p.  71. 


CHRONIC   LARYNGITIS.  457 

even  though  there  may  have  been  no  pulmonary  symptoms.  Demme  has 
reported  a  case  of  tubercular  laryngitis  in  a  boy  of  four  years,  whose 
lungs  were  healthy,  death  resulting  from  tuberculous  meningitis. 

The  symptoms  are  hoarseness,  aphonia,  laryngeal  cough,  and  muco- 
purulent, sometimes  bloody,  expectoration.  The  sputum  may  contain 
tubercle  bacilli.  With  the  laryngoscope  tubercular  deposits  may  be  seen, 
but  more  frequently  tuberculous  ulceration  of  the  mucous  membrane.  In 
children  this  is  usually  superficial,  the  deep  destructive  ulceration  seen  in 
adults  being  very  rare. 

It  is  to  be  differentiated  from  syphilis  chiefly  by  the  general  symptoms, 
as  the  laryngoscopic  appearances  may  be  very  similar.  The  treatment  con- 
sists in  keeping  the  ulcers  as  clean  as  possible  by  the  use  of  sprays  and 
the  local  application  of  astringent  powders,  like  nitrate  of  silver  and  sul- 
phate of  ziuc  or  iodoform. 

3.  Syphilitic  Laryngitis. — In  the  early  stage  of  syphilis  the  larynx  is 
often  the  seat  of  a  catarrhal  inflammation,  which  presents  nothing  espe- 
cially characteristic  excejit  its  protracted  course.  The  laryngitis  of  late 
hereditary  syphilis  is  quite  rare,  and  is  liable  to  be  overlooked  because  of 
the  difficulties  in  the  way  of  a  thorough  examination,  and  because  the  dis- 
ease is  usually  painless. 

Strauss*  has  collected  fourteen  cases  between  the  ages  of  three  and 
fifteen  years,  and  added  three  of  his  own.  He  states  that  deep-seated  pro- 
cesses are  much  more  rare  than  among  adults.  The  parts  most  frequently 
affected  are,  first,  the  epiglottis  ;  secondly,  the  aryteno-epiglottic  folds ; 
thirdly,  the  posterior  laryngeal  wall.  The  epiglottis  was  involved  in 
twelve  of  fourteen  cases.  Usually  there  was  only  perichondritis ;  in  the 
more  severe  cases  there  was  partial  or  complete  destruction  of  the  cartilage. 
In  four  cases  papillomatous  masses  were  seen.  In  five  cases  the  process 
extended  from  the  epiglottis  to  the  epiglottic  folds  of  one  or  both  sides. 
In  several  instances  the  superior  vocal  cords  were  thickened  from  hyper- 
plasia, and  occasionally  small  tumours  were  formed.  In  only  one  case  was 
there  ulceration  of  these  folds.  Changes  in  the  vocal  cords  and  the  aryte- 
noid cartilages  were  rare,  occurring  only  with  extensive  inflammation. 
The  symptoms  are  those  of  chronic  laryngitis ;  hoarseness,  sometimes 
aphonia,  and  in  a  few  cases  chronic  laryngeal  stenosis.  The  diagnosis 
can  be  made  only  by  means  of  the  laryngoscope.  In  most  of  the  cases 
there  are  present  ulcerations  of  the  palate  or  uvula,  or  scars  from  pre- 
vious ulcers ;  sometimes  the  disease  extends  into  the  nose.  Serious 
symptoms  often  result  when  to  old  syphilitic  lesions  there  is  added  acute 
laryngitis  or  cedema. 

In  addition  to  the  usual  constitutional  remedies  for  tertiary  syphilis, 
and  to  the  means  ordinarily  employed  for  the  relief  of  chronic  laryngitis, 

*  Archiv  fiir  Kiiulerh.,  Bd.  xiii. 


458  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

intubation  may  be  required  in  these  cases  for  the  relief  of  laryngeal  ste- 
nosis. Nowhere  are  its  advantages  over  tracheotomy  more  striking  than 
here.     The  tube  must  usually  be  worn  for  many  months. 

NEW  GROWTHS. 

New  growths  of  the  larynx  are  not  very  rare  in  children.  Excluding 
the  granulations  which  follow  the  use  of  the  tracheal  canula,  the  only  one 
that  is  likely  to  be  met  with  is  papilloma.  This  may  occur  even  in  in- 
fancy. According  to  Kauchfuss,  the  majority  of  the  cases  begin  during 
the  first  year.     Boys  are  more  frequently  affected  than  girls. 

The  symptoms  depend  upon  the  size  and  location  of  the  tumour.  The 
earlier  manifestations  are  usually  ascribed  to  chronic  laryngitis.  There 
is  hoarseness,  sometimes  loss  of  voice,  and  a  paroxysmal  cough  ;  later, 
dyspnoea  develops.  The  symptoms  are  slowly  progressive,  and  it  may  be 
several  months  before  they  are  sufficiently  severe  to  attract  special  atten- 
tion. A  positive  diagnosis  is  made  only  by  the  laryngoscope.  There  is 
seen  a  whitish  granular  tumour,  sometimes  pedunculated,  sometimes  with 
a  broad  base,  attached  to  any  part  of  the  larynx. 

The  treatment  of  these  cases  belongs  to  the  specialist.  Small  pedun- 
culated growths  may  be  removed  through  the  mouth  by  means  of  the 
forceps  or  snare.  Larger  ones  require  thyrotomy.  The  prognosis  is  gen- 
erally unfavourable,  on  account  of  the  danger  of  recurrence  after  opera- 
tion. Operative  measures  may  be  followed  by  bronchitis  or  broncho- 
pneumonia. 

FOREIGN   BODIES   IN   THE   LARYNX. 

The  aspiration  of  foreign  substances  into  the  larynx  is  not  a  very  rare 
accident  in  children.  It  usually  happens  from  an  attempt  to  cough, 
laugh,  or  cry  while  the  child  has  something  in  its  mouth.  If  the  body  is 
sharp  and  irregular,  like  a  pin,  the  shell  of  a  nut,  or  a  fragment  of  bone, 
it  is  liable  to  become  impacted  in  the  larynx.  If  smooth,  like  a  pea  or 
a  bead,  it  is  usually  drawn  into  one  of  the  bronchi,  generally  the  right. 

When  the  body  enters  the  larynx  there  is  immediately  excited  a  violent 
paroxysmal  cough,  with  dyspncea  amounting  almost  to  suffocation.  Often 
the  body  is  dislodged  by  this  initial  attack  of  coughing.  If  it  becomes 
impacted  in  the  larynx,  it  may  cause  sudden  death  by  occluding  the 
glottis ;  elsewhere  it  may  excite  acute  laryngitis,  usually  of  considerable 
severity. 

The  impaction  of  a  foreign  body  in  one  of  the  primary  bronchi,  or  one 
of  the  lobar  divisions,  is  indicated  by  cough  and  a  severe  localized  pain  in 
the  chest.  There  may  be  expectoration  of  blood.  On  auscultating  the 
chest,  there  is  found  an  absence  of  respiratory  murmur  over  one  lung  or 
one  lobe,  according  to  the  situation  of  the  foreign  body.    Percussion  gives 


THE  LUNGS  IN   INFANCY  AND   CHILDHOOD.  459 

increased  resonance,  which  may  even  be  tympanitic,  owing  to  emphysema 
which  rapidly  develops.  If  the  foreign  body  remains  impacted  in  one  of 
the  bronchi,  it  usually  excites  a  localized  inflammation,  which  extends  to 
the  surrounding  lung  and  terminates  in  the  formation  of  an  abscess. 
This  may  result  fatally,  or  there  may  follow  a  prolonged  illness,  with 
hectic  symptoms  resembling  pulmonary  tuberculosis  ;  and  finally,  after 
weeks  or  months,  the  foreign  body  may  be  expelled  by  an  attack  of  cough- 
ing, and  the  patient  recover  completely. 

The  diagnosis  of  a  foreign  body  in  the  larynx  is  made  by  the  sudden- 
ness of  the  attack  and  the  violence  of  the  early  symptoms.  In  older  chil- 
dren the  body  may  be  seen  with  the  laryngoscope,  but  in  young  children 
this  is  very  difficult.  The  prognosis  is  always  doubtful,  and  depends  upon 
the  nature  of  the  foreign  body  and  the  point  at  which  it  has  been  arrested. 

Treatment. — The  first  thing  to  be  tried  is  inversion  of  the  patient. 
By  this  means,  assisted  by  the  cough,  the  foreign  body  is  not  infrequently 
expelled,  even  though  it  has  passed  below  the  larynx.  The  symptoms  of 
laryngeal  obstruction  may  call  for  immediate  tracheotomy  or  laryngotomy, 
intubation  not  being  applicable  to  these  cases.  If,  after  tracheotomy,  the 
foreign  body  can  be  located  in  the  larynx,  but  can  not  be  extracted  through 
the  tracheal  wound,  the  thyroid  cartilage  should  be  divided  in  the  median 
line.  The  removal  of  a  foreign  body  from  the  bronchi  or  the  tracheal 
bifurcation  should  be  attempted  only  by  a  skilled  surgeon. 


CHAPTER  III. 

DISEASES  OF  THE  LUNOS. 

THE   PECULIARITIES  OP  THE  LUNGS  IN   INFANCY  AND  EARLY 

CHILDHOOD. 

Thorax. — The  general  shape  of  the  thorax  is  somewhat  cylindrical, 
the  conical  or  dome-shape  of  the  adult  not  being  attained  until  puberty. 
The  antero-posterior  and  the  transverse  diameters  are  nearly  equal  in  the 
newly  born,  but  after  the  third  year  the  transverse  diameter  is  always 
greater,  the  difference  increasing  steadily  up  to  adult  life.  On  account  of 
the  shape  of  the  chest,  the  lungs  are  situated  rather  more  posteriorly  in 
the  infant  than  in  the  adult. 

The  thoracic  walls  are  very  elastic  and  yielding,  owing  to  the  carti- 
laginous condition  of  a  large  part  of  the  framework.  They  are  rela- 
tively thinner  than  in  the  adult,  chiefly  owing  to  tlie  imperfect  develop- 
ment of  the  thoracic  muscles.  The  greater  part  of  the  thickness  of  the 
thoracic  walls  is  due  to  the  deposit  of  fat,  generally  abundant  in  well- 
nourished  infants ;  but  where  the  fat  is  scanty  the  walls  are  extremely 


460  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

thin.  Tlie  capacity  of  the  thorax  is  considerably  encroached  upon  by  the 
high  position  of  the  diaphragm,  the  large  size  of  the  thymus  gland,  and 
the  frequent  distention  of  the  stomach  and  intestines. 

Respiration. — According  to  Uffelmann,  the  rapidity  of  respiration  dur- 
ing sleep  at  the  different  ages  is  as  follows : 

At  birth 35  per  minute. 

At  the  end  of  the  first  year 27 

At  two  years 25 

At  SIX  years -^-^ 

At  twelve  years 20 

During  waking  hours  this  rate  is  very  materially  increased,  and  from  com- 
paratively slight  disturbance  it  may  be  nearly  twice  as  rapid. 

The  type  of  respiration  in  infants  is  diaphragmatic,  and  it  continues  to 
be  chiefly  so  until  after  the  seventh  year,  when  the  costal  element  grad- 
ually becomes  more  and  more  prominent.  The  rhythm  of  respiration  is 
easily  disturbed.  In  very  young  infants  the  regular  rhythm  is  seen  only 
in  sleep.  The  lungs  do  not  always  expand  equally;  at  certain  times  and 
in  certain  positions  respiration  may  be  carried  on  for  a  few  moments 
almost  entirely  with  one  lung.  For  some  moments  it  may  be  very  super- 
ficial, and  then  quite  deep.  The  length  of  the  interval  between  inspira- 
tion and  expiration  varies  much  at  different  times.  Kegular  rhythmical 
respiration  is  not  fully  established  before  the  end  of  the  second  year. 
After  this  time  disturbances  of  rhythm  are  chiefly  due  to  pulmonary  or 
cerebral  disease;  but  in  infancy  quite  marked  irregularity  may  have  little 
or  no  significance.     It  is  very  common  in  all  asthenic  conditions. 

Structure. — As  compared  with  the  adult,  the  trachea  of  the  young 
child  is  larger ;  the  bronchi  are  larger,  more  numerous,  and  occupy  a 
greater  space ;  the  air  cells  are  much  smaller  and  occupy  less  space ;  and 
the  interstitial  tissue  is  much  more  abundant  (Delafield). 

Physical  Examination. — This  requires  tact  and  time,  but  yields  results 
which  are  quite  as  satisfactory  as  in  adults.  It  should  be  undertaken  only 
in  a  room  having  a  temperature  of  about  72°  F.,  or  before  an  open  fire. 

Inspectio-n. — This  should  be  made  with  the  chest  bare.  There  should 
be  noted,  the  shape  of  the  chest,  the  presence  of  deformities  from  rickets, 
the  want  of  symmetry  in  the  two  sides,  bulging  of  the  intercostal  spaces, 
whether  the  two  lungs  expand  equally  or  not,  also  variations  in  rhythm, 
and  the  presence  and  extent  of  any  recession  of  the  soft  parts  or  bony 
walls  as  an  indication  of  obstructive  dyspnoea. 

Palpation. — This  also  should  be  made  upon  the  bare  skin,  always  with 
the  hand  well  warmed.  Although  we  can  not  get  the  fremitus  of  the 
voice,  we  can  get  that  of  the  cry.  This  is  usually  more  intense  than  in 
adults,  on  account  of  the  thinness  of  the  chest  walls.  We  frequently  get 
a  rhonchial  fremitus — a  vibration  produced  by  mucus  in  the  tubes.  This 
may  enable  one  to  recognise  bronchitis  quite  as  positively  as  by  the  ear. 


THE   LUNGS  IX  INFANCY   AND   CIIILDnOOD.  461 

The  position  of  the  apex  beat  of  the  heart  should  be  determined,  it  being 
remembered  that  in  infancy  this  is  normally  in  the  mammary  line,  or  just 
outside  of  it,  and  usually  in  the  fourth  intercostal  space. 

Percussion. — For  the  examination  of  the  back,  the  child  may  be  laid 
face  downward  upon  the  nurse's  lap,  or  be  seated  upon  her  arm.  For  the 
front  and  the  lateral  regions  of  the  chest,  the  child  is  most  conveniently 
placed  upon  its  side  across  a  hard  pillow.  The  percussion  blow  must  be 
light,  either  with  a  single  finger  or  a  small  percussion  hammer,  using  a 
finger  of  the  opposite  hand  as  a  pleximeter.  Percussion  should  be  made 
both  during  inspiration  and  expiration.  The  normal  percussion  note  is 
somewhat  tympanitic,  this  being  due  to  the  relatively  large  bronchi  and 
the  thin  chest  walls.  This  note  is  exaggerated  in  the  interscapular  region 
and  beneath  the  clavicle,  especially  upon  the  right  side.  Here  cracked- 
pot  resonance  may  be  obtained  even  in  health.  In  early  infancy  the 
thymus  gives  dulness  over  the  sternum  as  low  as  the  third  rib,  sometimes 
even  below  this  point,  this  gradually  diminishing  as  age  advances. 

Auscultation. — This  may  be  practised  with  the  naked  ear  or  with  the 
stethoscope.  A  stethoscope  is  absolutely  necessary  for  a  thorough  exam- 
ination of  the  apices  of  the  lungs  in  front  and  in  the  axillary  regions. 
Most  children  are  less  frightened  by  the  instrument  than  by  the  head  of 
the  physician  during  anterior  auscultation.  For  the  posterior  part  of  the 
lungs,  the  stethoscope  may  be  dispensed  with.  One  with  a  small  bell 
from  half  to  three  fourths  of  an  inch  in  diameter  is  of  great  advantage. 
In  auscultating  with  the  ear  it  is  not  necessary  to  bare  the  skin.  The 
physician  should  always  auscultate  the  posterior  part  of  the  chest  first, 
because  he  is  most  likely  to  find  signs  of  disease  there,  and  also  because 
this  is  not  so  apt  to  frighten  the  infant.  Every  part  of  the  chest  should, 
however,  be  thoroughly  auscultated,  not  omitting  the  high  axillary  regions. 
A  convenient  position  for  posterior  auscultation  is  to  have  the  child  held 
over  the  nurse's  shoulder. 

The  normal  respiratory  murmur  of  the  infant  is  generally  described  as 
puerile.  In  quality  tliis  has  been  likened  to  the  bronchial  breathing  of 
the  adult,  but  the  resemblance  is  not  a  very  close  one.  It  is  rude,  rather 
loud,  and  seems  very  near  the  ear.  Its  peculiar  character  is  due  to  the 
fact  that  the  tracheal  and  bronchial  sounds  are  more  distinct,  because 
not  transmitted  through  so  thick  a  layer  of  lung  and  chest  wall.  It  is 
especially  loud  in  the  regions  where  the  bronchi  are  superficial,  as  between 
the  shoulder-blades  and  beneath  the  clavicles,  particularly  of  the  right 
side.  A  careful  comparison  of  the  two  sides  of  the  chest  will  generally 
enable  an  observer  to  avoid  errors.  The  irregularity  of  rhythm  which 
occurs  from  slight  causes  should  be  remembered,  and  the  infant's  position 
changed  several  times  during  auscultation,  to  avoid  the  mistake  of  at- 
taching too  much  importance  to  a  feeble  respiratory  murmur  of  one  side. 

On  account  of  the  thinness  of  the  chest  walls,  there  is  always  great 


462  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

difficulty  in  distinguishing  between  rales  j^roduced  in  the  bronchi  and 
pleuritic  friction  sounds.  Before  drawing  any  inference  from  the  auscul- 
tatory signs,  both  lungs  must  be  examined  for  several  minutes,  changing 
the  child's  position,  and  often  inducing  a  cry  or  compelling  a  deep  inspi- 
ration by  other  means,  in  order  to  bring  out  signs  which  otherwise  may 
be  overlooked.  As  auscultation  is  extremely  difficult  or  impossible  in  a 
crying  infant,  this  part  of  the  physical  examination  should  first  be  made 
if  the  child  be  quiet,  since  upon  it  we  must  chiefly  depend  for  diagnosis. 
Inspection  and  percussion  can  be  deferred  until  later. 

Peculiarities  in  Disease. — There  are  several  peculiarities  connected 
with  the  respiratory  organs  in  infancy  and  early  childhood  which  must  be 
constantly  borne  in  mind  in  studying  their  diseases.  The  muscular  de- 
velopment of  the  thoracic  wall  is  feeble.  The  soft,  yielding  character  of 
the  thoracic  framework  causes  the  chest  to  sink  in  readily  from  atmos- 
pheric pressure  whenever  there  is  obstructive  dyspnoea.  On  account  of 
the  small  size  of  the  air  vesicles,  acute  congestion  may  interfere  with  their 
function  almost  as  completely  as  does  consolidation.  Because  of  the 
delicate  walls  of  the  air  vesicles,  emphysema  is  readily  produced  in  ob- 
structive dyspnoea,  but  it  is  rarely  permanent.  There  is  a  tendency  to 
collapse,  either  on  the  part  of  lobules  or  groups  of  lobules,  but  very 
rarely  of  an  entire  lobe.  This  is  a  much  less  important  factor  in  the 
production  of  symptoms  in  acute  pulmonary  disease  than  many  writers 
would  lead  us  to  suppose.  The  tendency  of  inflammation  to  spread 
from  the  large  to  the  small  bronchi  is  very  much  greater  than  in  adults. 
In  all  forms  of  pulmonary  disease  the  rapidity  of  respiration  is  much 
greater  than  in  adults,  on  account  of  the  rapid  metabolism  of  the  child. 
Areas  of  consolidation  often  exist  without  appreciable  changes  in  the 
percussion  note,  because  they  are  superficial  and  are  surrounded  by 
healthy  or  emphysematous  lung.  Flatness  should  always  suggest  the 
presence  of  fluid.  Disease  is  often  overlooked,  from  a  failure  to  examine 
the  whole  chest. 

Probably  the  most  common  mistakes  are  to  confound  bronchial  rales 
with  friction  sounds,  exaggerated  puerile  breathing  with  bronchial  breath- 
ing, and  to  overlook  the  existence  of  fluid  because  of  the  presence  of 
bronchial  breathing. 

ACUTE  CATARRHAL  BRONCHITIS. 

Acute  catarrhal  bronchitis  is  one  of  the  most  frequent  conditions  for 
which  the  physician  is  called  upon  to  prescribe  in  children.  It  occurs  at 
all  agds,  from  early  infancy  up  to  puberty.  Its  frequency,  however,  di- 
minishes steadily  after  the  second  year.  The  predisposition  to  acute 
bronchitis  exists  with  the  same  constitutional  conditions,  and  is  acquired 
in  the  same  manner  as  the  predisposition  to  the  acute  catarrhal  inflam- 
mations of  the  upper  respiratory  tract.    (See  Acute  Rhinitis).    Bronchitis  is 


ACUTE  CATARRHAL  BRONCHITIS.  4G3 

Tery  common  in  children  who  are  suffering  from  rickets  and  malnutrition. 
It  is  much  more  frequent  in  the  cold  months,  especially  in  the  late  winter 
and  early  spring,  when  there  are  sudden  atmospheric  changes  and  high 
winds. 

Bronchitis  may  be  a  primary  or  a  secondary  disease.  The  primary  form 
is  excited  by  cold,  exposure  with  insufficient  clothing  in  severe  weather, 
wetting  of  the  feet,  or  chilling  of  the  surface  in  any  manner.  Under 
these  conditions  it  may  occur  alone,  or  be  associated  with  or  preceded 
by  acute  catarrh  of  the  nose,  pharynx,  or  larynx.  In  rare  cases  it  is 
caused  by  the  inhalation  of  irritants.  Bronchitis  is  an  almost  invariable 
-accompaniment  of  measles  and  influenza.  It  is  very  common  in  pertussis, 
in  scarlet  and  tyjihoid  fevers  and  diphtheria,  and  may  occur  in  any  acute 
infectious  disease ;  it  also  complicates  pneumonia  and  pleurisy.  The  rela- 
tion of  micro-organisms  to  the  other  etiological  factors  is  the  same  as  in 
the  other  acute  catarrhs.     (See  Rhinitis). 

Lesions. — Acute  catarrhal  bronchitis  is  an  inflammation  of  the  mucous 
membrane  of  the  bronchi.  As  a  rule  it  is  bilateral,  both  sides  being 
involved  to  the  same  degree.  Localized  bronchitis  is  secondary  to  some 
other  pathological  process  in  the  lungs,  usually  tuberculosis  or  pneumonia. 
In  acute  bronchitis  only  the  larger  tubes  may  be  affected,  this  usually 
being  complicated  with  inflammation  of  the  trachea  (ordinary  tracheo- 
bronchitis) ;  or,  in  addition,  the  process  may  extend  to  the  medium-sized 
tubes  (severe  bronchitis) ;  or,  in  infants  especially,  it  may  extend  to  the 
smallest  tubes  (capillary  bronchitis).  In  the  last  form  there  are  invaria- 
bly changes  in  the  zones  of  air  vesicles  surrounding  the  bronchi,  and  these 
cases  are  therefore  more  properly  classed  as  broncho-pneumonia.  In  the 
first  form  the  inflammation  is  superficial,  and  affects  only  the  mucous 
membrane  of  the  bronchi.  In  the  second  form  it  may  involve  the  entire 
thickness  of  the  bronchial  wall,  and  in  the  third  form  it  does  so  regularly. 

The  pathological  changes  consist  in  congestion  and  swelling  of  the 
mucous  membrane,  desquamation  of  the  epithelium,  and  an  exudation  of 
mucus  and  pus-cells.  At  autopsy  the  injection  of  the  mucous  membrane 
is  usually  distinct ;  pus  and  mucus  line  the  walls  of  the  larger  bronchi, 
and  by  pressure  ooze  from  the  cut  extremities  of  the  smaller  tubes.  The 
chief  lesion  of  the  walls  of  the  bronchi  consists  in  an  infiltration  with  leu- 
cocytes. In  infants  dying  from  bronchitis,  the  lungs  are  much  more  fre- 
quently emphysematous  than  collapsed.  There  is  swelling  of  the  lymph 
glands  at  the  root  of  the  lung,  which  in  most  of  the  acute  cases  is  slight, 
but  in  protracted  cases,  and  after  recurring  attacks,  may  be  quite  marked. 

Symptoms. — It  is  convenient  to  consider  separately  the  symptoms  in 
infants  and  in  older  children. 

The  bronchitis  of  infants. — 1.  The  mild  form  (bronchitis  of  the  larger 
tubes). — The  onset  is  generally  gradual,  and  the  symptoms  of  bronchitis 
may  be  preceded  by  those  of  catarrh  of  the  nose,  pharynx,  or  larynx.  The 
31 


464  DISEASES  OF  THE   RESPIRATORY  SYSTEM. 

change  in  the  character  of  the  cough,  the  slightly  accelerated  breathing, 
and  a  further  rise  in  temperature,  indicate  an  extension  to  the  bronchi. 
The  cough  may  be  constant  and  severe,  or  very  slight.  There  is  no  ex- 
pectoration. The  secretions  are  usually  coughed  up  into  the  mouth  or 
pharynx,  and  swallowed.  This  sometimes  excites  vomiting.  At  other 
times  the  mucus  is  coughed  only  into  the  trachea  or  larynx,  and  aspirated 
again  into  the  lungs.  The  respirations  are  from  4U  to  50  a  minute,  and 
often  accompanied  by  a  rattling  sound,  due  to  mucus  in  the  large  bron- 
chi or  trachea.  The  general  symptoms  are  not  severe,  and  unless  the  in- 
fant is  very  young  or  very  delicate  no  apprehension  need  be  felt  as  to  the 
outcome.  The  temperature  is  generally  from  100°  to  102°  F.  for  two  or 
three  days,  then  below  100°  F.  There  are  a  moderate  amount  of  restless- 
ness dependent  upon  the  severity  of  the  cough,  usually  anorexia,  and 
sometimes  vomiting  and  diarrhoea. 

The  physical  signs  in  the  first  stage  are  dry,  sonorous  rdles  over  the 
whole  chest.  A  little  later  these  give  place  to  coarse  mucous  rales  heard 
everywhere,  but  especially  distinct  between  the  scapula?  and  in  the  infra- 
clavicular regions.  On  palpation  there  is  usually  a  marked  rhonchial 
fremitus.  Often  there  is  not  enough  dyspnoea  to  cause  recession  of  the 
soft  parts  of  the  chest.  Unless  the  disease  extends  to  the  smaller  bronchi 
and  the  air  vesicles,  the  illness  usually  lasts  about  a  week.  Coarse  rales 
in  the  chest  may  remain  for  some  time  after  the  symptoms  have  subsided. 
Relapses  are  exceedingly  common.  In  a  delicate  or  susceptible  child,  or  in 
one  whose  surroundings  are  bad,  one  attack  is  likely  to  be  followed  by  a 
succession  of  others,  so  that  the  child  may  not  be  really  well  until  warm 
weather  comes.  The  general  health  may  suffer  from  the  prolonged  con- 
finement to  the  house,  although  the  patient  may  never  have  been  seri- 
ously ill. 

2.  The  severe  form  (bronchitis  of  the  smaller  tubes). — This  differs 
from  the  preceding  variety  mainly  in  the  greater  severity  of  all  its  symp- 
toms. The  onset  may  be  like  that  just  described,  the  severe  symptoms  not 
appearing  until  the  patient  has  been  sick  two  or  three  days,  or  they  may 
be  severe  from  the  outset.  If  the  latter,  it  is  indistinguishable  from  that 
of  broncho-pneumonia.  There  are  cough,  dyspncea,  accelerated  breathing, 
fever,  and  moderate,  sometimes  severe,  prostration.  The  cough  is  tighter, 
and  more  frequently  of  a  short,  teasing  character  than  severe  and  paroxys- 
mal. There  is  difficulty  in  nursing.  Dyspnoea  may  be  quite  marked  and 
is  shown  by  the  active  dilatation  of  the  alae  nasi  and  the  recession  of  all  the 
soft  parts  of  the  chest  on  inspiration.  The  respirations  as  a  rule  are  from 
50  to  80  a  minute.  The  temperature  for  the  first  day  or  two  is  usually 
101°  or  102°,  but  it  may  be  103°  or  104°  F.  So  high  a  temperature  does 
not  continue  unless  pneumonia  develops.  The  prostration  is  in  most  cases 
more  closely  related  to  the  dyspnoea  and  the  rapidity  of  respiration  than 
to  the  temperature.     Often  there  is  slight  cyanosis. 


ACUTE  CATARRHAL  BRONCHITIS.  465 

In  the  beginning  the  chest  is  filled  with  sibilant  and  sonorous  rales, 
many  of  them  of  a  musical  character.  In  twelve  or  twenty-four  hours 
these  are  rej^laced  by  moist  rales — coarse  or  fine,  according  as  they  are 
produced  in  the  large  or  medium-sized  tubes.  There  are  often  loud, 
wheezing  rales  on  expiration.  The  respiratory  murmur  is  feeble ;  the 
resonance  on  percussion  is  normal  or  slightly  exaggerated.  As  the  case 
progresses  toward  recovery,  the  finer  rales  are  the  first  to  disappear.  The 
rales  are  always  best  heard  behind,  but  they  are  present  all  over  the  chest. 

At  the  onset  of  such  a  case  it  is  impossible  to  say  whether  the  disease 
will  be  limited  to  the  medium-sized  bronchi  or  will  extend  to  the  smallest 
bronchi  and  air  vesicles.  In  young  or  very  delicate  infants,  and  during 
measles,  it  is  very  common  for  the  disease  to  spread  rapidly  to  the  air  vesi- 
cles. In  other  cases,  usually  in  infants  under  six  months  old,  there  may 
develop  attacks  of  respiratory  failure  or  suffocation.  These  may  occur  in  a 
severe  case  at  any  time,  and,  because  of  the  infant's  inability  to  empty  the 
tubes  of  secretion,  the  dyspnoea  steadily  increases  until  the  respiratory  mus- 
cles are  exhausted,  the  inspiratory  force  being  too  feeble  to  overcome  the 
obstruction  in  the  tubes.  The  symptoms  which  follow  are  usually  ascribed 
to  pulmonary  collapse.  I  am,  however,  by  no  means  certain  that  this  is  the 
correct  explanation,  for  in  autopsies  made  in  such  cases  I  have  usually 
found  the  lungs  to  be  the  seat  of  acute  emphysema.  The  clinical  picture  is 
a  clear  one.  There  is  no  disposition  to  cough  or  cry ;  the  pulse  is  feeble ; 
the  respiration  very  rapid,  superficial,  often  irregular;  the  skin  cyanotic, 
and  often  clammy.  Finally,  there  may  be  added  to  the  others  signs  of  car- 
bonic-acid poisoning — dulness,  apathy,  and  stupor.  Such  attacks  may 
come  on  quite  suddenly  even  in  robust  infants,  and  unless  the  treatment 
is  energetic,  even  heroic,  death  often  follows  in  a  few  hours,  being  fre- 
quently preceded  by  convulsions. 

The  usual  course  of  the  disease  in  infants  previously  in  good  health 
is  that  the  severe  symptoms  continue  for  two  or  three  days  only,  after 
which  the  temperature  falls  to  100°  or  100-5°  F.,  and  gradually  becomes 
normal.  The  constitutional  symptoms  usually  decline  with  the  tempera- 
ture, and,  except  during  the  first  thirty-six  hours,  they  rarely  give  cause 
for  anxiety.  Recovery  almost  invariably  occurs  unless  the  disease  ex- 
tends to  the  finer  bronchi. 

Bronchitis  is  principally  to  be  distinguished  from  broncho-pneumonia. 
The  differential  diagnosis  is  more  fully  considered  under  that  disease.  The 
most  important  points  are  that  in  pneumonia  the  temperature  is  higher 
and  more  prolonged,  the  prostration  greater,  the  rales  very  often  localized 
— being  heard  only  behind,  often  over  only  one  lung — the  duration  is 
more  protracted,  and  all  the  symptoms  are  more  severe. 

The  bronchi ft-^  of  older  rhildren. — This  is  not  nearly  so  serious  as  in 
infants,  because  the  same  danger  does  not  exist -of  extension  of  the  inflam- 
mation to  the  finer  bronchi  and  air  cells. 


466  DISEASES  OF   THE  RESPIRATORY  SYSTEM. 

1.  The  mild  form. — This  is  very  common.  The  constitutional  symp- 
toms are  slight,  and  often  entirely  absent  after  the  first  day.  The  patient 
is  never  sick  enough  to  go  to  bed.  The  first  symptoms  are  cough  and 
soreness  or  a  sense  of  oppression  beneath  the  sternum.  The  cough  is 
always  worse  at  night.  It  is  at  first  tight,  hard,  and  racking ;  later  it  is 
loose,  and  in  children  over  five  years  old  there  is  usually  expectoration — 
first  of  white,  frothy  mucus,  but  after  a  few  days  it  becomes  more  abun- 
dant, and  of  a  yellow  or  yellowish-green  colour,  from  the  presence  of  pus. 
The  physical  signs  are  only  coarse  rales,  at  first  dry,  and  later  moist,  but 
heard  over  both  sides  of  the  chest,  in  front  and  behind.  There  may  be 
some  disturbance  of  digestion,  anorexia,  constipation,  or  diarrhoea.  The 
usual  duration  of  the  attack  is  from  one  to  two  weeks.  If  the  patient  is 
not  kept  indoors  the  disease  may  pass  into  a  subacute  form,  lasting  for 
several  weeks  as  a  protracted  "  winter  cough,"  but  without  any  other  im- 
portant symptoms. 

2.  The  severe  form. — The  onset  is  abrupt,  with  fever,  chill,  pains  in 
the  back,  headache,  cough,  and  sometimes  pain  in  the  chest.  There  is  a 
feeling  of  tightness  or  constriction  beneath  the  sternum.  The  onset  re- 
sembles pneumonia,  except  that  the  symptoms  are  less  severe.  The  tem- 
perature for  the  first  two  or  three  days  ranges  between  100°  and  103°  F. 
It  is  generally  highest  in  the  first  twenty-four  hours.  The  cough  resem- 
bles that  of  the  mild  form,  but  it  is  usually  more  severe.  The  expec- 
toration is  more  profuse,  and  occasionally,  in  the  early  stage,  it  may  be 
streaked  with  blood. 

The  coarse  rales  of  the  mild  form  are  present,  and  in  addition  there 
are  finer  rales — at  first  dry,  aud  later  moist — heard  all  over  the  chest.  Fre- 
quently, wheezing  rales  are  heard  on  expiration.  The  duration  of  the  at- 
tack is  ordinarily  from  two  to  three  weeks,  the  patient  being  sick  enough 
to  be  confined  to  bed  for  three  or  four  days  only.  There  is  frequently 
a  cough  for  some  time  after  all  physical  signs  have  disappeared.  Relapses 
are  easily  excited  by  any  indiscretion  before  the  patient  has  quite  recovered. 

The  prognosis  in  the  primary  cases  is  good,  such  almost  invariably  ter- 
minating in  recovery,  and  very  exceptionally  passing  into  broncho-pneu- 
monia ;  but  this  not  infrequently  happens  when  the  attack  comjDlicates 
measles  or  pertussis. 

Treatment  of  Broncliitis.  Prophylaxis. — To  remove  the  predisposition 
to  bronchitis  the  same  means  should  be  employed  as  those  mentioned 
in  acute  rhinitis  (page  430).  General  measures  also  should  be  adopted 
to  build  up  the  health  of  delicate  infants.  Those  with  tuberculous 
antecedents,  and  those  who  are  especially  prone  to  pulmonary  disease, 
should  if  possible  spend  the  winter  in  a  warm  climate.  In  all  such  pa- 
tients the  systematic  administration  of  cod-liver  oil  should  be  continued 
throughout  every  cold  season.  The  sleeping  apartments  of  susceptible 
infants  should  not  be  too  cold — never  below  60°  F. — but  they  must  be 


ACUTE   CATARRHAL  BRONXHITIS.  467 

well  ventilated,  best  by  an  open  fire.  Such  children  should  sleep  in  flan- 
nel night  clothes,  care  being  taken  to  see  that  the  feet  are  always  warm. 
While  bronchitis  of  the  large  tubes  is  not  per  se  a  serious  disease,  it  may 
become  so  by  extension  to  the  smaller  tubes.  It  is  consequently  very  im- 
portant in  infants  and  young  children  that  these  apparently  mild  attacks 
should  not  be  neglected. 

General  manage7nent. — Every  young  child  who  has  an  acute  catarrh  of 
the  nose,  pharynx,  larynx,  or  bronchi  should  be  kept  indoors.  In  every 
such  catarrh  accompanied  by  fever  the  child  should  be  kept  in  bed  while 
the  fever  lasts,  even  if  the  temperature  does  not  go  above  100'5°  F.,  and  is 
accompanied  by  no  other  constitutional  symptoms.  In  infants  and  young 
children,  many  cases  of  bronchitis  result  from  an  extension  of  an  acute 
rhinitis  or  laryngitis,  hence  this  precaution  is  of  more  importance  than 
everything  else  in  preventing  the  extension  downward  of  a  catarrhal  in- 
flammation. A  very  large  number  of  the  cases  will  recover  promptly  when 
no  other  treatment  is  employed  than  to  keep  the  child  in  bed.  The  tem- 
perature of  the  room  should  be  about  70°  or  73°  F.  It  should  be  well 
ventilated  and  frequently  aired,  the  child  being  removed  to  another  room 
while  this  is  done.  Infants  should  not  be  allowed  to  lie  for  hours  in  the 
same  position  as  there  is  a  great  advantage  in  changing  from  the  crib  to 
the  nurse's  arms.  Careful  attention  should  be  given  to  feeding  (page 
190)  and  to  the  condition  of  the  bowels.  A  cathartic,  preferably  castor 
oil,  should  be  administered  at  the  outset.  Distention  of  the  stomach  and 
bowels  with  gas  adds  greatly  to  the  discomfort  of  the  patient,  and  may 
cause  serious  symptoms. 

Abortive  measures  are  rarely  successful,  for,  by  the  time  the  physician 
is  summoned,  the  disease  is  generally  so  well  established  that  they  are 
futile.  Mild  cases  may  sometimes  be  cut  short  by  a  hot  foot-bath,  free 
catharsis,  and  diaphoresis,  especially  by  the  use  of  phenacetine  and  Dover's 
powder  (phenacetine  three  grains,  Dover's  powder  one  grain,  to  a  child  of 
three  years). 

Local  applications. — Poultices  are  objectionable  on  account  of  their 
weight  and  the  difficulty  in  getting  them  properly  applied.  For  in- 
fants the  oiled-silk  jacket  (page  59)  is  decidedly  preferable.  This  should 
be  applied  in  the  beginning,  and  may  be  worn  throughout  the  attack.  It 
accomplishes  all  that  a  poultice  does,  with  much  less  disturbance  to  the 
patient.  Counter-irritation  is  very  valuable.  In  infants  the  best  results 
are  obtained  by  the  frequent  use  of  a  mustard  paste  (page  52).  It  should 
be  large  enough  to  envelop  the  chest,  and  covered  by  a  towel,  so  as  not  to 
soil  the  oiled-silk  jacket  or  the  clothing.  The  paste  is  removed  as  soon  as 
the  skin  is  thoroughly  reddened,  which  will  be  in  from  five  to  ten  min- 
utes, according  to  the  strength  of  the  mustard  and  the  condition  of  the 
child's  skin.  The  skin  should  then  be  dried  and  the  oiled-silk  jacket 
again  pinned  snugly  about  the  chest.    This  may  be  repeated,  according  to 


468  DISEASES   OP   THE  RESPIRATORY   SYSTEM. 

indications,  from  two  to  eight  times  a  day.     If  properly  used,  it  may  be 
continued  for  a  week  without  causing  any  soreness  of  the  skin. 

Inhalations. — The  value  of  these  is  not  sufficiently  appreciated.  They 
may  in  the  gre'at  majority  of  cases  take  the  place  of  the  administration  of 
drugs  by  the  mouth,  a  very  great  advantage  in  infants.  They  may  be 
used  by  means  of  the  croup  kettle  or  vapourizer  (pages  58  and  59),  the 
child  always  being  placed  in  a  tent.  In  the  early  part  of  the  disease 
relaxing  inhalations,  like  simple  watery  vapour  or  limewater,  may  be 
used.  Later  turpentine,  creosote,  terebene,  or  eucalyptol  may  be  added. 
Of  these,  creosote  has  given  me  the  most  satisfaction.  Inhalations  are 
to  be  used  for  ten  or  fifteen  minutes  from  four  to  twelve  times  a  day. 

Expectorants.— \n  infancy  this  class  of  drugs  may  usually  be  advan- 
tageously dispensed  with.  For  older  children  the  relaxing  expectorants,, 
especially  antimony  and  ipecac  in  combination,  may  be  used  in  the  first 
stage.  When  the  secretion  is  more  abundant,  either  the  alkaline  or  the 
stimulating  expectorants  may  be  given.  Of  the  former,  the  best  are  liquor 
potassse,  citrate  of  potassium,  and  muriate  of  ammonia ;  of  the  latter,  creo- 
sote, turpentine,  terebene,  and  squills.  Small,  frequently  repeated  doses 
usually  give  the  best  results. 

Opium. — This  should  be  given  very  cautiously  to  young  infants,  as  it 
is  capable  of  doing  great  harm.  The  dry,  harassing  cough  of  the  early 
stage  sometimes  yields  to  nothing  so  quickly  as  to  small  doses  of  Dover's 
powder  (e.  g.,  one  tenth  of  a  grain  every  two  hours  to  a  child  of  one  year). 
In  the  case  of  infants,  late  in  the  disease,  and  especially  in  severe  cases, 
opium  should  be  withheld  altogether.  It  disturbs  the  stomach,  consti- 
pates the  bowels,  and,  most  of  all,  it  greatly  depresses  the  respiration. 

Emetics  may  sometimes  be  used  with  advantage  when  the  secretion  is 
very  abundant  and  the  cough  feeble,  but  they  should  be  avoided  with  weak 
pulse,  great  prostration,  and  slight  stupor.  Syrup  of  ipecac  is  the  best 
emetic  under  these  conditions. 

Cardiac  stimulants. — These  are  required  in  most  of  the  severe  cases. 
The  best  is  alcohol.  It  should  be  begun  as  soon  as  indicated  by  weak 
pulse  and  general  prostration.  For  a  child  a  year  old,  from  half  an 
ounce  to  one  ounce  of  brandy,  diluted  with  from  six  to  eight  parts  of  water, 
should  be  given  in  each  twenty-four  hours,  in  small  doses  at  short  intervals. 

Resj)iratory  stimulants. — The  most  valuable  drugs  are  strychnine  and 
atropine.  To  an  infant  of  six  months  -^-^  grain  of  strychnine  and  y^-o 
grain  of  atropine  may  be  given  every  two  hours.  For  a  short  time  twice 
these  doses  may  be  used.  They  are  needed  only  in  the  most  severe  cases, 
and  may  be  used  in  combination  or  alternately.  An  important  respira- 
tory stimulant  is  counter-irritation  over  the  entire  body  by  the  mustard 
paste  or  hot  mustard  bath. 

The  management  of  mild  cases  in  infants. — In  the  great  majority  of 
cases  the  disease  is  self-limited,  tending  to  spontaneous  recovery.     Often 


ACUTE  CATARRnAL   BRONXHITIS.  469 

no  treatment  is  needed,  except  the  hygienic  measures  mentioned.  An 
oiled-silk  jacket  should  be  applied.  If  the  cough  is  excessive,  inhalations 
of  creosote  or  turpentine  three  or  four  times  a  day  may  be  used,  or  small 
doses  of  Dover's  powder  or  phenacetine.  The  oppression  which  often 
comes  on  toward  evening  may  be  relieved  by  a  mustard  paste  at  bedtime. 
Stimulants  are  not  required.  All  other  drugs  may  be  advantageously 
omitted,  but  during  convalescence  cod-liver  oil  should  be  given. 

Tlie  management  of  severe  cases  in  infants. — These  must  be  treated 
very  much  like  cases  of  broncho-pneumonia.  The  temperature  is  rarely 
high  enough  to  require  interference,  but  the  chief  danger  is  due  to  the 
inability  of  the  child  to  get  rid  of  the  secretion  by  the  cough.  In  my 
experience  the  two  most  valuable  means  of  treatment  have  been  the  use 
of  inhalations  and  counter-irritation.  The  former  should  be  repeated  for 
ten  or  fifteen  minutes  every  two  hours,  and  for  a  short  period  may  often 
be  given  with  advantage  every  hour.  Early  in  the  disease,  vapour  of 
plain  water  or  limewater  may  be  used  ;  later,  creosote  is  best.  Counter- 
irritation  by  the  mustard  paste  should  be  repeated  every  three  hours, 
and  the  oiled-silk  jacket  worn  continuously.  Alcoholic  stimulants  are 
usually  needed  in  delicate  children,  and  in  secondary  bronchitis  accom- 
panying the  infectious  diseases.  In  most  of  the  cases  the  medication 
should  consist  only  of  cardiac  and  respiratory  stimulants.  In  strong  chil- 
dren the  occasional  use  of  an  emetic  at  bedtime  is  admissible. 

Attacks  of  suffocation  and  respiratory  failure. — The  indications  here 
are  to  get  as  much  blood  as  possible  to  the  surface  and  to  the  extremities, 
in  order  to  relieve  the  overloaded  right  heart,  and  to  compel  the  child  to 
make  full  and  deep  inspiratory  efforts.  One  plan  of  treatment  (Jacobi's) 
is  to  induce  frequent  crying  by  flagellation  or  spanking,  this  being  kept 
up  for  several  hours.  Another  (11.  C.  Wood's)  is  to  use  alternately  hot 
and  cold  douches  to  the  chest  until  some  reaction  is  obtained,  and  then  to 
follow  up  this  by  the  occasional  use,  for  a  few  moments,  of  a  very  hot  bath 
(120°  F.).  Both  these  means,  but  especially  the  first  mentioned,  are  of 
great  value,  as  I  have  had  abundant  opportunity  to  verify.  Another  use- 
ful measure  is  the  hot  mustard  bath,  or  the  hot  mustard  pack  applied  to 
the  entire  body.  In  conjunction  with  the  above  means,  both  heart  and 
respiratory  stimulants  should  be  given  in  full  doses.  If  possible,  oxygen 
should  be  administered.  As  these  symptoms  are  liable  to  recur  every  few 
hours  for  a  day  or  two,  a  repetition  of  the  treatment  will  be  needed,  and 
if  possible  the  physician  should  remain  with  the  patient. 

If  a  young  infant  can  be  tided  over  these  critical  attacks,  recovery  is 
probable.  After  this  danger  is  past,  the  treatment  previously  indicated 
may  be  pursued.  The  use  of  expectorants,  particularly  the  composite 
cough  mixtures  containing  opium,  can  not  be  too  strongly  condemned 
in  all  severe  cases  of  infantile  bronchitis. 

The  management  of  cases  in  older  children. — In  the  non-febrile  cases 


470  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

confinement  in  bed  is  unnecessary,  but  children  should  be  kept  indoors. 
In  the  early  stage,  with  hard,  dry  cough,  one  of  the  best  remedies  is  brown 
mixture  (the  mistura  glycyrrhizge  comjiosita  of  the  U.  S.  P.).  It  will 
be  found  advantageous  in  most  cases  to  have  the  formula  made;  up  with 
one  half  the  usual  amount  of  opium.  When  the  cough  is  especially  hard 
and  dry,  a  single  inhalation  may  be  used  at  bedtime.  In  the  second  stage,, 
muriate  of  ammonia  may  be  added  to  the  mixture ;  or  terebene,  two  or 
three  drops  upon  sugar,  may  be  given  four  or  five  times  a  day.  In- 
halations of  creosote  or  turpentine  should  be  used. 

In  the  more  severe  cases  accompanied  by  fever  the  patients  should  be 
kept  in  bed  and  an  oiled-silk  jacket  applied.  In  the  beginning  the  liquor 
ammonise  acetatis  and  spiritus  ^theris  nitrosi  may  be  given  for  their  effect 
upon  the  skin  and  kidneys.  For  the  general  discomfort,  pain,  headache,, 
etc.,  nothing  is  better  than  phenacetine  and  Dover's  powder  (three  grains 
of  the  former  to  one  grain  of  the  latter  to  a  child  of  five  years),  repeated 
every  three  to  six  hours.  For  the  cough  the  same  remedies  may  be  used 
as  in  the  mild  cases.  All  patients  should  be  kept  in  bed  as  long  as  the- 
temperature  is  above  normal.  Subsequently,  the  cases  may  be  managed 
as  in  the  milder  form  of  the  disease. 

The  protracted  cough  of  convalescence. — It  often  happens,  both  in 
infants  and  in  older  children,  that  after  all  physical  signs  and  constitu- 
tional symptoms  have  disappeared,  a  cough  continues  sometimes  for  weeks.. 
Expectoration  is  scanty,  or  is  wanting  altogether  ;  the  cough  is  hard,  dry,, 
often  paroxysmal,  and  in  some  cases  occurs  at  night  only.  For  this  con- 
dition the  best  remedies  are  quinine,  cod-liver  oil,  and  creosote.  The  last 
named  may  easily  be  given  to  young  infants  as  well  as  to  older  children,  in 
combination  with  liquid  beef  peptonoids.*  It  may  be  also  used  in  pill  form 
or  by  inhalation.  These  measures  may  be  tried  alternately  or  in  combina- 
tion.    Where  they  are  not  effective  a  change  of  climate  should  be  advised. 

FIBRINOUS  BRONCHITIS  (BRONCHIAL  CROUP). 

Fibrinous  bronchitis  is  seen  in  diphtheria,  usually  as  an  extension  from- 
the  larynx  or  trachea.  There  is,  however,  another  form  of  bronchitis 
attended  by  a  fibrinous  exudate,  which  occurs  as  a  primary  disease.  This 
is  very  rare  in  children.  Weil  has,  however,  collected  twenty  cases  of  the 
primary  form.  The  etiology  is  obscure.  It  is  seen  at  all  ages,  from  in- 
fancy up  to  puberty,  and  it  may  be  either  acute  or  chronic.  From  the  cases 
thus  far  reported  it  would  appear  that  the  acute  form  is  relatively  more 
common  in  children  than  in  adults.  The  disease  may  be  confined  to  cer- 
tain branches  of  the  bronchial  tree,  or  it  may  affect  all  the  bronchi,  even 
to  the  minute  subdivisions.     The  fibrinous  membrane  is  found  loose  in 

*  A  preparation  put  up  by  the  Arlington  Chemical  Company,  and  a  very  palatable 
way  of  giving  creosote. 


CHRONIC  BRONCHITIS.  47I 

the  tubes  or  adherent.  There  are  generally  associated  other  pulmonary- 
changes,  such  as  emphysema,  areas  of  atelectasis  or  of  broncho-pneumonia. 

The  acute  form  somewhat  resembles  ordinary  catarrhal  bronchitis. 
The  diagnostic  features  are  the  severity  of  the  dysjonoea  and  the  expectora- 
tion of  tube  casts  from  the  larger  bronchi,  or  elongated  cylinders  from 
the  smaller  ones,  the  former  resembling  macaroni,  the  latter  vermicelli. 
The  expectorated  masses  are  often  in  balls  or  plugs,  and  their  peculiar 
character  is  not  recognised  until  they  are  j^laced  in  water.  The  casts 
are  dissolved  by  alkalies,  especially  by  limewater.  After  the  expulsion  of  a 
large  cast,  improvement  in  all  the  symptoms  occurs.  These,  however, 
return  as  the  exudate  ^reappears.  The  ordinary  duration  of  acute  cases, 
is  from  one  to  three  weeks. 

In  the  chronic  form  there  are  no  constitutional  symptoms,  but  only 
dyspnoea  and  cough,  often  recurring  in  paroxysms,  with  the  expectoration 
of  fibrinous  casts.  The  patient  may  have  these  attacks  at  intervals  of  a 
few  days  or  weeks,  extending  over  a  period  of  months,  or  even  years. 
There  are  no  characteristic  physical  signs.  The  diagnosis  rests  upon  the 
peculiar  character  of  the  expectoration.  The  prognosis  in  acute  cases  is 
unfavourable,  the  mortality  being  75  per  cent  (Weil).  Chronic  cases  are 
not  dangerous  to  life. 

Treatment. — This  is  quite  unsatisfactory.  To  loosen  the  membrane  and 
facilitate  its  expulsion,  the  most  efficient  means  are  inhalations  of  the 
vapour  of  limewater  and  the  internal  administration  of  pilocarpine.  Oc- 
casionally emetics  are  of  value.  Improvement  in  some  of  the  chronic 
cases  has  resulted  from  the  use  of  iodide  of  potassium. 

CHRONIC   BRONCHITIS. 

Chronic  bronchitis  is  not  a  common  disease  in  children,  particularly 
in  young  children,  one  reason  being  that  chronic  emphysema,  so  fre- 
quently an  associated  condition  in  adults,  is  rare  in  early  life.  Chronic 
bronchitis  always  accompanies  chronic  pulmonary  tuberculosis  and  chronic 
interstitial  pneumonia,  with  or  without  the  occurrence  of  bronchiectasis. 
It  is  seen  in  chronic  cardiac  disease,  especially  with  lesions  of  the  mitral 
valve.  It  may  occur  as  a  late  symptom  of  hereditary  syphilis.  Excluding 
the  varieties  mentioned,  it  usually  follows  attacks  of  acute  bronchitis,  the 
process  becoming  chronic  because  of  the  patient's  constitutional  condition 
or  his  unhygienic  surroundings.  The  acute  attack  may  be  primary,  but  it 
often  follows  measles  and  whooping-cqugh.  Rickets,  general  malnutrition, 
and  lymphatism  are  the  constitutional  conditions  in  which  acute  bronchitis 
is  most  likely  to  pass  into  the  chronic  form.  Deformities  of  the  chesty 
the  result  either  of  rickets  or  of  Pott's  disease,  are  occasionally  a  cause. 

Symptoms. — The  only  constant  symptom  is  cough,  which  is  persistent, 
obstinate,  and  nearly  always  worse  at  night  or  early  in  the  morning.  It 
often  occurs  in  paroxysms  strongly  suggestive  of  pertussis.     Expectora- 


472  DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

tion  is  not  generally  abundant,  but  in  older  children  there  is  usually  some 
expectoration  present,  and  in  a  few  cases  it  is  profuse.  A  copious  morn- 
ing expectoration  of  fetid  pus  or  muco-pus  indicates  bronchiectasis. 
There  is  no  fever,  little  or  no  dyspnoea,  and  although  the  patients  are  thin 
they  are  not  emaciated,  and  in  many  cases  the  general  health  is  not  much 
affected.  There  may  be  coarse  mucous  rales,  or  no  physical  signs  what- 
ever. The  duration  of  the  disease  is  indefinite,  depending  upon  the 
cause.  All  these  patients  are  better  in  summer  and  worse  in  winter, 
and  suffer  frequently  from  exacerbations  of  acute  or  subacute  bronchitis. 

The  diagnosis  is  to  be  made  mainly  from  pertussis  and  tuberculosis. 
From  mild  attacks  of  pertussis  the  diagnosis  may  be  impossible  except  by 
the  course  of  the  disease.  Tuberculosis  may  be  suspected  if  the  thermom- 
eter shows  regularly  a  slight  evening  rise  of  temperature,  if  there  is  much 
anemia,  and  steady  loss  of  flesh.  A  positive  diagnosis  can  be  made  only 
by  the  discovery  of  tubercle  bacilli  in  the  sputum. 

Treatment. — The  first  indication  is  to  treat  the  primary  disease.  In 
cardiac  cases  digitalis  is  the  best  remedy,  and  all  sedatives  are  to  be 
avoided.  Attention  should  be  directed  to  the  general  condition — rickets, 
malnutrition,  and  lymphatism  each  receiving  its  appropriate  treatment. 
In  most  cases  a  general  tonic  plan  of  treatment  is  best,  particularly  the 
continuous  use  of  cod-liver  oil.  In  many  cases  a  change  of  climate  is  the 
only  thing  which  is  really  curative.  For  the  relief  of  cough,  opiates  are 
to  be  avoided  as  much  as  possible.  The  main  reliance  should  be  upon 
potassium  iodide,  creosote  and  terebene,  given  both  by  mouth  and  by 
inhalation. 

REFLEX  COUGH— NERVOUS  COUGH. 

Strictly  speaking,  all  cough  is  reflex  and  of  nervous  origin.  The  term 
*'  reflex  cough  "  is,  however,  commonly  used  to  denote  that  which  occurs 
without  any  evidence  of  disease  in  the  larynx,  trachea,  bronchi,  lungs,  or 
pleura.  On  account  of  the  close  nervous  connection  through  the  vagus 
and  its  branches  between  the  mouth,  ear,  throat,  stomach,  and  thoracic 
organs,  it  is  possible  for  cough  to  be  produced  by  many  forms  of  irritation 
in  these  organs  or  cavities.  Clinically,  the  following  varieties  of  nervous 
cough  are  observed  : 

1.  That  dependent  upon  pharyngeal  irritation.  One  cause  of  this  is  an 
elongated  uvula.  This  cough  occurs  usually  at  night,  and  is  tickling,  hack- 
ing, or  hemming  in  character.  A  similar  irritation  may  be  produced  by  the 
trickling  of  mucus  into  the  lower  pharynx  from  the  nose  or  rhino-pharynx. 

2.  That  due  to  aural  irritation.  This  is  rare,  and  may  be  associated 
with  chronic  otitis  of  any  variety.     It  has  no  special  characteristics. 

3.  That  due  to  gastric  irritation — the  "  stomach  cough."  This  is 
much  more  frequent  than  the  other  forms.  It  is  usually  associated  with 
chronic  indigestion  and  occurs  both  in  infants  and  in  older  children. 


REFLEX  COUGH.  473 

4.  That  due  to  dental  irritation.  The  cough  of  dentition  is  often 
spoken  of,  although  I  have  never  seen  a  case  which  could  fairly  be  as- 
cribed to  it. 

5.  Cardiac  cough.  This  is  usually  associated  with  mitral  disease, 
and  due  to  pulmonary  congestion.  The  cough  is  dry,  hard,  and  often 
severe. 

6.  The  variety  which  occurs  usually  about  the  time  of  puberty,  and 
often  associated  with  anasmia,  chorea,  or  spinal  irritation.  It  is  a  short, 
hacking,  or  teasing  cough,  sometimes  very  distressing,  and  it  seems  to  be 
a  manifestation  of  extreme  nervous  irritability. 

7.  The  periodical  night  cough,  which  is  generally  ascribed  to  irritation 
of  the  vagus  or  its  branches  by  enlarged,  sometimes  caseous,  lymph  nodes 
of  the  tracheo-bronchial  group.  This  often  occurs  in  severe  paroxysms, 
the  character  of  which  is  very  much  like  pertussis.  The  attacks  are  apt 
to  come  on  about  the  middle  of  the  night  and  last  for  several  hours. 
Vomiting  is  rare.  The  cough  may  recur  regularly  every  night  for  months. 
On  account  of  the  loss  of  sleep  the  patient's  general  health  may  be  con- 
siderably undermined. 

8.  A  very  similar  cough  may  occur  in  connection  with  abscesses  in  the 
posterior  mediastinum  due  to  Pott's  disease. 

Symptoms  and  Diagnosis. — These  cases  are  not  common  in  infants, 
but  are  quite  frequent  in  older  children.  In  nearly  all  the  varieties 
the  cough  is  worse  at  night,  and  in  many  it  may  be  confined  to  that 
time.  The  influence  of  habit  is  often  seen,  the  attacks  coming  on  regu- 
larly at  certain  periods.  The  general  health  may  not  be  affected,  except 
from  the  disturbance  of  sleep.  The  diagnosis  between  the  different 
forms  is  often  very  difficult.  The  precise  cause  in  a  given  case  is  discov- 
ered only  by  a  careful  examination  of  the  ear,  nose,  pharynx,  heart,  stom- 
ach, lungs,  and  a  consideration  of  the  patient's  general  condition.  The 
existence  of  enlarged  or  tuberculous  bronchial  glands  may  be  suspected  in 
patients  of  tuberculous  antecedents,  in  those  Avho  have  previously  suffered 
from  measles,  pertussis,  or  repeated  attacks  of  bronchitis,  and^when  the 
cough  is  very  severe  and  paroxysmal.  A  similar  group  of  symptoms  may 
exist  with  abscesses  from  Pott's  disease.  In  either  of  these  conditions 
there  may  be  attacks  of  suffocation. 

Treatment. — Opium  and  expectorants  are  not  indicated,  and  inhala- 
tions are  of  little  value.  The  only  successful  treatment  is  that  which  is 
directed  to  the  cause  of  the  disease.  If  no  cause  can  be  found,  and  the 
cough  appears  to  be  of  purely  nervous  origin,  the  best  results  follow  the 
use  of  the  bromides  or  the  administration  of  antipyrine  at  bedtime. 

ASTHMA. 

Astlima  may  be  defined  as  a  vaso-motor  neurosis  of  the  respiratory 
tract.     It  is  characterized  by  attacks  of  severe  spasmodic  dyspnoea,  which 


474  DISEASES   OF  THE   RESPIRATORY   SYSTEM. 

may  be  preceded,  accompanied,  or  followed  by  bronchial  catarrh  of  greater 
or  less  severity.  In  the  asthmatic  attacks  of  infancy  the  catarrhal  ele- 
ment is  very  prominent,  and  these  cases  present  quite  a  different  clinical 
picture  from  the  disease  as  seen  in  older  children,  which  differs  in  no 
essential  j^oints  from  the  asthma  of  adults. 

Writers  differ  very  much  in  their  statements  regarding  the  frequency 
of  asthma  in  early  life,  mainly  because  of  a  want  of  agreement  in  re- 
gard to  what  shall  be  included  under  this  term.  The  asthmatic  attacks 
of  infants  are  considered  by  some  as  a  stage  of  bronchitis,  by  others  as 
distinct  from  that  disease.  Typical  attacks  resembling  those  of  adult  life 
are  rare  in  children,  and  extremely  so  before  the  seventh  year.  How- 
ever, of  225  cases  of  asthma  reported  by  Hyde  Salter,  the  disease  began 
before  the  tenth  year  in  nearly  one  third  the  number. 

Etiology. — The  general  or  constitutional  causes  are  the  same  in  chil- 
dren as  in  adults.  Asthma  may  be  hereditary.  It  occurs  especially  in 
children  whose  antecedents  have  suffered  from  gout  or  from  other  neu- 
roses. The  local  cause  may  be  any  form  of  irritation  in  the  nose  or 
pharynx— hypertrophic  rhinitis,  adenoid  growths  of  the  pharynx,  hyper- 
trophied  tonsils,  or  elongated  uvula — or  in  the  bronchial  mucous  mem- 
brane, as  a  result  of  previous  attacks  of  acute  bronchitis.  It  is  probable 
that  it  may  also  be  caused  by  the  irritation  of  enlarged  bronchial  glands. 
In  susceptible  persons  a  paroxysm  may  be  excited  by  cold  or  damp  air, 
indigestion,  constipation,  or  the  inhalation  of  various  irritating  sub- 
stances, such  as  dust,  the  pollen  of  certain  plants,  etc.  First  attacks  of 
asthma  in  children  are  apt»to  follow  bronchitis. 

Symptoms. — Four  quite  distinct  clinical  types  of  asthma  are  seen  in 
children  :  (1.)  Cases  which  in  their  onset  simulate  attacks  of  capillary 
bronchitis.  (2.)  Those  in  which  asthmatic  symptoms  follow  an  attack  of 
bronchitis,  continuing  for  weeks  or  months,  but  not  necessarily  recur- 
ring. (3.)  Hay  fever,  or  the  periodical  form  which  occurs  every  summer. 
(4.)  That  which  resembles  the  ordinary  adult  asthma,  with  the  nervous 
element  predominating.  The  prominence  of  the  catarrhal  symptoms  is 
characteristic  of  all  asthma  of  children,  the  first  two  varieties  being 
peculiar  to  early  life. 

Attacks  resembling  capillary  hronchitis. — These  cases  are  rare,  but 
may  be  seen  even  in  infants.  The  onset  is  sudden,  with  moderate  fever, 
incessant  cough,  severe  dyspnoea,  and  sometimes  symptoms  of  suffocation 
— cyanosis,  prostration,  and  cold  extremities.  The  chest  is  filled  with 
sonorous,  sibilant,  and  soon  with  subcrepitant  rales.  Instead  of  running 
the  usual  course  of  bronchitis  of  the  finer  tubes,  the  symptoms  may  pass 
away  very  rapidly,  and  in  forty-eight,  sometimes  in  twenty-four,  hours  the 
patient  may  be  quite  well.  It  is  only  by  the  course  of  the  disease  and  by 
recurring  attacks  that  their  true  nature  can  be  recognised.  In  infants: 
this  form  may  be  fatal. 


ASTHMA.  475 

Cases  folio IV iiifj  attacks  of  bronchitis — (Jatarrhal  asthma. — This  form  is 
not  uncommon,  though  it  is  frequently  designated  by  some  other  term  than 
asthma — sometimes  as  spasmodic  bronchitis,  or  catarrhal  spasm  of  the  bron- 
chi. The  symptoms  are,  however,  indistinguishable  from  astlima,  and 
they  evidently  belong  in  the  same  category.  This  form  is  usually  seen  in 
infants,  being  rare  after  the  third  year.  Many  of  the  patients  are  rachitic ; 
others  have  large  tonsils,  or  adenoid  growths  of  the  pharynx ;  while  in 
still  others  there  is  every  reason  to  suspect  the  presence  of  large  bronchial 
glands.  Usually  there  is  nothing  peculiar  about  the  antecedent  bronchitis ; 
in  most  cases  it  is  not  especially  severe,  and  is  limited  to  the  larger  tubes. 
The  febrile  symptoms  subside  in  a  few  days,  but  the  cough  continues, 
as  do  also  the  dyspnoea  and  wheezing.  When  the  symptoms  are  fairly 
established  they  are  very  uniform  and  characteristic.  The  respiration  is 
accelerated,  usually  to  50  or  60,  sometimes  to  70  or  80,  a  minute.  The 
temperature  from  time  to  time  may  be  very  slightly  elevated,  or  it  may 
remain  normal.  The  respiration  is  noisy,  laboured,  and  accompd.nied  by 
distinct  wheezing,  which  can  sometimes  be  heard  all  over  the  room. 

On  auscultation,  there  is  prolonged  expiration  accompanied  by  loud, 
wheezing  rales,  either  sonorous,  sibilant,  or  musical,  and  occasionally 
moist  rales  are  present.  In  cases  which  have  lasted  some  time  a  moderate 
amount  of  emphysema  can  be  inferred  from  prominence  of  the  infraclavicu- 
lar regions,  and  exaggerated  resonance  over  the  chest  in  front. 

These  symptoms  and  signs  may  continue  for  three  or  four  weeks  only, 
and  gradually  wear  off,  or  they  may  last  as  many  months — if  they  begin  in 
the  winter  or  spring,  often  continuing  until  the  middle  of  the  summer. 
While  they  are  constantly  present,  they  vary  in  intensity  from  time  to  time, 
being  usually  much  worse  at  night.  The  symptoms  are  always  increased 
by  exposure  to  a  cold,  damp  atmosphere,  by  any  fresh  accession  of  bron- 
chitis, and  often  by  trivial  digestive  disturbances.  The  usual  duration 
of  the  cases  I  have  seen  has  been  two  to  six  weeks.  The  cough  is  not 
usually  severe,  and  expectoration  in  most  cases  is  absent.  The  general 
health  is  often  but  little  atfected.  With  recovery  from  the  asthmatic 
symptoms  the  emphysema  usually  disappears  gradually,  although  I  have 
seen  one  severe  case  in  which  it  persisted. 

What  proportion  of  these  children  afterward  develop  ordinary  asthma, 
from  personal  experience  I  am  unable  to  say.  Some  undoubtedly  do,  but 
in  others  which  I  have  been  able  to  follow,  recovery  has  seemed  to  be 
permanent.  This  would  appear  more  likely  in  those  cases  closely  associ- 
ated with  rickets,  or  with  other  causes  which  disappear  spontaneously 
with  time  or  as  a  result  of  treatment. 

Hay  fever. — This  is  very  rare  before  the  seventh,  and  but  few  well- 
marked  cases  are  seen  before  the  tenth  year.  In  its  clinical  aspects  it  does 
not  differ  essentially  from  the  disease  as  seen  in  adults,  except  possibly 
by  the  greater  prominence  of  the  bronchial  catarrh. 


476  DISEASES   OF   THE   RESPIRATORY   SYSTExM. 

Ordinary  attacks  of  the  adult  type. — These  usually  occur  at  inter- 
vals of  a  few  weeks  or  months,  depending  upon  the  nature  of  the  exciting 
cause.  The  beginning  is  usually  at  night,  with  dyspnoea,  a  short,  dry 
cough,  and  loud,  wheezing  respiration.  Deep  recession  of  the  soft  parts 
of  the  chest  is  seen,  as  in  laryngeal  stenosis.  There  is  prolonged  ex- 
piration, accompanied  by  loud,  sonorous,  sibilant  and  wheezing  rales,  and 
the  vesicular  murmur  is  very  feeble.  Later,  moist  rales  may  be  heard. 
After  many  attacks  emphysema  is  present.  This  occurs  more  rapidly  than 
in  adults,  and  may  be  extreme,  giving  rise  in  marked  cases  to  serious 
thoracic  deformity.  On  account  of  the  loss  of  sleep  and  interference  with 
nutrition,  the  general  health  may  become  seriously  impaired. 

Diagnosis. — Typical  attacks  of  asthma  are  easily  recognised.  Some  of 
the  catarrhal  forms  seen  in  infancy,  however,  present  great  difficulty,  and 
a  positive  diagnosis  may  be  impossible  except  by  the  progress  of  the  case. 

Prognosis. — This  is  best  in  the  cases  of  catarrhal  asthma  in  infants,, 
and  in  older  patients  when  it  depends  upon  some  local  cause  which  can 
be  removed,  as  when  the  disease  is  due  to  reflex  nasal  or  pharyngeal  irrita- 
tion. In  the  majority  of  other  cases,  asthma  is  likely  to  become  chronic 
unless  the  child  is  removed  to  some  climate  in  which  the  attacks  do  not 
occur.  The  younger  the  child,  the  shorter  the  duration  of  the  disease, 
and  the  less  marked  the  hereditary  tendency,  the  better  the  prognosis. 

Treatment. — The  nose  and  the  rhino-pharynx  should  be  carefully 
examined  in  every  case  of  asthma,  and  any  pathological  condition  there 
present  should  be  removed  as  the  first  step  in  the  treatment.  Special 
importance,  in  children,  should  be  attached  to  the  removal  of  adenoid 
growths  of  the  pharynx.  During  attacks,  the  best  means  of  relieving  the 
symptoms  is  the  inhalation  of  fumes  of  nitre  paper  or  stramonium  leaves. 
Most  of  the  proprietary  remedies  (Papier  de  Fruneau,  Himrod's  cure, 
and  Kidder's  pastilles)  contain  these  ingredients.  The  two  preparations 
last  mentioned  are  by  most  children  particularly  well  tolerated.  The 
sleeping  room  may  be  filled  with  the  fumes  from  these  substances,  or  the 
child  may  be  placed  in  a  tent  into  which  the  fumes  are  introduced. 
Emetics  should  be  employed  when  the  attack  is  brought  on  by  indi- 
gestion. Lobelia  is  the  most  satisfactory  remedy  for  this  purpose.  To 
prevent  the  recurrence  of  night  attacks,  nothing  in  my  experience  has 
been  so  valuable  as  a  full  dose  of  antipyrine  at  bedtime — four  grains 
at  five  years  and  six  grains  at  ten  years.  Between  the  attacks  the 
main  reliance  should  be  upon  the  syrup  of  hydriodic  acid  and  potassium 
iodide,  which  are  to  be  given  for  a  long  time  in  full  doses.  Tonics  are 
to  be  used  in  nearly  all  cases.  Those  especially  valuable  in  asthmatic 
patients  are  cinchonidia  and  arsenic. 

In  the  cases  of  catarrhal  asthma  following  bronchitis,  expectorants 
and  ordinary  cough  remedies  are  useless.  Cod-liver  oil  and  the  iodide 
of  potassium  are  valuable  in  some  of  the  cases.     Others  get  much  relief 


PNEUMONIA.  477 

from  the  regular  use  of  creosote  inhalations  several  times  a  day,  with  a 
nightly  dose  of  antipyrine.  The  fumes  of  nitre  and  stramonium  often 
afford  no  relief,  and  sometimes  the  cases  are  made  distinctly  worse  by 
them.  The  best  of  all  measures  is  to  send  the  child  at  once  to  a  warm» 
dry  climate. 

For  all  children  who  have  had  repeated  attacks,  whether  in  the  form 
of  hay  fever  or  the  ordinary  variety,  the  most  important  thing  is  removal 
to  a  place  where  they  do  not  have  the  disease,  and  a  residence  there  long 
enough  to  break  up  the  tendency  to  recurrence.  This  will  usually  require 
at  least  three  or  four  years.  The  region  best  suited  to  most  asthmatics  is 
one  which  is  high,  dry,  and  moderately  warm.  Patients  often  suffer  less 
in  cities  than  in  the  country.  If  taken  early,  asthma  in  children  is  fre- 
quently curable  by  these  means ;  if  neglected,  the  disease  is  almost  sure 
to  continue  until  adult  life. 


CHAPTER   IV. 

DISEASES  OF   TEE  LUyGS.— (Continued.) 
PNEUMONIA. 

In  early  life  the  lungs  are  more  frequently  the  seat  of  organic  disease 
than  any  other  organs  in  the  body.  Pneumonia  is  very  common  as  a  pri- 
mary disease,  and  ranks  first  as  a  complication  of  the  various  forms  of 
acute  infectious  disease  of  children.  It  is  one  of  the  most  important 
factors  in  the  mortality  of  infancy  and  childhood  (page  39). 

Cases  of  acute  pneumonia  are  divided,  from  an  anatomical  point  of 
view,  into  two  principal  groups :  (1.)  Broncho-pneumonia,  also  known  as 
catarrhal  and  as  lobular  pneumonia.  (2.)  Lobar  pneumonia,  also  known 
as  croupous  and  as  fibrinous  pneumonia.  These  differ  from  each  other 
as  to  the  products  of  inflammation,  the  distribution  of  the  disease  in  the 
lung,  and  somewhat  as  to  the  parts  involved  and  the  nature  of  the  changes 
in  them. 

In  broncho-pneumonia  the  large  bronchi  are  the  seat  of  a  superficial 
inflammation,  while  in  those  of  small  size  the  entire  bronchial  wall  is 
affected  ;  the  exudation  into  the  air  vesicles  is  mainly  cellular,  being 
made  up  of  epithelial  cells,  leucocytes,  and  red  blood-cells  (Fig.  Vi), 
fibrin  being  either  absent,  or  present  only  in  small  amount.  In  many 
cases  there  are  marked  changes  both  in  the  alveolar  septa  and  in  the  in- 
terstitial tissue  of  the  lung ;  resolution  is  often  imperfect,  and  there  is  a 
strong  tendency  of  the  inflammation  to  pass  into  a  chronic  form,  in- 
volving the  connective-tissue  framework  of  the  lung.  The  lesion  is 
widely  and  often  irregularly  distributed,  usually  being  most  marked  in 


478  DISEASES  OF   THE   RESPIRATORY  SYSTEM. 

the  vicinity  of  the  small  bronchi,  from  which  the  inflammation  spreads, 
and  in  the  most  superficial  lobules  of  the  Inng. 

In  lobar  pneumonia,  bronchitis,  when  present,  is  usually  superficial,  the 
walls  of  the  bronchi  being  very  slightly  or  not  at  all  affected ;  the  same 
is  true  of  the  alveolar  septa.  The  principal  product  of  the  inflammation 
is  fibrin  (Fig.  73),  which  fills  the  alveoli  and  the  terminal  bronchi,  the  cells 
being  relatively  few  and  chiefly  leucocytes.  The  process  is  usually  sharply 
circumscribed,  involving  an  entire  lobe  or  a  part  of  a  lobe.  In  most  cases 
it  clears  up  rapidly  and  completely,  there  being  but  little  tendency  to  in- 
volve the  framework  of  the  lung  in  a  chronic  process. 

While  in  typical  cases  the  two  forms  of  inflammation  are  quite  dis- 
tinct, there  are  seen  many  intermediate  forms  which  partake  of  the  char- 
acters of  both,  and  one  may  be  in  doubt,  even  after  a  microscopical  ex- 
amination, into  which  group  to  place  a  case.     It  not  infrequently  happens 


v^  i-     '-    •'*-* 


Fig.  72.— Broncho-pneumonia.  The  picluiv  ,>1h.\v>  at  its  centre  one  entire  air  vesicle,  and  at  its 
margin  parts  of  four  or  five  other  vesicles  ;  tliey  are  tilled  with  large  epithelial  cells  having 
small  nuclei.  There  are  also  seen  leucocytes  with  intensely  black  nuclei  and  narrow  proto- 
plasm. Between  the  cells  is  a  finely  granular  material,  which  is  the  exudation  tluid  coatju- 
lated  during  the  hardening  process.  The  alveolar  septa  are  somewhat  infiltrated.— From 
Karg  and  Schmorl. 

that  both  varieties  of  pneumonia  are  present  in  different  parts  of  the  same 
lung  or  in  opposite  lungs  at  the  same  time.  These  mixed  forms  are  espe- 
cially frequent  during  the  second  and  third  years;  but  during  the  first 
year,  and  after  the  third,  the  types  are  usually  well  marked. 


PNEUMONIA.  479 

The  following  table  shows  the  relative  frequency  of  lobar  and  broncho- 
pneumonia in  three  hundred  and  seventy  cases,*  nearly  all  taken  from 


mm 


Fio.  73. — Lobar  pneumonia.  In  tlie  air  vcsick-  sliown  in  the  picture  there  is  a  firm,  Close  net- 
work of  fibrin,  in  the  meshes  of  which  are  leucocytes.  At  the  lower  part  the  exudation  has 
contracted  away  from  the  wall  in  consequence  of  the  process  of  hardening.— From  Karg 
and  Sehmorl. 

one  institution  (Xew  York  Infant  A.sylum).  There  are  included  all  the 
cases  of  acute  primary  pneumonia  occurring  during  a  period  of  seven 
years : 

Under    six    months,  broncho-pneumonia,  73  cases;  lobar  pneumonia,  11  cases. 
Six  to  twelve      "  "  96      '•  "  "  29     " 

Second  year,  "  73      "  "  "  40     " 

Third       "  "  19      "  "  "  23     '■ 

Fourth     "  "  0      "  "  "  6     " 

Totals,  '•  261      >•  ••  '•         109     •' 

Thus  it  will  be  seen  that,  of  the  cases  of  acute  pneumonia  occurring 
during  the  first  two  years,  25  per  cent  were  lobar  and  75  per  cent  were 
broncho-pneumonia. 

When  we  come  to  a  consideration  of  the  micro-organisms  with  which 
the  different  forms  of  pneumonia  are  associated,  we  find  that  they  do  not 

*  The  division  was  here  made  according  to  the  predominant  clinical  or  pathological 
features.     Most  of  the  doubtful  cases  were  classed  as  broncho-pneumonia. 
32 


480  .         DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

correspond  to  the  anatomical  varieties.  Lobar  pneumonia  is  regularly 
associated  with  the  presence  of  the  pneumococcus  (micrococcus  lanceo- 
latus),  which  in  most  cases  is  found  pure.  In  broncho-pneumonia  no 
one  form  is  always  present.  In  the  primary  cases  the  pneumococcus  is 
usually  found,  and  in  many  cases  it  is  alone.  In  the  secondary  cases 
there  is  almost  always  mixed  infection.  In  measles  and  diphtheria  the 
streptococcus  is  the  principal  form,  such  cases  being  usually  of  the  worst 
type.  In  other  secondary  cases  there  are  found  the  staphylococcus,  and 
sometimes  Friedlander's  bacillus.  Each  of  these  varieties  of  bacteria  may 
be  found  alone,  but  they  are  often  associated,  and  with  any  of  them  may 
be  found  the  pneumococcus,  or  other  specific  germs,  most  frequently  the 
bacillus  of  influenza,  diphtheria,  or  tuberculosis. 

The  reason  why  the  same  cause — the  pneumococcus — in  one  case  pro- 
duces broncho-pneumonia  and  in  another  lobar  pneumonia,  is  in  part 
owing  to  the  difference  in  the  structure  of  the  lung  at  the  different  ages — 
that  of  infancy  being  more  bronchial,  and  that  of  older  children  more 
vesicular  (page  460).  Another  reason  is  to  be  found  in  the  constitu- 
tion of  the  patient :  in  the  very  young  and  in  feeble  and  delicate  chil- 
dren, the  process  tends  to  become  diffuse  and  the  products  are  chiefly 
cellular  ;  in  those  who  are  older  and  more  vigorous  it  is  likely  to  be  cir- 
cumscribed, with  fibrin  as  its  chief  product ;  in  the  intermediate  ages 
and  intermediate  conditions  the  types  are  often  mingled. 

Etiologically  as  well  as  clinically,  lobar  pneumonia  is  a  single  disease, 
usually  running  a  regular  self-limited  course.  Broncho-pneumonia,  on 
the  other  hand,  includes  a  number  of  quite  distinct  diseases,  which  are 
not  only  etiologically  but  clinically  different.  Sometimes  when  it  is  due 
to  the  pneumococcus  it  has  more  features  in  common  with  lobar  pneu- 
monia than  with  cases  of  broncho-pneumonia  due  to  another  kind  of 
infection,  such  as  the  streptococcus. 

The  immediate  source  of  infection  of  the  lungs  is  the  mouth,  the  nose, 
or  the  pharynx.  All  the  forms  of  bacteria  found  in  pneumonia  are  found 
in  these  cavities,  some  of  them  constantly,  others  only  at  certain  times, 
especially  during  an  attack  of  any  of  the  acute  infectious  diseases.  What 
part  direct  contagion  plays  in  the  spread  of  pneumonia  can  not  be  settled 
without  fuller  data  than  at  present  exist.  There  seems  to  be  no  doubt, 
from  clinical  observations  alone,  that  the  secondary  forms,  especially  those 
complicating  measles  and  diphtheria,  are  sometimes  communicated  in  this 
way.  This  is  probably  not  often  true  of  primary  cases,  except  in  hospitals 
for  infants  where  the  rapid  development  of  case  after  case  in  ihe  same 
ward  can  not  be  well  explained  on  any  other  hypothesis. 

The  different  forms  of  pneumonia  whicli  will  be  considered  are:  (1) 
Acute  broncho-pneumonia.  (2)  Acute  fibi-inous  pneumonia,  (o)  Acute 
pleuro-pneumonia.  (4)  Hypostatic  pneumonia.  (5)  Chronic  broncho- 
pneumonia. 


ACUTE    HRON(;nO-PNEUMONIA.  481 

Tuberculous  broncho-pneumonia  will  be  discussed  in  tlie  chapter  de- 
voted to  Tuberculosis. 


ACUTE   BRONCnO-PNEUMONIA. 

Synonyms:  Catarrhal  |iiK'uin<itiia,  lolmlar  f)n(Minionia,  capillary  bronchitis. 

This  is  essentially  the  pneumonia  of  infancy.  Under  two  years,  the 
great  majority  of  the  cases  of  primary  pnetamonia  are  of  this  variety,  and 
throughout  childhood  nearly  all  the  cases  of  secondary  pneumonia.  The 
term  broncho-pneumonia  describes  a  lesion  rather  than  a  disease,  several 
quite  distinct  forms  of  infection  being  included  under  this  head.  Its  mor- 
tality is  high,  because  of  the  tender  age  of  the  patients  in  which  the  pri- 
mary cases  occur,  and  also  because  when  secondary  it  complicates  the 
most  severe  forms  of  the  acute  infectious  diseases  of  children. 

Etiology. — Age. — The  42G  cases  of  broncho-pneumonia  of  wiiich  I 
have  notes  occurred  as  follows  : 

During  the  first  year 224  cases,  or  53  per  cent. 

"         "     second  year 142      "       "   33   "       " 

••     third        "    40      "       "    11    " 

"     fourth      "    10     "       "     2    *' 

"     fifth         "    4      •'       "      1    "       " 

426  100 

After  four  years  broncho-pneumonia  is  very  infrequent  as  a  primary 
disease,  although  it  is  seen  throughout  childhood  as  a  complication  of  the 
infectious  diseases. 

Sex. — In  the  primary  cases  males  are  more  frequently  affected  than 
females,  the  proportion  being  five  to  four.  In  the  secondary  cases  the 
sexes  are  about  equally  affected. 

Season. — Of  the  cases  referred  to,  38  per  cent  occurred  during  the  win- 
ter months,  31  per  cent  during  the  spring,  13  per  cent  during  the  sum- 
mer, and  18  per  cent  during  the  autumn.  While,  therefore,  nearly  70  per 
cent  of  the  cases  occurred  in  the  cold  months,  broncho-pneunu)nia  is  seen 
throughout  the  year. 

Previous  condition. — Broncho-pneumonia  affects  all  classes,  but  is 
most  frequent  in  children  having  poor  hygienic  surroundings,  especially 
in  inmates  of  institutions,  and  in  those  previously  debilitated  by  constitu- 
tional or  local  disease.  In  24G  consecutive  cases  of  primjiry  pneumonia, 
IIU  were  in  good  condition  prior  to  the  attack,  and  1"2G  were  delicate, 
rachitic,  or  syphilitic. 

Previous  disease. — The  following  table  gives  a  good  idea  of  the  condi- 
tions with  which  acute  broncho-pneumonia  is  most  frequently  seen ;  443 
cases  were  classed  as  follows  : 


482  DISEASES  OF   THE  RESPIRATORY   SYSTEM. 

Primary  * 164 

Secondary  to  bronchitis  of  the  large  tubes 41 

Complicating  measles 89 

"              pertussis 66 

"              diphtheria 47 

"             acute  ileo-colitis - 19 

"             scarlet  fever 7 

"              influenza 6 

"             varicella 3 

"             erysipelas 2 

443 

A  large  number  of  the  patients  had  previously  suffered  from  one  or 
more  attacks  of  bronchitis,  and  fifteen  previously  had  broncho-pneumonia. 

As  an  exciting  cause,  exposure  to  cold  must  still  be  classed  among  the 
potent  factors  of  primary  pneumonia. 

Bacteriology. — Much  light  has  already  been  thrown  upon  broncho- 
pneumonia by  bacteriology,  but  many  points  still  remain  to  be  settled. 
In  1889  Prudden  and  Northrup  f  showed  that  the  broncho-pneumonia  of 
diphtheria  was  usually  due  to  the  streptococcus.  In  1891  Mosuy  |  pub- 
lished a  report  upon  17  cases  of  broncho-pneumonia  :  4  were  primary,  7 
were  secondary  to  measles,  3  to  diphtheria,  and  1  to  scarlet  fever.  In  the 
4  primary  cases,  the  pneumococcus  was  found  alone  in  3,  and  the  strepto- 
coccus alone  in  1.  In  the  11  secondary  cases,  the  pneumococcus  was  found 
in  3  ;  in  one  of  these,  a  case  of  measles,  it  was  alone.  The  streptococcus 
was  found  in  10  cases — alone  in  5,  with  the  pneumococcus  in  1,  with  the 
pneumococcus  and  Loeffler's  bacillus  in  1,  with  the  staphylococcus  in  2, 
with  Friedlander's  bacillus  in  1 ;  in  one  case  Friedliinder's  bacillus  was 
found  alone,  and  in  one  case  a  peculiar  streptococcus. 

In  1892  Netter  *  published  a  report  upon  42  cases.  He  has  not  sepa- 
rated the  primary  and  secondary  cases.  Of  25  cases  in  which  but  one 
form  of  bacteria  was  found,  the  pneumococcus  was  present  in  10,  the 
streptococcus  in  8,  the  staphylococcus  in  5,  and  Friedlander's  bacillus  in 
2.  In  the  17  cases  of  mixed  infection,  the  streptococcus  was  present  in 
15,  the  pneumococcus  in  9,  the  staphylococcus  in  8,  and  Friedlander's 
bacillus  in  4. 

I  am  indebted  to  Dr.  Martha  Wollstein,  Pathologist  to  the  Babies' 
Hospital,  for  permission  to  include  here  the  results  of  observations  made 
by  her  but  not  yet  published.  I  had  the  opportunity  of  observing  most 
of  the  cases  clinically,  they  having  been  treated  in  my  wards.     Thus 

*  It  is  probable  that  a  number  of  cases  complicating  influenza  were  included 
among  these  primary  cases. 

\  American  Journal  of  the  Medical  Sciences,  June,  1889. 
X  Etude  sur  la  Broncho-Pneumonie,  Paris,  1891. 

*  Archives  de  Medecine  experimentale,  January,  1892. 


ACUTE   BRONCHO-PNEUMONIA.  483 

far  33  cases  have  been  studied,  lit  of  which  were  primary  and  14  sec- 
ondary. Of  the  secondary  cases,  2  complicated  measles,  3  diphtheria,  3 
marasmus,  and  6  tuberculosis.  The  pneumococcus  was  found  in  1?  of 
the  19  primary  cases,  occurring  alone  in  9,  with  the  streptococcus  in  7, 
and  with  the  staphylococcus  in  1.  Of  the  two  remaining  primary  cases, 
the  streptococcus  was  found  alone  in  one,  and  with  the  staphylococcus  in 
the  other.  Of  the  14  secondary  cases,  the  pneumococcus  was  present  in 
11,  and  alone  in  2,  both  of  these  being  cases  of  measles.  The  pneumo- 
coccus was  associated  with  the  streptococcus  in  1  (a  case  of  diphtheria), 
with  the  staphylococcus  in  2  (both  marasmus  cases),  with  the  tubercle 
bacillus  in  2,  with  the  tubercle  bacillus  and  streptococcus  in  3,  with  the 
tubercle  bacillus  and  the  staphylococcus  in  1.  Of  the  three  cases  in 
which  the  pneumococcus  was  absent,  all  showed  the  streptococcus — once 
alone,  once  with  the  staphylococcus,  and  once  with  the  tubercle  bacillus. 

Our  present  knowledge  of  the  bacteriology  of  broncho-pneumonia  may 
be  summarized  as  follows :  In  the  primary  cases  the  pneumococcus  is 
nearly  always  present,  and  in  a  large  proportion  of  the  cases  it  occurs  alone. 
In  cases  of  mixed  infection  it  is  most  frequently  associated  with  the  strep- 
tococcus. The  secondary  cases  are  usually  due  to  a  mixed  infection.  The 
pneumococcus  is  found  in  a  large  number  of  these  cases,  but  plays  a  much 
less  important  part  than  the  streptococcus,  particularly  in  cases  compli- 
cating measles,  diphtheria,  and  scarlet  fever.  The  staphylococcus  is  next 
in  point  of  frequency  in  the  mixed  cases,  and  it  may  occur  alone.  Still 
less  important  is  the  part  taken  by  Friedliinder's  bacillus  both  in  primary 
and  secondary  cases.  The  association  of  the  pneumococcus  in  all  of  the 
six  tuberculous  cases  studied  by  Dr.  Wollstein  is  of  special  interest,  as  it 
explains  what  is  so  often  observed  clinically,  that  in  cases  of  tuberculous 
broncho-pneumonia  the  symptoms  are  indistinguishable  from  the  simple 
form.  Three  of  these  cases  ran  the  course  of  simple  acute  broncho-pneu- 
monia, and  were  so  diagnosticated  during  life. 

We  have  not  yet  sufficient  data  definitely  to  connect  the  different  forms 
of  infection  either  with  any  set  of  lesions  or  with  any  group  of  clinical 
symptoms.  The  cases  due  to  streptococcus  infection  are  usually  the  worst 
forms,  and  are  apt  to  show  widely  disseminated  lesions.  The  cases  in 
which  the  onset  and  clinical  history  resemble  lobar  pneumonia,  and  where 
there  are  found  extensive  areas  of  consolidation,  and  often  excessive  pleu- 
risy, are  usually  due  to  the  pneumococcus. 

Lesions. — The  term  broncho-pneumonia  is  now  generally  adopted  as  a 
generic  one,  and  it  is  to  be  preferred  either  to  lobular  or  catarrhal  pneu- 
monia, as  it  gives  prominence  to  the  bronchial  element  in  the  inflam- 
mation. The  process  may  begin  in  the  larger  tubes  and  gradually  extend 
to  those  of  smaller  calibre,  finally  involving  the  pulmonary  lobules  in 
which  these  tubes  terminate ;  or  it  may  extend  to  the  air  vesicles  which 
surround  the  tube  in  its  course  through  the  lung,  so  that  in  whatever 


484  DISEASES  OF   THE   RESPIRATORY  SYSTEM. 

direction  the  lung  is  cut,  there  are  seen  surrounding  tlie  small  bronchi,  zones 
of  pneumonia  (Fig.  74).  In  other  cases  the  process  seems  to  begin  almost 
at  the  same  time  in  the  small  bronchi  and  the  air  vesicles,  as  both  are  found 
involved,  even  when  death  occurs  within  a  few  hours  of  the  first  symptoms. 
There  are,  however,  cases  in  which  the  parts  of  the  lung  affected  bear 
no  relation  to  the  bronchi — where  there  are  found  simply  smaller  or  larger 


Fig.  74. — Broncho-pneumonia,  with  thickening  of  a  small  bronchus.  In  the  centre  of  the  pic- 
ture is  seen  a  small  bronchus,  B,  which  is  cut  smnewliat  obliquely,  so  that  the  degree  to  wliich 
its  wall,  C,  is  thickened  is  well  shown.  It  is  jiartially  tilled  witli  pus,  its  mucous  membrane 
is  nearly  destroyed,  and  its  walls  greatly  tliickened  from  infiltration  with  leucocytes.  This 
inftltration  extends  to  the  lung  tissue  in  the  neighbourhood ;  it  forms  a  peri-bronchitic  zone 
of  pneumonia.  Elsewhere  in  the  picture  the  lung  tissue.  A,  is  practically  normal.  D  is  a 
small  blood-ves.sel.  E  is  another  snialler  bronchus.  Throughout  the  lung  everywhere  accom- 
panying the  small  bronchi  similar  changes  were  seen,  in  addition  to  which  there  were  present 
some  large  areas  of  consolidation.  The  disease  was  of  four  and  a  half  weeks'  duration;  the 
child,  five  months  old. 

areas  of  pneumonia  irregularly  scattered  through  the  lung,  usually  near 
the  surface  (Plate  XII).  From  the  distribution  of  the  lesions  such  cases 
might  better  be  termed  lobular  than  broncho-pneumonia. 

Much  has  been  said  in  the  past  about  pulmonary  collapse  from  ob- 


Acute  Broncho-Pneumonia. 

Priiimrv  }>iuniraonia  in  a  child  two  years  old,  showing  the  irrcijular  distribution  of 
the  hepatization  and  its  incomplete  character.  A  is  tlie  phMira  somewhat  tliickened  ; 
B,  lung  tissue  which  is  practically  normal  ;  V  C  arc  hcfiatizcd  aretis.  scattered  through 
which  are  groups  of  air  vesicles  still  containing  air.     (Sliglilly  magnifieil.) 


ACUTE   BROXCriO-PNP:rMOXIA.  485 

struction  of  the  small  bronchi,  as  an  antecedent  condition  to  this  form  of 
pulmonary  inflammation.  80  far  as  my  own  observations  go,  there  has 
been  adduced  but  little  evidence  that  this  is  the  rule,  or,  indeed,  that  it  often 
occurs.  Even  in  autopsies  made  very  early  in  the  disease,  but  little  collapse 
was  found,  most  of  the  cases  supporting  the  view  of  Delafield,  that  when 
tiie  disease  extends  from  the  bronchi  to  the  air  cells  it  involves  those  sur- 
rounding the  tube  quite  as  regularly  as  those  to  which  the  tube  leads. 

The  following  observations  are  made  from  a  study  of  170  autopsies  of 
which  I  have  records,  microscopical  examinations  having  been  made  in 
about  one  third  of  the  number. 

Seat  of  the  disease. — In  82  per  cent  of  the  autopsies  extensive  disease 
was  found  in  both  lungs.  The  parts  most  affected  were  the  lower  lobes 
posteriorly;  next  to  this  the  posterior  part  of  both  the  upper  and  lower 
lobes.  The  left  lower  lobe  was  more  extensively  diseased  than  the  right 
in  over  two  thirds  of  the  cases.  Only  a  single  lobe  was  involved  in  but  9 
per  cent  of  the  cases.  It  is  not  common  for  the  disease  to  be  situated  in 
the  anterior  portion  of  the  lung  only,  but  when  this  occurs  the  right 
apex  is  the  most  frequent  seat. 

Just  as  the  clinical  symptoms  of  broncho-pneumonia  follow  no  regular 
type,  so  the  pathological  process  does  not  pass  tiirough  a  regular  order  of 
changes  such  as  are  seen  in  lobar  pneumonia.  There  are  a  certain  number 
of  cases  which  appear  to  follow  tolerably  well-defined  stages  of  conges- 
tion, red  hepatization,  gray  hepatization,  and  resolution ;  but  the  dis- 
ease may  be  arrested  at  any  of  the  stages  and  the  case  recover,  or  death 
may  occur  at  any  stage  and  there  may  be  found  at  autopsy  different  por- 
tions of  the  lung  representing  all  the  stages  mentioned.  In  considering, 
therefore,  the  lesions  of  broncho-pneumonia,  it  seems  best  to  describe  the 
condition  in  which  the  lungs  are  found  at  the  various  periods  when  death 
is  likely  to  occur,  rather  than  to  attempt  to  describe  the  different  stages  of 
the  disease,  as  in  lobar  pneumonia. 

1.  The  acute  congestive  form  {acute  red  pneumonia). — This  is  the  con- 
dition in  which  the  lung  is  usually  found  if  death  occurs  during  the  first 
two  or  three  days  of  the  disease.  In  the  cases  severe  enough  to  cause 
death  in  the  first  twenty-four  hours,  very  little  can  be  seen  by  the  naked 
eye  except  acute  congestion.  The  vessels  of  the  i)leura  are  distended, 
and  there  may  be  small  superficial  haemorrhages.  Both  lower  lobes  are 
usually  heavy  and  dark-coloured.  There  is  to  the  naked  eye  no  consolida- 
tion. All,  or  nearly  all,  the  lung  can  be  inflated.  On  section,  there  is 
found  intense  congestion  with  some  wdema.  When  the  process  has  lasted  a 
little  longer  the  affected  areas  are  more  sharply  defined.  These,  usually  the 
posterior  portions  of  both  lungs,  are  of  a  brownish-red  colour,  and  appear 
partially  hepatized,  although  with  a  little  force  they  may  in  most  cases  be 
inflated.  After  section,  pus  and  mucus  flow  from  the  divided  bronchi, 
and  the  whole  lune:  mav  be  more  or  less  cousrested  or  o'dematous. 


486 


DISEASES  OF  THE  RESPIRATORY   SYSTEM. 


The  microscope  alone  reveals  the  fact  that  these  are  not  cases  of  sim- 
ple pulmonary  congestion  or  bronchitis  of  the  finer  tubes.  In  one  case  in 
which  death  occurred  twelve  hours  from  the  first  symptoms,  I  found  well- 


FiG.  75. — Acute  broneho-pnemnonia  with  intra-al\ f>Mai  JiHin^irliage  (liigbly  magnified).  In  the 
picture  is  shown  a  small  vein,  which,  as  well  as  the  surrounding  alveoli,  is  filled  with  blood- 
cells.  In  other  respects  the  lung  shown  is  normal.  This  is  from  the  border  of  a  consoli- 
dated area.  Child  fifteen  months  old ;  pneumonia  of  ten  days'  duration,  with  a  severe  ex- 
acerbation forty-eight  hours  before  death,  tempei'ature  10(j°  F.  Extensive  haemorrhagic  areas 
were  scattered  through  the  lung  most  affected. 


marked  evidences  of  inflammation  of  the  air  vesicles.  In  these  hyper-acute 
cases,  the  microscope  shows  great  distention  of  all  the  small  blood-vessels 
of  the  affected  area,  and  small  or  large  extravasations  of  blood  just  be- 
neath the  pleura,  into  the  alveoli  (Fig.  75)  and  interstitial  tissue  of  the 
lung.  In  some  cases  these  haemorrhages  form  the  most  striking  feature 
of  the  lesion.  The  air  vesicles  are  partially,  some  almost  completely,  filled 
with  red  blood-cells,  swollen  and  desquamated  epithelial  cells,  and  a  few 
leucocytes  (Fig.  73).  The  red  blood-cells  predominate.  The  inflamma- 
tion may  be  diffuse,  involving  nearly  a  whole  lobe,  or  in  small  areas  in  the 


ACUTE   BRONCHO-PNEUMONIA.  487 

neighbourhood  of  the  small  bronchi  (Fig.  76).  The  mucous  membrane  of 
the  large  and  small  bronchi  is  the  seat  of  catarrhal  inflammation,  and  the 
walls  of  the  latter  are  infiltrated  with  round  cells. 

When  the  process  has  lasted  from  twenty-four  to  forty-eight  hours 
all  the  changes  described  are  more  marked,  but  the  red  colour  of  the  in- 
flammatory products  still  persists.  Such  cases  give  during  life  only  the 
signs  of  congestion  and  bronchitis. 

2.  The  mottled  red  and  graif  pneumonia. — This  is  the  usual  appearance 
when  the  disease  has  lasted  somewhat  longer,  and  is  found  in  most  of  the 
cases  dying  between  the  fourth  and  fourteenth  days.  There  are  usually  at 
this  time  quite  large  areas  of  consolidation,  sometimes  affecting  nearly  an 
entire  lobe,  so  that  at  first  sight  the  case  may  resemble  lobar  pneumonia. 
This  is  sometimes  described  as  the  "  pseudo-lobar  "  form.     The  extent  of 


Fig.  76. — Early  stage  of  broncho-pneumonia.  Tliere  is  shown  at  B  B  B  small  bronchi,  some 
of  which  at  the  right  of  the  picture  have  been  cut  somewhat  obliquely,  and  hence  appear 
irregular  in  shape.  These  bronchi  everywhere  contain  pus;  the  air  cells  in  the  neigh- 
bourhood are  partially  tilled  with  leucocytes.  The  intervening  pulmonary  tissue  is  normal. 
Cliild  five  months  old. 

these  areas  depends  largely  upon  the  duration  of  the  disease.  In  most  cases 
there  is  pleurisy  over  the  consolidated  portions.  This  may  cause  the  lung 
to  adhere  to  the  chest  wall,  the  firmness  of  the  adhesions  depending  upon 
the  duration  of  the  process.     The  surface  of  the  lung  is  usually  of  a  mot- 


488 


DISEASES  OF   THE   RESPIRATORY  SYSTEM. 


tied  red  and  gray  colour ;  it  often  has  a  granular  feel,  due  to  the  consoli- 
dation of  some  of  the  superficial  lobules  of  the  lung.  On  section,  it  is 
rarely  found  that  an  entire  lobe  is  consolidated,  the  superficial  portion 


Fig.  77. — Acute  broncho-pneumonia.  In  tln'  ct  litre  is  shown  a  small  bronchus,  B,  with  a 
zone  ot  pneumonia  about  it.  The  greater  part  of  the  section  is  made  up  of  emphysematous 
lunff  tissue,  E  E,  showing  dilatation  of  the  alveolar  spaces  and  rupture  of  some  of  the 
alveolar  septa.     At  the  border,  A  A  A,  are  .seen  the  margins  of  consolidated  areas  of  lung. 


being  most  affected,  while  the  central  part  is  normal  or  only  congested. 
The  colour  is  mottled,  like  that  of  the  surface.  In  some  places  the  hepa- 
tization appears  complete  ;  in  others  the  hepatized  areas  are  separated  by 
healthy,  congested,  or  emphysematous  lung  tissue  (Fig.  77).  The  gray 
areas  surround  the  small  bronchi  and  vary  in  size  from  a  pin's  head  up- 
ward. The  smallest  ones  look  very  much  like  miliary  tubercles.  The 
larger  ones  are  seen  where  the  process  has  existed  for  a  longer  time  and 
has  gradually  invaded  the  contiguous  air  cells.  If  the  lung  is  cut  parallel 
with  the  bronchi,  there  may  be  seen  small  gray  stride  of  pneumonia  along 
their  course  (Fig.  74,  C).  From  the  cut  bronchi,  pus  flows  quite  freely  on 
pressure.  The  bronchial  walls  can  often  be  seen  even  by  the  naked  eye 
to  be  thickened.  The  parts  affected  are  usually  the  posterior  portions  of 
the  lower  lobes  of  one  side,  the  remainder  of  the  lobes  being  congested  or 
cedematous,  while  in  front  the  lung  is  emphysematous. 

CFnder  the  microscope  the  smaller  bronchi  (Figs.  74  and  78)  are  seen 


ACUTE   BRONX'IIO-PXECMON  I  A. 


4S9 


to  be  much  thickened  and  iiitiltrated  with  leucocytes.  The  gray  areas 
surrounding  the  bronchi  are  made  up  of  groups  of  air  vesicles,  which  are 
packed  with  leucocytes  (Figs.  "]',)  and  80).  Fibrin  is  sometimes  seen  in 
snudl  amount,  also  red  blood-cells  and  desquamated  epithelial  cells,  but 
tiie  leucocytes  predominate.  Surrounding  the  areas  densely  infiltrated 
are  groups  of  air  vesicles  which  are  normal  or  congested,  or  wliich  show 
only  the  earlier  stages  of  the  inflammatory  process.     Under  the  micro- 


^      'iv 


Fig.  78. — Thickening  of  a  small  bronchus  in  subacute  broncho-pneumonia  following  pertussis  ; 
child  ten  months  old.  The  epithelium  is  wfll  preserved,  hut  the  walls  oftlie  bronchus  are 
infiltrated  with  leucocytes  and  sliow  some  enlarjjed  blood-vessels.  Majrnitied  about  thirty 
diameters.  All  the  snuiU  bronchi  in  the  luni;  examined  .sliowcd  simihir  cliauires.  In  addi- 
tion, there  were  superficial  areas  of  consolidation  in  both  lungs  behind. 

scope,  even  better  than  to  the  naked  eye,  is  shown  the  irregularity  of  the 
consolidation. 

3.  Gray  pneumonia  {persistent  hroncho-pneumonia). — This  form  is 
seen  in  protracted  cases  where  there  have  been  continuous  symptoms 
usually  for  from  three  to  eight  weeks;  it  is  not  very  uncommon.  The 
pleuritic  adhesions  are  more  general  and  firmer.     The  amount  of  lung 


490 


DISEASES   OF   THE   RESPIRATORY   SYSTEM. 


involved  may  be  ver}'  great,  often  nearly  the  whole  of  both  lungs  poste- 
riorly. The  affected  lung  appears  completely  consolidated  and  slightly 
enlarged.  On  section,  it  is  of  a  nearly  uniform  gray  colour,  sometimes  of 
a  yellowish  gray.  On  pressure,  pus  exudes  from  the  smaller  and  larger 
bronchi.  The  bronchial  walls  are  markedly  thickened,  and  in  some  places 
there  may  be  a  slight  dilatation  of  the  smaller  bronchi.  The  part  of  the 
lung  not  consolidated  may  be  almost  white,  owing  to  vesicular  emphy- 
sema. In  some  cases  there  is  also  interstitial  emphysema.  Small  cavi- 
ties containing  pus  may  be   found  in  the  lung.     The  bronchial  glands 


''  '  \-l  ,'■■'  V 


Fig.  79. — Broncho-pneumonia.  Dense  infiltration  of  pus  cells  in  and  about  a  small  bronchus; 
under  a  low  power.  The  cavity  shown  in  the  specimen  is  a  cro.ss-section  of  one  of  the  small 
bronchi,  which  is  partially  filled  with  pus  cells;  the  epithelium  is  destroyed.  The  bron- 
chial wall  and  the  pulmonary  tissue  in  the  neighbourhood  are  so  densely  infiltrated  with 
leucocytes  that  almost  every  trace  of  normal  structure  is  efiFaeed.  Child  fifteen  months  old, 
disease  of  four  weeks'  duration.     Extensive  areas  like  this  were  found  iu  both  lungs. 


are  frequently  swollen  to  the  size  of  a  large  bean,  and  are  of  a  reddish- 
gray  colour. 

The  microscope  shows  that  the  air  vesicles  of  the  consolidated  portions 


ACUTE   BRONCHO-PNEUMONIA. 


491 


are  distended  chiefly  witli  leucocytes,  but  there  are  also  epithelial  and  con- 
nective-tissue cells.     The  alveolar  septa  may  be  so  much  thickened  as  to 


Fig.  80. — Acute  broncho-pneumonia,  under  a  low  power,  sliowing  a  portion  of  the  lung,  A, 
densely  infiltrated  with  leucocytes.  At  B  is  a  small  bronchus,  the  wall  of  one  side  partly 
broken  down  by  the  inflammatory  process.  At  the  margin  of  the  specimen  D  are  seen 
alveoli  more  or  less  filled  with  epithelial  cells  and  leucocytes.  At  C  is  a  small  blood- 
vessel. In  other  parts  of  the  lung  small  gangrenous  areas  were  seen.  The  disease  was 
of  nine  days'  duration,  the  child  seven  months  old. 

encroach  upon  the  alveolar  spaces  (Fig.  81).     Complete  resolution  is  then 
impossible. 

Terminations. — Death  may  occur  at  any  stage,  or  the  pathological 
process  may  be  arrested  at  any  stage  and  the  case  go  on  to  recovei'y. 
Resolution  may  take  place  before  any  consolidation  recognisable  by  phys- 
ical signs  has  occurred  ;  in  such  cases  it  is  usually  rapid  and  complete. 
If  there  has  been  consolidation,  resolution  may  take  place  after  two  or 
three  weeks  and  be  complete,  or  it  may  be  delayed  for  five  or  six  weeks 
and  still  be  complete.  In  many  cases,  especially  those  in  which  it  is  de- 
layed, resolution  is  only  partial,  and  there  are  relapses  or  recurring  attacks. 
After  the  first,  or  after  several  attacks,  there  may  develop  a  chronic  inter- 
stitial pneumonia ;  or  simple  pneumonia  may  be  followed  by  tuberculosis. 
Such  cases  as  these  are  to  be  carefully  distinguished  from  the  much  more 
frequent  ones  in  which  the  broncho-pneumonia  has  been  tuberculous  from 
the  outset. 


492 


DISEASES   OF   THE    RESPIRATORY   SYSTEM. 


Associated  Lesions  of  the  Lungs. — Pleurisy  is  almost  invariably  found 
over  every  large  area  of  consolidation,  and  in  cases  of  more  than  four 
days'  duration ;  while  in  most  of  those  fatal  within  the  first  two  or  three 
days  the  pleura  is  normal  or  only  congested.  It  is  seen  in  all  grades  of 
severity,  from  a  slight  gray  film  of  fibrin  that  can  hardly  be  stripped  off, 
to  a  yellowish-green  exudation  one  fourth  of  an  inch  thick.  A  small 
amount  of  serum — one  or  two  ounces — in  the  pleural  sac  is  not  uncom- 
mon, but  a  large  serous  effusion  is  very  rare.     Cases  in  which  there  is  an 


A] 


4   P 


Fig.  81. — Persistent  broncho-pneumonia;  Jut^lily  mairnitied.  There  are  shown  at  A  A  marked 
thickening  of  the  alveolar  septa,  encroaching  upon  the  alveolar  spaces.  All  the  alveoli,  B  B, 
are  densely  packed  with  leucocytes.  A  similar  condition  also  through  nearly  the  whole  of 
the  atlected  lung.     (For  history  and  temperature,  see  Fig.  90.) 

excessive  inflammation  of  the  pleura  are  considered  elsewhere  under  the 
head  of  Pleuro-Pneumonia.  Empyema  occurs  both  during  the  stage  of 
acute  inflammation  of  the  lung  and  while  this  is  subsiding,  but  it  is  less 
frequent  than  in  lobar  pneumonia. 

Bronchial  glands. — In  all  the  recent  acute  cases  these  are  swollen  and 
red ;  the  usual  size  is  that  of  a  pea  or  a  bean.     They  show  microscopically 


ACUTE    BROXCIIO-PNEUMONIA.  493 

the  usual  changes  of  acute  hyperplasia.  In  protracted  cases,  and  after 
repeated  attacks,  they  may  be  two  or  three  times  the  size  mentioned,  and 
of  a  gray  colour.  It  is  rare  that  they  are  large  enough  to  give  rise  to 
symptoms  unless  they  become  the  seat  of  tuberculous  deposits. 

J'JmpJn/sema. — In  almost  all  cases  a  certain  amount  of  emphysema  is 
present,  it  being  more  marked  in  the  protracted  cases.  It  is  usually  vesic- 
ular, involving  the  greater  part  of  the  upper  lobes  in  front  and  the  ante- 
rior margin  of  the  lower  lobes.  Occasionally  interstitial  emphysema  is 
seen,  forming  either  large  stria;  upon  the  surface  of  the  lung,  or  blebs  of 
considerable  size  along  the  anterior  margin.  This  may  occur  even  in 
cases  uncomplicated  by  pertussis  or  laryngeal  stenosis. 

(iangreite. — Gangrenous  areas  were  found  in  six  of  my  cases.  In  four 
of  these  the  pneumonia  was  primary,  in  one  it  followed  diphtheria,  and  in 
one  ileo-colitis.  It  occurred  in  scattered  areas  of  a  grayish-green  colour, 
varying  from  one  fourth  of  an  inch  to  two  inches  in  diameter. 

Abscesses  of  the  lung  are  by  no  means  uncommon.  They  were  noted 
in  seven  per  cent  of  my  autopsies.  They  are  usually  minute  and  multiple, 
varying  in  size  from  one  sixth  to  one  half  inch  in  diameter.  Sometimes 
a  portion  of  a  lobe  is  fairly  honeycombed  with  minute  abscesses.  In  one 
case  a  large  abscess  was  found  occupying  the  greater  part  of  a  lobe,  the 
symptoms  resembling  those  of  empyema.  Abscesses  are  usually  found  in 
regions  where  the  inflammatory  process  has  been  especially  intense.  They 
may  be  found  in  prolonged  cases,  in  those  of  unusual  severity,  as  shown 
by  excessively  high  temperature  and  rapid  extension  of  the  disease,  and 
in  very  delicate  subjects.  The  microscope  shows  that  these  abscesses  usu- 
ally begin  as  an  accumulation  of  pus  in  the  small  bronchi,  whose  walls 
become  softened  and  break  down  on  account  of  the  intensity  of  the  in- 
flammation (Figs.  79  and  80).  Tliey  may  be  superficial,  but  are  more 
commonly  in  the  interior  of  the  lung;  they  contain  yellow  pus  and  some- 
times broken-down  lung  tissue.  Such  abscesses  can  not  be  recognised 
clinically,  and  they  are  associated  with  other  conditions  which  render  the 
case  almost  certainly  fatal. 

The  lesions  in  other  organs  will  be  considered  under  Complications. 

Symptoms. — The  clinical  picture  presented  by  broncho-pneumonia  is 
an  exceedingly  varied  one.  There  is  no  typical  course.  The  cases  differ 
from  each  other  very  markedly,  but  they  may  be  divided  into  a  few  ([uite 
distinct  groups. 

1.  77ie  acute  congestive  type. — This  may  be  seen  at  any  age,  but  is 
more  frequent  in  young  infants.  It  may  be  either  primary  or  secondary, 
being  not  uncommon  in  either  form.  Its  symptoms  are  few  and  irregular, 
and  the  disease  is  often  unrecognised.  The  entire  duration  may  be  only 
twenty-four  hours.  High  temperature,  extreme  prostration,  cyanosis,  and 
rapid  respiration  may  be  the  only  sym})toms.  The  temperature  varies  be- 
tween 104°  HTul  107°  F.,  usually  rising  stiadily  until  ileath  occurs.      The 


494  disease:s  of  the  respiratory  system. 

prostration  is  extreme  from  the  outset,  the  patient  being  overwhelmed  by 
the  suddenness  and  severity  of  the  attack.  Cyanosis  is  frequently  present, 
and  is  almost  always  seen  shortly  before  death.  The  respirations  are  from 
60  to  80  a  minute,  but  in  most  cases  not  strikingly  laboured.  Cough  is 
frequently  absent.  Cerebral  symptoms  are  often  marked.  There  are  dul- 
ness  and  apathy,  sometimes  quite  profound  stupor,  and  not  infrequently 
convulsions  just  before  death.  The  physical  signs  are  few  and  inconclu- 
sive. There  is  often  nothing  abnormal  except  very  rude  breathing  over 
both  lungs  behind  ;  sometimes  the  breathing  on  one  side  is  feeble,  and  on 
the  other  much  exaggerated.  There  may  be  no  rales  whatever,  and  no 
change  in  the  percussion  note. 

The  suddenness  and  severity  of  these  symptoms  are  something  which 
it  is  hard  for  one  who  has  not  observed  them  to  appreciate.  I  have  known 
an  infant  to  die  in  twelve  hours  from  the  time  in  which  it  was  apparently 
in  perfect  health,  and  had  an  o^jportunity  to  confirm  the  diagnosis  of 
l^neumonia  by  a  microscopical  examination  of  the  lung.  The  diagnosis 
can  not  be  positively  made  during  life,  and  in  most  of  the  cases  the  disease 
passes  under  some  other  namo.  It  is  often  regarded  as  malignant  scarlet 
fever  or  measles  with  suppressed  eruption,  or  cerebro-spinal  meningitis. 

If  the  children  are  sufficiently  strong  to  withstand  the  first  onset  of 
violent  symptoms,  they  may  recover  completely  in  four  or  five  days,  the 
lung  clearing  up  very  rapidly.  In  other  cases  these  grave  symptoms  may 
abate  in  a  day  or  two,  to  be  followed  by  those  of  ordinary  broncho-pneu- 
monia, which  runs  its  usual  course. 

The  symptoms  of  some  of  these  cases  may  be  exjilained  by  the  sudden 
intense  engorgement  of  the  lung,  which,  owing  to  the  small  size  of  the 
air  vesicles,  interferes  with  its  function  almost  as  much  as  does  consolida- 
tion. In  other  cases  the  symptoms  are  not  so  much  due  to  the  lungs,  as 
the  result  of  a  general  pneumoeoccus  infection.  A  case  lately  came  under 
my  notice  in  which  death  occurred  after  a  thirty  hours'  illness,  where  the 
pneumoeoccus  was  found  by  culture  in  both  kidneys,  spleen,  heart's  blood, 
and  both  lungs. 

2.  Acute  disseminated  broncho-pneumonia  {cajjillary  brojichitis). — 
Although  the  symptoms  in  this  class  of  cases  are  chiefly  due  to  the  bron- 
chitis, I  have  never  failed  to  find  at  autopsy  evidences  of  pneumonia  also. 
These  are  not  very  common  cases.  The  process  begins  as  an  inflamma- 
tion of  the  medium-sized  and  small  bronchi,  but  not  of  the  finest  bronchi. 
The  onset  is  acute,  with  fever,  very  rapid  and  laboured  breathing,  severe 
cough,  moderate  prostration,  and  in  most  cases  cyanosis. 

The  temperature  is  not  high,  usually  only  from  100°  to  103°  F.,  and  it 
often  continues  so  for  three  or  four  days.  The  pulse  is  rapid,  and  at  first 
is  full  and  strong.  The  respirations  are  exceedingly  rapid,  often  from  80 
to  100  a  minute.  There  is  dyspnuea  with  marked  recession  of  all  the  soft 
parts  of  the  chest  during  inspiration.     Cough  is  always  present,  usually 


ACUTE   BRONCHO-PNEUMONIA.  495 

severe,  and  sometimes  almost  incessant.  The  prostration  is  not  so  great 
as  in  the  cases  previously  described,  and  the  development  of  the  symptoms 
is  much  less  rapid. 

There  are  at  first  sibilant  and  afterward  subcrepitant  rales  over  the 
entire  chest,  with  which  are  usually  mingled  coarser  moist  rales.  There 
are  no  evidences.of  consolidation.  The  respiratory  murmur  is  everywhere 
feeble,  but  not  otherwise  altered.  Percussion  generally  gives  exaggerated 
resonance,  owing  to  the  emphysema  which  is  present,  the  note  being  some- 
times almost  tympanitic. 

The  symptoms  may  gradually  increase  in  severity  until  death  takes 
place  by  the  third  or  fourth  day,  from  respiratory  and  cardiac  failure. 
There  is  usually  marked  cyanosis,  and  toward  the  end  rapidly  increasing 
prostration.  Just  before  death  the  temperature  often  rises  rapidly  to  lOG** 
or  107°  F.  At  the  autopsy  there  are  found  evidences  of  bronchitis  of  the 
tubes  of  all  sizes,  and  minute  zones  of  pneumonia  about  the  smaller 
bronchi.  The  lungs  are  generally  in  a  state  of  hyper-inflation,  on  account 
of  which  they  do  not  collapse  on  opening  the  chest.  There  may  be  in 
addition  extensive  congestion  or  oedema,  the  development  of  which  has 
been  the  immediate  caitse  of  death. 

In  cases  which  do  not  prove  fatal  there  is  usually  by  the  third  or  fourth 
day  great  improvement  in  the  general  symptoms;  the  finer  rales  may  dis- 
appear, and  the  coarse  ones  become  more  and  more  prominent.  By  the 
end  of  a  week  there  may  be  complete  recovery.  Instead  of  this,  there 
may  be  a  continuance  of  the  constitutional  symptoms,  and  disappearance 
of  the  fine  rales  in  front  only,  while  behind  there  are  gradually  added  to 
them  the  signs  of  consolidation  in  one  of  the  lower  lobes  near  the  spine. 
From  this  time  the  case  may  progress  as  one  of  ordinary  broncho-pneu- 
monia. 

The  prognosis  in  this  class  of  cases  is  very  much  better  than  in  the 
congestive  variety,  recovery  being  probable  unless  the  patients  are  very 
young  or  very  delicate  infants. 

3.  Broncho-pneumonia  of  the  common  type. — Wheti  primary,  this  usu- 
ally begins  suddenly  with  symptoms  not  unlike  those  of  lobar  pneumonia. 
This  was  the  mode  of  onset  in  two  thirds  of  my  cases.  In  only  ten  per 
cent  was  the  pneumonia  preceded  by  bronchitis  of  the  large  tubes.  In 
these  the  symptoms  of  bronchitis  may  be  slowly  (Fig.  91,  p.  504)  or  rap- 
idly (Fig.  8^)  merged  into  those  of  pneumonia.  AVhen  the  onset  is  sud- 
den it  is  marked  by  high  fever,  frequently  by  vomiting,  rarely  by  convul- 
sions. In  addition  there  are  rapid  respiration,  cough,  prostration,  and 
sometimes  cyanosis.  The  symptoms  are  more  distinctly  pulmonary  than 
is  generally  the  case  in  lobar  pneumonia. 

The  temperature,  as  a  rule,  is  high ;  rarely  is  it  continuously  so,  but 
it  is  of  a  remittent  type.  The  daily  fluctuations  often  amount  to  four  or 
five  degrees.  The  fever  usually  continues  from  one  to  three  weeks,  and 
33 


496  DISEASES   OP  THE  RESPIRATORY  SYSTEM. 

gradually  subsides.  It  is  rare  for  it  to  terminate  by  crisis.  Although, 
as  a  rule,  we  expect  a  high  temperature  Avith  acute  pneumonia,  this 
is  not  invariable.  Primary  cases  may  run  their  course,  and  even  ter- 
minate fatally,  although  the  temperature  has  not  been  above  101°  F. 
I  have  records  of  several  such  cases.  A  low  temperature  is  more  often 
seen  in  young  and  delicate  infants  than  in  those  who  are  older  and  more 
robust. 

The  respirations  are  frequent  and  laboured ;  there  is  real  dyspnoea. 
On  inspiration,  there  are  marked  recessions  of  all  the  soft  parts  of  the 
chest,  and  the  alje  nasi  dilate  actively.  The  usual  rapidity  of  the  respira- 
tions is  from  60  to  80  per  minute  ;  very  often,  however,  it  rises  to  100,  and 
on  several  occasions  I  have  seen  it  even  120,  Kespiration  generally  seems 
more  embarrassed  than  the  action  of  the  heart,  and  respiratory  failure  is 
a  more  frequent  cause  of  death  than  cardiac  failure.  The  pulse  is  always 
rapid — from  150  to  200  a  minute — and  when  so  it  is  often  irregular.  The 
pulse  rate  is  of  much  less  importance  than  its  character.  Early  it  is  full 
and  strong,  but  soon  it  becomes  soft,  compressible,  and  weak. 

The  prostration  is  usually  moderate  for  the  first  day  or  two,  but 
steadily  increases  as  the  lung  becomes  more  and  more  involved.  Toward 
the  close  of  the  disease  there  may  be  present  all  the  symptoms  of  the- 
typhoid  condition. 

Cough  is  mnch  more  constant  than  in  lobar  pneumonia,  and  more  dis- 
tressing; sometimes  it  is  almost  incessant.  It  disturbs  rest  and  sleep,  and 
may  cause  vomiting  if  the  paroxysm  occurs  soon  after  eating.  There  is 
no  expectoration.  Mucus  is  sometimes  coughed  up  into  the  trachea,  or 
even  the  pharynx,  to  be  swallowed  again,  or  more  frequently  aspirated 
into  the  lung.  If  during  a  severe  paroxysm  the  patient  is  turned  upon 
his  face  or  inverted,  much  of  this  mucus  may  be  dislodged.  A  strong 
cough  is  a  good  symptom  :  suppression  of  the  cough  is  always  a  bad 
symptom,  indicating  a  loss  of  the  reflex  sensibility  of  the  bronchial  mucous 
membrane  and  feeble  respiratory  muscles. 

Pain  in  the  chest  is  not  common,  and  is  rarely  an  annoying  symptom. 

Cyanosis  is  present  at  some  time  in  most  of  the  severe  cases.  It  may 
occur  at  the  onset,  or  at  any  time  during  the  course  of  the  disease.  It  is 
usually  due  to  sudden  congestion  of  a  portion  of  the  lung  not  previously 
involved.  Even  when  slight,  it  is  always  a  danger-signal  of  respiratory 
failure,  and  when  present  only  in  the  finger  tips  or  lips  indicates  that  the 
patient  must  be  carefully  watched  and  energetically  treated.  In  the  severe 
cases  the  whole  body  may  be  of  a  dull  leaden  hue. 

Nervous  symptoms  at  the  onset  are  not  so  frequent  as  in  lobar  pneu- 
monia, convulsions  being  rare ;  but  late  convulsions,  particularly  in  the 
pneumonia  which  complicates  pertnssis,  are  exceedingly  frequent,  and 
usually  fatal.  Delirium  may  be  present  at  any  time  during  the  attack. 
In  infants  this  shows  itself  by  excitement  and  inability  to  recognise  the 


ACUTE   BRONCHO-PNEUMONIA. 


497 


nurse  or  mother.  Occasionally  patients  present  marked  cerebral  symptoms 
throughout  the  disease.  In  one  of  my  cases  nearly  every  symptom  of 
tuberculous  meningitis  was  present,  the  autopsy  revealing  only  an  extreme 
degree  of  cerebral  anaemia.  As  elsewhere  stated,  the  nervous  symptoms 
depend  not  upon  the  location  of  the  disease,  but  upon  its  extent,  the 
intensity  of  the  infection,  and  upon  the  susceptibility  of  the  patient,  such 
symptoms  being  especially  common  in  rachitic  children  and  in  those  suf- 
fering from  pertussis. 

Gastro-enteric  symptoms  are  frequent  in  infancy,  and  are  of  much 
importance.  Often  there  are  from  four  to  six  stools  a  day,  of  a  green 
colour,  containing  mucus  and  undigested  food.  These  symptoms  depend 
upon  the  feeble  digestion  which  is  associated  with  the  febrile  process, 
and  are  often  from  improper  feeding.  This  may  lead  to  vomiting,  which 
is  also  due  to  over-medication  or  to  severe  paroxysms  of  coughing.  Vom- 
iting and  diarrhoea  add  jnuch  to  the  danger  of  the  attack,  and  not  in- 
frequently, when  the  issue  is  doubtful,  turn  the  scale  against  the  patient. 
In  summer  this  complication  is  more  frequent  and  is  likely  to  be  more 
severe.  Distention  of  the  stomach  or  intestines  from  gas  may  be  the 
cause  of  severe  symptoms,  owing  to  the  added  embarrassment  of  respira- 
tion produced  by  this  upward  pressure.  In  infants  it  may  lead  to  attacks 
of  cyanosis,  and  even  convulsions. 

The  urine  in  most  cases  is  scanty,  high-coloured,  and  loaded  with 
urates.  A  trace  of  albumin  is  often  present  when  the  temperature  is 
very  high ;  but  casts,  renal  epithelium,  and  a  large  amount  of  albumin 
are  rare. 

The  following  temperature  chart  (Fig.  82)  is  a  good  example  of  a  very 
frequent  course  of  primary  pneumonia  of  moderate  severity  terminating 


10j° 

1     2   ;  3     1    i  0 

6 

7 

g 

9 

10    n    12    13   11    15    lti| 

101° 
103° 
102° 
101° 
100° 

y9° 

! 

*! 

A 

I 

\ 

r 

7  A 

"v 

/\ 

A 

\ 

/ 

V 

/       \ 

V 

' 

V 

/\ 

\ 

I 

1 

V;     . 

\^ 

V 

^ 

Fig.  82. — Temperature  curve  in  typical  broncho-pneumonia  of  the  milder  form. 

History. — Male,  sixteen  months  old;  delicate  child;  previous  bronchitis;  onset  gradual; 
signs  of  consolidation  at  left  base  on  fifth  day,  but  fine  rales  over  both  lower  lobes  behind  ;  reso- 
lution slow,  rales  persisting  for  a  long  time  in  both  lungs. 


in  recovery.     In  cases  of  this  type  the  constitutional  symptoms  are  not 
grave,  and  follow  very  closely  the  temperature  curve. 

The  next  chart  (Fig.  83)  illustrates  a  more  severe  but  not  uncommon 
course  of  the  disease  in  which  the  fever  is  prolonged.  The  usual  duration 
of  cases  of  this  type  is  between  three  and  four  weeks.  The  irregular  fluc- 
tuations of  the  temperature,  rarely  touching  the  normal  line,  are  exceed- 
ingly characteristic  of  broncho-pneumonia. 


498 


DISEASES   OP   THE   RESPIRATORY  SYSTEM. 


The  chart  shown  iu  Fig,  84  is  that  of  relapsing  pneumonia.     The  first 
attack  was  fairly  typical,   with   about  the   usual  duration.      Resolution 


107° 
100° 
105° 
lOi""' 
103° 
102° 
101° 
100° 
99° 

1 

2 

3 

i 

5 

6 

7 

8" 

9  llO 

u 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

21J25 

2fi 

27 

28 

29 

30 

31 

32 

— 

\ 

-/I 

A 

. 

A 

1^    li 

A 

/ 

A.A 

sr\  i\  A  \ . 

/  v/ 

* 

« 

/ 

|\ 

1 

'\ 

1  vi/^v 

/  ,     / 

A 

^-~\ 

/ 

1 

\A 

/ 

1 

V-^ 

/ 

V  y    v\i 

J 

I 

y 

/ 

/ 

1 

i 

y 

1 
1 

V 

\ 

/ 

V 

/ 

I 

V 

\J 

V 

'\ 

98° 

Fig.  83. — Temperatui'e  curve  of  broncho-pneumonia  with  a  prolonged  course ;  recovery. 

Histot^y. — Female,  eighteen  months  old  ■  in  fair  condition  ;  sudden  onset.  Early  signs  were 
localized,  tine  rales  over  left  base;  on  fifth  day  signs  of  consolidation  at  left  base,  with  rales  on 
both  sides  behind.  General  symptoms  of  moderate  severity.  Signs  of  consolidation  disappeared 
about  a  week  after  cessation  of  fever ;  rales  persisted  nearly  two  weeks  longer. 

had  begun,  and  was  apparently  progressing  favourably,  when  there  was  a 
retur».>of  the  fever,  accompanied  by  new  signs  in  the  chest,  the  second 


107° 

1 

2 

3 

i 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14!l5 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26|27 

28 

29 

30 

31 

32 

33 

34 

106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

^ 

A 

^ 

« 

1 

H 

1 

A ' 

\v 

,A/\/ 

A  I 

^ 

f  A 

.     / 

n^ 

V 

I 

V 

u\  V      w. 

/ 

V 

^/ 

^ 

\\ 

\1 

V 

\ 

■ 

1 

/ 

A 

'\ 

\ 

y 

\ 

f 

V 

\ 

1 

V 

\ 

/ 

\h 

h 

y 

\ 

u 

V 

V 

^ 

V^ 

s 

N 

vy 

A 

^ 

/ 

98° 

_ 

.._ 

V 

\ 

^ 

V 

•N.. 

Fig.  84. — Temperature  curve  of  relapsing  broncho-pneumonia :  recovery. 

History. — Male,  nineteen  months  old  ;  delicate.  Consolidation  on  si.xth  day  in  left  lower  lobe 
behind;  two  days  later  small  area  of  consolidation  in  right  lower  lobe  behind;  many  rales  both 
Bides ;  eighteenth  day,  signs  of  consolidation  had  disappeared,  but  many  rales  persisted.  Acces- 
sion of  fever  on  nineteenth  and  twentieth  days,  accompanied  by  extension  of  disease  as  shown 
by  new  rales,  but  no  evidences  of  consolidation  during  second  attack.  Slow  resolution  and  con- 
valescence. 

attack  being  shorter  and  milder  than  the  first.  Very  often  the  tempera- 
ture falls  to  normal  without  any  signs  of  resolution,  and  after  an  interval 
varying  from  two  or  three  days  to  a  week  there  is  recurrence  of  the  fever 


1 

2 

3 

4 

5 

C 

7 

107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

/ 

• 

-A  ri7 

1 

li  V 

4 

/ 

V 

f 

If 

- 

Fig.  85. — Temperature  curve  of  broncho-pneumonia ;  fatal. 

History. — Male,  six  months  old ;  markedly  rachitic ;  sudden  onset.  Signs  first  day  were  tine 
moist  rides  throughout  the  chest,  marked  prostration,  and  cyanosis;  on  third  day,  a  small  area 
of  consolidation  in  upper  lobe  of  left  lung  behind  ;  increasing  prostration,  cyanosis,  and  death. 
Avtopsy. — No  pleurisy  ;  consolidation  at  left  apex  behind,  and  posterior  two  thirds  of  left  lower 
lobe ;  consolidation  of  right  apex  posteriorly,  lower  lobe  intensely  congested. 


ACUTE   BRONCHO-PNEUMONIA.  499 

and  other  constitutional  symptoms,  the  second  attack  frequently  proving 
fatal. 

A  frequent  course  in  fatal  cases  is  shown  in  Fig.  85.  The  duration  of 
the  disease,  instead  of  being  five  days  as  in  this  case,  is  often  only  three  or 
four.  The  temperature  at  first  fluctuates  widely,  then  rises  gradually 
until  death. 

Duration  of  the  fever. — The  following  figures  give  the  duration  of  the 
fever  in  331  cases.  The  majority  were  primary  ;  iione  were  secondary  to 
diphtheria,  and  only  a  few  complicated  measles.  Of  the  169  cases  that 
were  fatal — 

There  died  during  the  first  six  days 25-0  per  cent. 

'*         "     between  the  seventh  and  twenty-first  days.  ..  .     55-5   " 

"        "  "  "    twenty-first  and  sixtieth  days. .. .     19'5   "       " 

100-0  "      " 

Of  78  cases  which  recovered,  the  duration  of  the  fever  was — 

Less  than  seven  days 11-5  per  cent. 

From  seven  to  twenty-one  days 66-6   " 

From  twenty- one  to  ninety  days 21-9   "       " 

100-0   "       " 

Physical  Signs. — In  considering  the  signs  of  broncho-pneumonia,  it  is 
better  to  connect  them  with  the  different  conditions  in  the  lung  than  to 
group  them  in  stages,  as  in  lobar  pneumonia. 

(«)  Mlthout  consoUdatioti. — It  can  not  too  often  be  repeated  that 
broncho-pneumonia  may  exist  without  signs  of  consolidation  at  any  period 
during  the  course  of  the  disease.  When  the  attack  is  jDrimary,  the  ear- 
liest signs  are  due  to  congestion  of  the  lung,  associated  with  bronchitis 
of  the  fine  tubes,  which  is  usually  localized,  but  which  may  be  general. 
If  the  disease  has  followed  bronchitis  of  the  large  tubes,  its  signs  are 
added.  Congestion  of  the  lung  gives  feeble  breathing  over  the  affected 
area,  and  occasionally  slight  dulness  or  diminished  resonance.  With  this 
are  found  coarse  sonorous,  and  finer  sibilant  rales,  due  to  congestion  and 
swelling  of  the  mucous  membrane  of  the  larger  and  smaller  bronchi  re- 
spectively. These  signs  are  soon  replaced  by  very  fine  moist  rales,  which 
are  usually  localized  in  one  of  the  lower  lobes  behind  (Fig.  86).  These 
localized  fine  rales  are  the  first  distinctive  sign  of  broncho-pneumonia. 
Soon  a  change  in  the  respiratory  murmur  is  heard  in  the  att'ected  area, 
becoming  feebler  in  intensity  and  higher  in  pitch.  Elsewhere  in  the  chest 
there  may  be  coarse  rdles,  due  to  bronchitis  of  the  large  tubes.  In  stich 
cases  the  areas  of  pneumonia  are  so  small  and  so  scattered  as  to  give  in 
themselves  no  additional  signs,  and  the  case  may  go  on  to  recovery  with- 
out presenting  anything  more  distinctive  than  the  signs  mentioned. 

{b)  With  areas  of  jjartial  consolidation. — In  the  lung  at  this  time 
there  are  small  areas  of  consolidation,  generally  superficial  and  separated 


PHYSICAL   SIGNS    OF   BRONCHO-PNEUMONIA. 


I'lo.  86. — First  stage.    Coarse  rales  over  both  lungs  ;     Fig.  87. — Second  stage.     Coarse  and  tine  rales  over 
localized    fine  (subcrepitant)   rales  at  the  left  both  lungs  behind;    at  left  base  an  area  of 

base.     No  change  in  breathing  sounds.  partial   consolidation,  with    broncho-vesicular 

breathing,  exaggerated  voice,  and  very  sharp 
rales. 


■ 

V'^'^^H 

■F 

'^ 

■ 

r 

Y^ 

O              0 

0      0      0 

1    ■ 

■    3'-:^ 

1-^'         ■    1 

1         M^H  ^     ^'' 

J 

v^B 

Fig.  88. — Third  stage.  A  larger  area  <if  partial 
consolidation,  and  in  the  centre  a  small  area  of 
complete  consolidation,  with  bronchial  breath- 
ing and  voice  and  slight  dulness.  Signs  over 
the  right  lung  similar  to  what  were  previously 
present  over  the  left. 


Fig.  89. — Fourth  stage.  Extensive  ilisease  of  both 
sides;  large  area  of  complete  consolidation  on 
the  left,  with  dulness,  bronchial  lireathing  and 
voice,  and  no  rales ;  surrounding  this,  bror'cho- 
vesicular  breathing,  with  many  rales.  Signs 
in  the  right  lung  similar  to  those  previously 
present  over  the  left. 


Note. — The  disease  may  stop  at  any  one  of  these  stages  and  resolution  take  place. 


500 


ACUTE   BRONCHO-PNEUMONIA.  501 

by  healthy  or  congested  lobules.  Percussion  in  these  cases  usually  gives 
negative  results,  but  sometimes  there  is  very  slight  dulness.  The  vocal 
fremitus  is  not  usually  altered.  The  fine  moist  rales  may  be  heard  over 
quite  a  large  area,  but  at  some  point,  usually  near  the  spine,  over  one  of  the 
lower  lobes,  they  are  sharper,  louder,  higher  pitched,  and  seem  close  under 
the  ear  (Fig.  87).  Respiration  is  feebler  here  than  elsewhere,  and  broncho- 
vesicular  in  quality,  approaching  bronchial  breathing  more  and  more  as 
the  consolidation  increases.  The  resonance  of  the  voice  and  cry  is  exag- 
gerated. 

(c)  With  areas  of  consolidation  more  or  less  com2)lete.  On  percussion 
there  is  dulness,  but  surprisingly  little  in  comparison  with  the  other  signs 
of  consolidation  present.  It  is  due  to  the  fact  that  the  consolidated  por- 
tion, though  extensive,  is  superficial,  and  does  not  involve  the  lung  to  any 
great  depth,  and  also  that  there  are  in  the  consolidated  area  many  alveoli 
which  still  contain  air  (Plate  XII).  On  palpation  there  is  usually  a  slight 
increase  in  the  vocal  fremitus.  On  auscultation,  there  are  still  present  the 
evidences  of  bronchitis,  usually  only  behind,  but  sometimes  over  the  entire 
chest.  Coarse  and  fine  rales  are  intermingled.  Over  the  consolidated 
parts  are  heard  bronchial  breathing  and  bronchial  voice.  At  the  centre 
of  these  areas  the  bronchial  breathing  is  pure  and  rales  are  usually  absent, 
but  at  the  margin  rales  are  present  and  the  breathing  approaches  the 
broncho-vesicular  type  (Fig.  88).  The  signs  of  consolidation  thus  are 
rarely  sharply  circumscribed  as  they  are  in  lobar  pneumonia,  but  shade  off 
gradually.  The  consolidated  area  is  at  first  small,  usually  in  one  of  the 
lower  lobes  near  the  spine,  but  may  gradually  extend  until  nearly  the 
whole  of  one  or  even  both  lungs  behind  are  more  or  less  completely  solidi- 
fied (Fig.  89).  The  signs  are  found  as  far  forward  as  the  axillary  line, 
but  usually  stop  here.  Friction  sounds  may  be  heard  over  the  consolidated 
areas,  but  very  rarely  except  where  signs  of  complete  consolidation  are 
present.  It  is  often  impossible  to  obtain  any  idea  of  the  condition  of  an 
infant's  lung  during  quiet,  superficial  respiration.  Sometimes  over  a  part 
which  is  completely  consolidated  there  is  heard  only  very  feeble  breathing, 
or  the  lung  may  be  almost  silent.  If,  however,  the  child  be  made  to  cry 
or  to  take  a  deep  inspiration,  both  the  bronchial  breathing  and  rales  are 
distinctly  brought  out.  The  intensity  of  the  consolidation  increases  as 
the  case  advances,  and  the  signs  become  more  and  more  like  those  of  lobar 
pneumonia.  During  resolution  there  is  first  a  disappearance  of  the  signs 
of  consolidation,  which  may  be  quite  rapid,  but  friction  sounds  and  rales 
of  all  kinds  often  persist  for  three  or  four  weeks  longer. 

The  following  statistics  are  of  some  interest,  as  showing  the  frequency 
with  which  signs  of  consolidation  were  found,  and  the  day  when  they  were 
discovered.  Their  value  is  increased  by  the  fact  that  the  children  were 
under  observation  in  an  institution  at  the  time  they  were  taken  sick,  and 
that  in  all  the  fatal  cases — thirty-six  in  number — in  which  signs  of  con- 


502  DISEASES  OP  THE   RESPIRATORY  SYSTEM.      . 

solidation  were  absent,  the  diagnosis  of  pneumonia  was  confirmed   by 
autopsy : 

Consolidation  noted  on  or  before  the  fourth  day 47  cases. 

"      from  the  fifth  to  the  seventh  day  86     " 

"      the  eighth  to  the  twelfth  day 13     " 

"  "      after  the  twelfth  day 9     " 

No  signs  of  consolidation 62     " 

166     " 

In  general,  it  must  be  borne  in  mind  that  in  many  cases  signs  of  con- 
solidation are  never  present,  as  the  areas  of  pneumonia  are  small  and 
widely  scattered ;  that  where  there  is  consolidation  it  is  usually  incom- 
plete, because  there  are  small  areas  of  healthy  lung  tissue  between  the 
hepatized  portions ;  that  the  signs  of  consolidation  usually  shade  off 
gradually ;  and  that  both  sides  are  almost  invariably  involved,  although 
one  side  usually  to  a  greater  degree  than  the  other. 

(4)  The  ])rotracted  form — Persistent  bronclio-pneumonia. — This  is 
seen  in  primary  cases,  especially  among  delicate  children,  and  it  is  not 
uncommon  in  pneumonia  complicating  pertussis.  The  onset  and  course 
of  the  disease  for  the  first  two  or  three  weeks  do  not  differ  from  an  ordi- 
nary attack  of  moderate  severity,  but  at  the  end  of  this  period  there  is  seen 
no  tendency  in  the  process  to  subside.  The  fever  continues,  but  it  is  not 
high,  and  by  physical  examination  it  is  found  that  the  areas  of  consolida- 
tion are  gradually  increasing  day  by  day,  until  sometimes  the  greater  part 
of  both  lungs  behind  are  involved.  The  air  vesicles  become  so  distended 
with  cells  that  the  signs  of  consolidation  are  more  complete  than  in  ordi- 
nary broncho-pneumonia.  There  is  marked  dulness,  sometimes  almost 
flatness ;  bronchial  breathing  is  exaggerated  in  intensity,  until  it  resem 
bles  cavernous  breathing,  and  it  may  be  impossible  to  distinguish  between 
them.  However,  the  fact  that  it  is  heard  over  so  large  an  area,  that  it 
shades  off  gradually,  and  that  it  is  accompanied  by  friction  sounds,  usually 
make  a  distinction  possible. 

The  temperature  in  these  protracted  cases  for  the  first  two  or  three 
weeks  is  from  100°  to  105°  F. ;  but  after  this  time  it  is  generally  lower 
—from  100°  to  102°  or  103°  F.  The  course  is  not  at  all  regular,  but 
marked  by  frequent  exacerbations  and  remissions.  The  general  symptoms 
are  those  of  progressive  asthenia.  There  are  continued  wasting,  anemia, 
and  steadily  increasing  prostration.  The  appetite  is  lost,  often  there  is 
an  aversion  to  food,  and  vomiting  is  easily  excited  if  food  or  stimulants 
are  forced.  The  stools  show  that  even  what  food  is  taken  is  very  imper- 
fectly digested  and  assimilated.  The  skin  becomes  dry,  and  loses  its  elas- 
ticity ;  bed-sores  may  form ;  fine  punctate  haemorrhages  are  seen  over  the 
abdomen,  sometimes  over  the  chest  and  extremities.  The  latter  is  always 
a  very  bad  symptom,  and  I  have  never  seen  recovery  where  it  was  present. 

The  chart  in  Fig.  90  is  typical  of  the  course  of  one  of  these  protracted 


ACUTE   BRONCHO-PNEUMONIA. 


503 


cases  terminating  fatally.     The  temperature  shows  four  distinct  exacer- 
bations. 

Death  takes  place  from  slow  asthenia,  usually  after  five  or  six  weeks, 
but  the  attack  may  be  prolonged  for  eight  or  ten  weeks.     The  general 


lajHIlS  lG|17|ia:iU  20121 '2^24  25  20  27  28^29[3O|3132j33|34j35|36|37|38J39i4ul4l!42[43|44U5|40U7l4^^^^^ 


Fig.  90 


' ' — ' — ' — ' — • — ' — ' — ' — ^—' — ' — ' — ' — ' — ' — •—• — I — ' — I — ' — I — ' — I — I — I — 1 — I — I — : — > — I ! i L 

'. — Temperature  curve  of  persistent  broncho-pneumonia,  terminating  fatally. 


HLitory. — Male,  two  and  a  half  years  old  ;  healthy  ;  sudden  onset ;  for  two  weeks  the  only 
signs  were  very  line  moist  rales  throughout  both  lungs,  front  and  back.  The  rales  in  front  in 
great  part  gradually  cleared  up ;  those  behind  persisted,  but  it  was  not  until  the  thirty-fourth  day 
that  positive  signs  of  consolidation  were  discovered  in  the  left  lower  lobe  behind";  these  signs 
gradually  extended,  and,  before  death,  were  present  over  nearly  the  whole  left  lung  behind  and 
over  the  right  lower  lobe.  There  were  also  friction  sounds  over  both  lungs.  Autopsy. — Old  and 
recent  pleurisy  with  general  adhesions;  left  lower  lobe  completely  solid,  patches  of  consolida- 
tion in  left  up[ier  lobe.  Right  lower  lobe  about  one  half  consolidated,  with  patches  elsewhere. 
Bronchial  glands  large,  but  not  cheesy.  JSo  evidence  of  tuberculosis  upon  either  gross  or  mici'o- 
scopical  e.xaniination  (see  Fig.  81j. 


symptoms,  the  temperature,  and  the  wasting  strikingly  resemble  cases  of 
tuberculosis,  and  such  is  the  diagnosis  often  made. 

Although  the  majority  of  the  cases  in  which  the  fever  lasts  over  four 
weeks  run  the  fatal  course  just  described,  such  apparently  hopeless  cases 
occasionally  recover.  The  temperature  gradually  falls  lower  and  lower, 
until  it  remains  at  the  normal  point.  For  some  time  after  this,  often  two 
or  three  weeks,  little  change  can  be  seen,  either  in  the  general  symptoms 
or  in  the  physical  signs.  Gradually  the  appetite  returns,  the  child  is 
brighter  and  begins  to  take  an  interest  in  its  surroundings,  the  cough 
abates,  and  little  by  little  the  signs  in  the  lungs  clear  up,  and  the  case 
may  go  on  to  complete  recovery.  Convalescence,  however,  is  always  slow, 
and  may  be  interrupted  by  relapses,  it  being  many  months  before  health 
is  fully  restored.  Although  the  signs  of  consolidation  disappear  in  a  few 
weeks,  rales  are  apt  to  persist  for  a  much  longer  time.  It  is  probable  in 
such  cases,  even  though  all  signs  of  disease  disappear  from  the  chest,  that 
the  lung  does  not  become  quite  normal,  and  relapses  and  second  attacks 
are  always  possible.  The  general  health  may  be  so  undermined  that  the 
child  never  regains  his  former  vigour ;  yet  in  a  surprising  number  of 
these  cases  recovery  seems  to  be  complete. 

5.  Secondary  p^ieumonia. — {a)  Complicating  pertussis. — It  is  not  often 
that  pneumonia  develops  during  the  first  two  weeks  of  this  disease.  The 
most  frequent  time  is  from  the  third  to  the  fifth  week,  when  the  patient 
has  become  exhausted  from  the  previous  severity  of  the  pertussis.  In  two 
thirds  of  my  cases  the  development  of  the  pneumonia  was  gradual,  follow- 
ing bronchitis  of  the  larger  tubes.  The  temperature  chart  shown  in  Fig. 
91  illustrates  well  this  course. 


504 


DISEASES   OF   THE   RESPIRATORY   SYSTEM. 


When  the  onset  is  sudden,  the  symptoms  do  not  differ  essentially  from 
those  of  primary  pneumonia.  The  temperature  of  pertussis-pneumonia  is 
usually  low,  in  a  very  large  number  of  cases  not  rising  above  103-5°  F., 
and  ranging  most  of  the  time  from  101°  to  103°  F.  These  cases  are  very 
apt  to  be  prolonged,  the  fever  often  lasting  for  three  or  four  and  some- 


102° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

1 

2 

3 

~ 

5 

6 

7 

ti 

9 

10 

11 

12 

13 

M 

15 

16 

/ 

,  J 

/ 

y\ 

r 

-^ 

\ 

^ 

/ 

,/ 

s/ 

A 

y 

V 

/ 

\ 

/ 

v 

98° 

^ 

^ 

J 

^ 

Fig.  91.— Temperature  curve  of  fatal  broncho-pneumonia,  complicating  pertussis. 

History. — Male,  si.x  months  old ;  delicate ;  pertussis  for  three  weeks.  Early  signs  of  bron- 
chiti.s  of  large  tubes  only  ;  on  the  eleventh  day  signs  of  consolidation  in  right  upper  lobe.  In- 
creasing prostration,  cyanosis,  and  death.  Autopay. — Large  areas  of  consolidation  in  right  middle 
and  upper  lobe,  small  scattered  spots  throughout  left  lung. 


times  even  for  six  weeks.  The  physical  signs  of  consolidation  may  per- 
sist for  a  long  time  after  the  temperature  has  become  normal,  and  yet 
the  case  may  recover  entirely.  I  have  seen  one  case  in  which  complete 
recovery  occurred  after  the  signs  of  consolidation  had  persisted  for  six 
months,  and  another  in  which  they  had  persisted  for  over  eight  months. 
Very  often  the  signs  continue  during  the  entire  attack  of  pertussis. 
Cerebral  symptoms  are  common,  especially  toward  the  close  of  the  disease. 
Of  fifty-four  fatal  cases  twenty-five  had  convulsions,  and  in  twenty-two 
this  was  the  mode  of  death.  Only  one  case  which  developed  convulsions 
recovered. 

(J)  Complicating  measles. — In  a  small  number  of  cases  the  pneumonia 
begins  simultaneously  with  the  invasion  of  measles,  but  generally  not  until 
the  eruption  appears.  Instead  of  gradually  falling  to  normal  with  the 
fading  of  the  eruption,  the  temperature  continues  high.  Any  of  the 
clinical  types  of  primary  pneumonia  may  occur  in  measles,  the  acute  con- 
gestive variety  which  is  fatal  in  two  or  three  days,  being  especially  com- 
mon. In  its  course  and  duration  the  pneumonia  of  measles  resembles 
the  severe  form  of  primary  pneumonia.  The  broncho-pneumonia  of  scar- 
let fever  differs  in  no  way  from  that  of  measles. 

(c)  Complicating  diphtheria. — In  many  cases  this  does  not  give  a  dis- 
tinct clinical  picture  of  its  own,  its  symptoms  being  mingled  with  those  of 
diphtheritic  bronchitis,  with  which  it  is  frequently  associated.  In  others  the 
forms  resemble  those  seen  in  measles.  The  ma'^nty  of  cases  occur  as  a 
complication  of  diphtheria  of  the  larynx,  althougL  •:  is  not  infrequent  in 
the  septic  cases  in  which  only  the  upper  air  passages  are  involved.  Pneu- 
monia developing  after  laryngitis  is  usually  seen  within  two  days  from 


ACUTE   BRONCHO-PNEUMONIA.  505 

the  beginning  of  laryngeal  symptoms,  and  runs  a  very  rapid  course.  In 
rare  cases  it  may  develop  as  late  as  the  middle  or  end  of  the  second 
week.  When  it  complicates  diphtheritic  bronchitis,  pneumonia  is  recog- 
nised by  the  high  temperature,  rapid  breathing,  and  increased  prostra- 
tion, much  more  certainly  than  by  the  physical  signs,  which  are  always 
obscured  by  the  laryngeal  sounds.  Percussion  may  aid  in  the  diagnosis 
of  consolidation  where  the  signs  on  auscultation  are  doubtful.  In  the 
early  cases,  death  usually  occurs  before  the  disease  has  advanced  far 
enough  to  give  the  physical  signs  of  consolidation,  but  in  the  late  pneu- 
monia, which  develops  more  slowly,  these  may  be  present. 

(d)  Complicating  influenza. — Without  doubt  many  cases  regarded  as 
primary  are  really  secondary  to  influenza,  particularly  when  that  disease 
is  prevailing,  for  very  often  the  pneumonia  of  influenza  differs  in  no 
essential  points  from  the  primary  form.  There  are,  however,  two  types 
which  are  quite  characteristic.  In  the  lirst,  high  temperature  and  pros- 
tration exist  for  several  days  before  there  are  any  physical  signs  of  pul- 
monary disease,  and  often  before  there  are  any  symptoms  pointing  defi- 
nitely to  the  lungs.  Pneumonia  may  then  develop  and  run  its  usual 
course.  The  second  variety  are  the  cases  of  short  duration  often  lasting 
but  three  or  four  days,  and  sometimes  only  two,  but  with  excessively  high 
temperature  and  very  severe  general  symptoms. 

(e)  Complicating  ileo-colitis. — This  is  usually  a  somewhat  subacute 
form  of  pneumonia,  which  is  scarcely  recognisable  except  by  the  phys- 
ical signs.  It  is  seen  in  the  protracted  cases  of  ileo-colitis,  usually  of  the 
ulcerative  variety,  and  occurs  late  in  its  course.  The  temperature  is  not 
high.  Cough,  pain,  and  dyspnoea  are  slight  or  entirely  wanting.  Accel- 
erated respiration  is  frequently  the  only  symptom  suggestive  of  j^ulmo- 
nary  disease.  By  physical  examination  there  are  found  the  usual  signs, 
generally  involving  both  lungs  posteriorly.  Very  often  pneumonia  is 
not  suspected  during  life,  the  constitutional  symptoms  being  sufficiently 
explained  by  the  intestinal  lesions,  although  the  autopsy  discloses  the  fact 
that  death  was  due  to  pneumonia. 

Complications. — Those  relating  to  the  lungs  have  been  described  with 
the  lesions.  Pleurisy  will  be  separately  considered.  Emphysema  can 
rarely,  and  abscess  and  gangrene  never,  be  recognised  by  the  physical 
signs. 

Purulent  meningitis  may  complicate  acute  broncho-pneumonia.  It 
was  met  with  twice  in  one  hundred  and  seventy  autopsies.  It  is  in  all 
respects  similar  to  that  occurring  with  lobar  pneumonia.  Meningeal 
haemorrhage  was  seen  only  once,  and  was  the  cause  of  death  in  a  patient 
eleven  months  old,  who  r  few  days  before  was  seized  with  convulsions,  fol- 
lowed by  a  gradually  .ncreasing  stupor,  which  continued  until  death. 
The  hfemorrhage  covered  the  entire  convexity  of  the  brain.  Endocar- 
ditis is  extremely  rare ;   it  was  not  observed  in  any  of  my  cases.     Acute 


506  DISEASES   OP   THE   RESPIRATORY   SYSTEM. 

pericarditis  was  seen  but  twice,  in  both  cases  complicating  pneumonia  of 
the  left  side.  Complications  referable  to  the  digestive  tract  are  quite 
common.  Herpetic  stomatitis  is  frequent,  and  occasionally  the  ulcerative 
variety  is  seen.  Thrush  often  occurs  in  the  protracted  cases  among 
very  young  infants.  Gastro-enteritis  is  not  very  common,  considering 
the  frequency  of  vomiting  and  diarrhoea,  these  depending  usually  upon 
functional  derangement.  In  only  three  of  my  cases  was  there  nephritis. 
In  all  it  was  of  the  acute  exudative  variety,  and  in  only  one  case  was  it 
severe  enough  to  affect  the  prognosis. 

Old  lesions  of  tuberculosis — cheesy  nodules  in  the  lungs  and  some- 
times in  the  pleura — are  not  infrequently  met  with  in  patients  dying  of 
acute  pneumonia  of  a  non-tuberculous  character. 

Diagnosis. — An  acute  onset  with  continuous  high  fever,  rapid  respira- 
tion, and  cough,  should  always  lead  one  to  suspect  pneumonia.  When 
to  these  symptoms  are  added  prostration  and  cyanosis,  the  diagnosis  of 
pneumonia  is  almost  certain.  Cases  of  the  acute  congestive  type  are 
the  ones  most  frequently  unrecognised,  and  in  many  of  these  cases  a  posi- 
tive diagnosis  is  im.possible  during  life.  Many  atypical  cases  of  pneumo- 
nia are  seen,  particularly  in  young  infants.  An  unusual  temperature 
course  is  perhaps  the  symptom  most  likely  to  lead  to  a  mistake.  While 
this,  as  a  rule,  is  high  and  remittent,  it  is  sometimes  not  so,  and  may  be 
but  little  above  normal.  Rapid  respiration  is  almost  always  present,  but 
cough  may  be  very  slight,  especially  in  infants.  In  very  young  infants, 
the  diagnosis  often  rests  upon  the  prostration,  cyanosis,  and  rapid  respi- 
ration, the  other  acute  inflammatory  symptoms  being  absent.  Only  the 
physical  signs  of  the  disease  can  positively  settle  the  question  of  diagnosis. 

When  pneumonia  follows  bronchitis  of  the  large  tubes,  whether  the 
bronchitis  is  primary  or  complicates  one  of  the  infectious  diseases,  the 
extension  of  the  disease  to  the  lungs  is  usually  marked  by  three  symptoms 
— a  steadily  rising  temperature,  more  frequent  respiration,  and.  increasing 
prostration.  It  may  be  twelve  or  twenty-four  hours  before  the  change  is 
indicated  by  the  physical  signs. 

The  diagnosis  of  broncho-pneumonia  from  congenital  atelectasis  has  to 
be  considered  only  during  the  first  three  or  four  months,  it  being  rare  for 
atelectasis  to  give  symptoms  after  this  time.  In  early  infancy  the  danger 
of  confusing  the  two  is  increased  by  the  fact  that  atelectasis  and  broncho- 
pneumonia may  be  associated.  If  the  infant  has  been  strong  and  well  for 
the  first  two  months,  congenital  atelectasis  can  be  excluded.  It  is  likely 
to  be  found  in  delicate  infants,  where  there  is  a  history  of  difficulty  in 
resuscitation  at  birth  and  feeble  cry  during  the  early  days  of  life.  The 
temperature  is  low,  often  subnormal,  the  cyanosis  is  out  of  proportion  to 
the  other  symptoms,  and  the  physical  signs  are  doubtful  or  absent. 

At  the  outset,  pneumonia  can  not  be  positively  diagnosticated  from 
severe  bronchitis.     Such  a  bronchitis  often  begins  with  severe  pulmonary 


ACUTE    BRONCHO-PNEUMONIA.  597 

symptoms  and  a  temperature  of  103°  or  104°  F. ;  but  this  high  tempera- 
ture is  of  short  duration,  usually  falling  after  twenty-four  or  forty-eight 
hours  to  100°  or  101°  F.  The  prostration  is  much  less,  and  all  the  symp- 
toms, possibly  excepting  the  cough,  less  severe.  The  only  physical  signs 
are  coarse  rales,  which  are  heard  throughout  the  chest. 

The  same  rules  apply  to  bronchitis  of  the  smaller  tubes.  The  rales  are 
heard  both  in  front  and  behind,  and  usually  over  both  sides.  If  with  such 
rales  the  temperature  continues  to  rise  for  three  days  in  succession  above 
103°  F.,  it  may  be  assumed  that  pneumonia  is  present,  provided  there 
is  no  other  disease  vehich  might  explain  the  temperature.  If,  instead 
of  being  generalized,  the  signs  of  bronchitis  are  limited  to  a  single  lung, 
or  to  one  lung  posteriorly,  the  existence  of  broncho-pneumonia  may  be 
regarded  as  certain.  Localized  bronchitis,  then,  is  always  to  be  inter- 
preted as  broncho-pneumonia,  provided  tuberculosis  can  be  excluded.  In 
doubtful  cases  the  chances  largely  favour  broncho-pneumonia  rather  than 
bronchitis.  Attention  is  again  called  to  the  fact  already  mentioned, 
that  there  are  a  large  number  of  cases  of  pneumonia  without  signs  of 
consolidation. 

The  differential  diagnosis  of  broncho-  from  lobar  pneumonia  will  be 
considered  in  connection  with  the  latter  disease.  On  account  of  the  remit- 
tent temperature,  broncho-pneumonia  may  be  confounded  with  malarial 
fever;  if  with  the  latter  there  is  some  bronchitis,  or  if  accompanying  the 
onset  of  a  severe  malarial  paroxysm  there  is  pulmonary  congestion — two  not 
infrequent  combinations — the  difficulties  are  increased.  A  positive  diag- 
nosis is  often  impossible  except  by  careful  observations  of  the  temperature 
for  one  or  two  days.  The  jDoints  of  differentiation  are,  that  the  tempera- 
ture of  pneumonia,  though  often  remittent,  is  very  rarely  intermittent,  and 
that  it  is  not  affected  by  quinine.  In  addition,  the  characteristic  features 
of  malaria — enlargement  of  the  spleen,  the  plasmodium  in  the  blood,  and 
a  history  of  exposure — must,  of  course,  be  taken  into  account. 

Both  the  acute  and  the  persistent  forms  of  simple  broncho-pneumonia 
may  be  confounded  with  the  tuberculous  form ;  the  points  of  distinction 
are  considered  in  the  chapter  on  Tuberculosis. 

Prognosis. — Broncho-pneumonia  is  always  a  serious  disease,  and  in  an 
infant  dangerous  to  life.  The  prognosis  depends  upon  the  age,  surround- 
ings, and  previous  condition  of  the  patient,  upon  the  nature  of  the  in- 
fection, whether  the  disease  is  primary  or  secondary,  and,  if  the  latter, 
upon  the  character  of  the  primary  disease.  In  private  practice  the  mor- 
tality from  broncho-pneumonia  is  from  10  to  30  per  cent,  depending  upon 
the  conditions  mentioned.  One  whose  knowledge  of  broncho-pneumonia 
is  derived  from  observations  in  private  practice  can,  however,  form  but 
little  idea  of  the  frequency  and  severity  of  this  disease  in  hospitals  and 
asylums  for  infants  and  young  children,  particularly  when  it  occurs  with 
epidemics  of  measles,  diphtheria,  and  pertussis.     The  statistics  in  the  fol- 


508 


DISEASES  OF   THE   RESPIRATORY  SYSTEM. 


lowing  table  are  taken  from  the  records  of  two  institutions  with  which  I 
am  connected,  and  fairly  represent  the  results  seen  in  such  places  in  chil- 
dren under  three  years : 


Forms  of  Pneumonia. 

Cases. 

Deaths. 

Percentage 
mortality. 

Prirnary  broncho-pneumonia 

194 

29 

89 

66 

7 

47 

19 

6 

2 

2 

96 

19 
56 
54 

7 
47 
18 
1 
2 
2 

49-4 

Following  bronchitis  of  the  large  tubes 

Secondary  to  measles   

65-5 
62-9 

"           "   pertussis 

81-8 

"           "  scarlet  fever 

100-0 

"           "  diphtheria 

100-0 

"           "  ileo-colitis 

94-7 

"           "  epidemic  influenza       .          .... 

16-6 

"           "  varicella 

100-0 

"           *'  erysipelas 

100-0 

Totals 

461 

302 

65-5 

The  mortality  varies  directly  Avith  the  age  of  the  patient,  being  the 
highest  during  the  first  year,  and  diminishing  steadily  thereafter,  as  shown 
by  the  following  table  giving  the  result  in  three  hundred  and  forty-five 
cases : 


Age. 

Cases. 

Percentage 
mortality. 

During  the  first  year 

202 

102 

33 

6 

3 

66 

''         "    second  vear 

55 

"         "    third  year 

33 

"         "    fourth  year 

16 

"         "    fifth  year 

In  this  table  are  included  no  cases  secondary  to  measles,  scarlet  fever, 
or  diphtheria. 

Probably  the  best  of  all  guides  to  the  nature  and  virulence  of  the  in- 
fection is  the  temperature.  An  excessively  high  temperature  indicates  a 
virulent  t3'pe  of  infection.  Some  idea  of  this  may  be  gained  from  these 
figures,  giving  the  highest  temperature  and  the  mortality  in  two  hundred 
and  thirty-one  cases,  not  including  cases  with  measles  or  diphtheria : 


Highest  Temperature. 

Cases. 

Deaths. 

Percentage 
mortality. 

106°  F.  or  over 

55 
94 
53 

22 

7 

47 
56 
26 
13 
5 

85-5 

105°  or  105-5° 

60-0 

104°  or  104-5° 

49-0 

102°  to  103-5° 

60-0 

99-5°  to  101-5° 

71-0 

The  high  mortality  of  the  cases  with  unusually  low  temperature  is  due 
to  the  fact  that  they  nearly  always  were  seen  in  infants  with  very  feeble 


ACUTE  BRONCHO-PNEUMONIA.  509 

vitality.  Cases  with  a  steadily  high  temperature — between  103-5°  and 
104°  F. — usually  do  better  than  those  with  wide  fluctuations,  such  as  100° 
to  105-5°  F.  The  probable  explanation  of  this  is,  that  the  former  are 
due  to  the  pneumococcus,  while  the  latter  are  apt  to  be  cases  of  mixed 
infection,  or  due  to  the  streptococcus.  As  a  rule,  the  danger  of  the  disease 
increases  steadily  with  every  degree  of  temperature  above  104-5°  F. 

An  important  factor  in  the  prognosis  is  the  previous  condition  of  the 
patient.  One  of  the  most  unfavourable  is  rickets,  both  on  account  of  the 
feeble  muscular  power  of  these  children  and  their  thoracic  deformities. 
Any  condition  which  diminishes  the  general  vitality  increases  the  danger 
from  broncho-pneumonia.  As  a  rule,  second  attacks  are  more  serious  than 
the  primary  ones,  especially  if  the  interval  between  them  is  short. 

In  making  the  prognosis  in  any  given  case,  the  symptoms  to  be  con- 
sidered are  the  height  and  course  of  the  temperature,  the  presence  or 
absence  of  nervous  symptoms,  the  condition  of  the  organs  of  digestion, 
the  presence  of  cyanosis  and  the  extent  of  the  disease  as  shown  by  the 
physical  signs. 

Nervous  symptoms  early  in  the  disease  do  not  affect  the  prognosis. 
Three  cases  in  which  convulsions  occurred  at  the  onset  all  recovered,  but 
of  thirty-seven  cases  in  which  convulsions  occurred  at  a  late  period  during 
the  course  of  the  disease,  all  but  one  proved  fatal. 

So  long  as  the  food  is  well  taken  and  retained  and  the  stools  show 
that  it  is  being  assimilated,  no  case  is  hopeless,  no  matter  how  severe  the 
other  symptoms  may  be;  but  the  existence  of  vomiting,  diarrhoea,  or 
severe  indigestion  makes  the  issue  doubtful,  even  though  the  other  symp- 
toms are  very  favourable.  These  conditions  are  especially  important  in 
protracted  cases,  where  death  is  usually  due  to  slow  asthenia. 

Treatment. — The  most  important  part  of  prophylaxis  is  to  give  careful 
and  early  attention  to  every  attack  of  bronchitis  in  an  infant,  for  every 
such  attack  should  be  regarded  as  a  possible  precursor  of  pneumonia.  It 
is  striking  that  one  sees  broncho-pneumonia  so  seldom  in  private  practice 
among  the  better  classes,  even  though  bronchitis  is  very  frequent ;  while 
among  hospital  and  dispensary  patients,  where  bronchitis  is  very  often 
neglected,  broncho-pneumonia  is  constantly  seen.  The  question  of  isolat- 
ing eases  of  pneumonia  is  one  which  is  lately  becoming  more  and  more 
important.  While  it  may  not  often  be  the  case  that  primary  pneumonia 
is  due  to  contagion,  there  seems  to  be  little  doubt  that  this  is  at  times  true 
of  the  pneumonia  secondary  to  measles  and  diphtheria.  Twice  in  one  insti- 
tution have  I  seen  regular  epidemics  of  broncho-pneumonia  occur  with 
outbreaks  of  measles — in  some  of  the  wards  nearly  every  case  of  measles 
developing  pneumonia.  In  another  institution,  during  one  entire  season 
(1888-'89),  almost  every  case  of  diphtheria  transferred  to  a  certain  isola- 
tion pavilion  developed  pneumonia,  and  died  from  that  complication. 
Cases  of  measles  and  diphtheria  which  are  complicated  by  pneumonia 


510  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

should,  if  possible,  be  carefully  isolated  from  others,  and  wards  in  which 
they  are  treated  should  be  thoroughly  disinfected  before  they  are  used 
for  simple  cases. 

The  hygienic  treatment  of  pneumonia  is  important,  and  usually  it 
receives  too  little  attention.  The  child  should  be  kept  in  a  large,  well- 
ventilated  room,  preferably  one  with  an  open  fire ;  if  possible,  being 
changed  from  one  room  to  another  two  or  three  times  a  day,  to  allow 
thorough  airing.  Nothing  is  more  important  for  an  infant  sick  with 
acute  pulmonary  disease  than  plenty  of  oxygen.  Older  children  should 
be  kept  in  bed.  Infants  for  a  considerable  part  of  the  time  may  be  held 
in  the  nurse's  arms.  A  frequent  change  of  position  in  all  cases  is  essen- 
tial ;  no  child  should  be  allowed  to  lie  for  hours  directly  on  the  back. 
The  general  rules  for  feeding  all  sick  children  (page  190)  should  be  fol- 
lowed here.  As  a  rule,  neither  stimulants  nor  medicine  should  be  ad  minis- 
tered in  the  food. 

The  same  local  treatment  may  be  employed  as  in  cases  of  bronchitis 
(page  467).  The  oiled-silk  jacket  should  be  worn  throughout  the  attack, 
and  counter-irritation  maintained  by  the  use  of  the  mustard  paste.  Hot 
poultices  of  flaxseed  may  be  employed  occasionally,  but  never  continuously. 

Emetics. — What  was  said  of  expectorant  mixtures  and  emetics  in  the 
treatment  of  bronchitis  applies  here  with  even  greater  force.  In  infants 
both  had  better  be  omitted  altogether. 

Stimulants. — Alcoholic  stimulants  are  needed  in  all  secondary  cases, 
and  in  a  large  proportion  of  those  which  are  primary.  No  doubt  they  have 
been  greatly  abused,  and,  when  pushed  in  the  early  stage,  often  do  much 
harm  ;  but  in  most  of  the  severe  cases  they  are  indispensable.  They  are 
usually  needed  from  the  outset,  where  the  pneumonia  is  secondary  to 
measles,  diphtheria,  scarlet  fever,  or  other  infectious  diseases.  They  are 
called  for  when  the  pulse  is  weak,  compressible,  rapid,  and  irregular. 
Whisky  or  brandy  is  usually  to  be  preferred,  although  the  taste  of  the 
patient  often  has  to  be  consulted,  and  when  these  are  refused,  some  wines, 
like  sherry  or  tokay,  may  be  readily  taken.  (For  methods  of  adminis- 
tration see  page  49.)  The  dose  is  to  be  regulated  by  the  condition  of  the 
patient.  From  one  half  to  two  ounces  daily  may  be  given  to  an  infant  of 
one  year.  It  is  rarely  advisable  to  go  above  this  limit  except  for  a  few 
hours  at  a  time  at  critical  periods  ;  then  two  or  three  times  as  much 
may  be  used.  Contrary  to  the  statement  of  many  writers,  these  stimu- 
lants are  usually  well  borne,  even  by  young  children.  Stimulants  are 
most  needed  when  the  temperature  is  low,  or  falls  suddenly,  as  at  the 
crisis  of  the  disease.  When  the  temperature  is  high,  smaller  amounts  are 
generally  required. 

In  many  cases  strychnine  is  even  more  valuable  than  alcohol.  Usually 
they  should  be  combined,  as  the  indications  are  the  same.  Where  the 
dose  is  to  be  repeated  every  three  hours,  ^J-g-  of  a  grain  is  as  much  as  it  is 


ACUTE   BRONCnO-PNEUMONlA.  511 

wise  to  give  to  an  infant  a  year  old.  This  may  be  kept  up  for  days,  and 
for  a  shorter  time  larger  doses  may  be  given,  the  effect  always  being 
carefully  watched.  For  older  children  digitalis  may  be  used,  but  I  have 
rarely  seen  much  benefit  from  it  in  infants.  In  attacks  of  heart  failure 
associated  with  pulmonary  congestion,  nitroglycerin  should  be  given — 
gr.  g-i-Q  every  hour  for  four  or  five  doses,  or  even  longer. 

Respiratory  stimulants  are  needed  in  most  cases,  even  more  than  are 
cardiac  stimulants,  but  we  have  none  which  can  be  wholly  depended  upon. 
For  a  short  time,  atropine  gr.  -g^^,  caffein  gr.  ^i^,  or  strychnine  gr.  ^i^, 
may  sustain  a  child  with  sudden  failure  of  respiration,  but  in  the  slow 
respiratory  failure  that  results  from  exhaustion  their  effect  is  but  tem- 
porary. The  doses  mentioned  are  for  an  infant  of  one  year.  The  drugs 
may  be  used  successively  or  together  ;  for  immediate  effect  they  should 
be  given  hypodermically.  Oxygen  may  be  classed  with  the  respiratory 
stimulants.  It  should  be  given  continuously,  but  always  freely  mixed  with 
atmospheric  air.  A  good  method  is  to  place  the  child  in  a  half-open  tent, 
beneath  which  the  gas  is  introduced.  Gentle  friction  of  the  chest  wall, 
without  disturbing  the  patient,  is  sometimes  useful  in  stimulating  the 
respiratory  muscles,  especially  in  protracted  cases. 

Antipyretics. — It  must  be  remembered  that  the  normal  range  of  tem- 
perature in  broncho-pneumonia  is  from  101°  to  104-5°  F.  This  tempera- 
ture is  not  in  itself  exhausting,  and  the  chances  of  recovery  are  not,  I 
think,  improved  by  systematic  efforts  at  reducing  it  so  long  as  it  re- 
mains within  these  limits.  Too  much  can  not  be  said  in  condemnation 
of  the  practice  of  giving  such  drugs  as  phenacetine,  antipyrine,  and  anti- 
febrine  in  full  doses  for  the  reduction  of  temperature.  In  small  doses 
they  are  often  useful  to  allay  nervous  irritability,  restlessness,  and  pro- 
mote sleep.  Quinine  can  not  be  considered  an  antipyretic  in  pneumonia 
except  in  cases  complicated  by  malaria.  Otherwise  it  does  little  if  any 
good,  and  often  great  harm,  by  disturbing  the  stomach. 

Antipyretic  measures  are  indicated  in  cases  of  hyperpyrexia,  which  we 
may  define  as  105°  F.  or  over,  or  when  extreme  nervous  symptoms  exist, 
even  though  the  thermometer  may  not  register  the  degree  mentioned. 
Under  these  circumstances,  the  most  certain,  the  most  within  our  control, 
and  hence  the  safest  antipyretic,  is  cold.  It  may  be  used  by  the  gradu- 
ated bath,  the  cold  pack  (pages  47,  48),  sponging,  or  an  ice-bag  applied  to 
the  chest. 

The  most  convenient  and  efficient  methods  of  using  cold  are  the  bath 
and  the  cold  pack — the  bath  for  infants,  and  the  pack  for  older  children. 
The  peripheral  circulation  should  be  closely  watched,  and  maintained  by 
friction  of  the  body  during  the  bath,  and  the  application  of  heat  to  the  ex- 
tremities immediately  after  it.  In  most  cases  the  bath  should  be  preceded 
by  stimulants.  The  effects  are  often  very  striking  ;  when  there  have  been 
a  flushed  face,  hot  dry  skin,  extreme  restlessness,  and  muscular  twitchings, 
34 


512  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

all  these  symptoms  may  subside  rapidly  and  a  quiet  sleep  follow.  The 
bath  should  be  repeated  as  soon  as  these  symptoms  return,  whether  the 
thermometer  has  risen  to  its  former  height  or  not.  When  with  hyper- 
pyrexia we  have  general  cyanosis,  cold  surface,  feeble  i:»ulse,  shallow  respi- 
ration, and  stupor,  cold  is  contraindicated  and  a  hot  mustard  bath  should 
be  used. 

InJialations. — These  are  of  more  v;ilue  in  relieving  cough  and  in  pro- 
moting bronchial  secretion  than  any  other  means  we  possess.  At  the  same 
time,  they  seem  often  to  have  a  beneficial  influence  upon  the  local  process. 
They  are  useful  in  proportion  to  the  amount  of  bronchitis  which  is  pres- 
ent. The  same  substances  are  to  be  used,  and  in  the  same  way  as  men- 
tioned in  the  article  on  Bronchitis. 

The  nervous  symptoms,  restlessness,  loss  of  sleep,  etc.,  are  often  best 
controlled  by  cold  or  tepid  sponging ;  in  other  cases  by  small  doses  of 
phenacetine — i.  e.,  one  grain  every  two  hours  to  a  child  of  six  months. 
Opium  is  to  be  avoided  unless  there  is  severe  pain,  which  is  very  rare ; 
or,  when  the  incessant  cough  is  not  relieved  by  inhalations.  Dover's 
powder  is  the  preparation  to  be  preferred,  and  an  occasional  dose  of  a 
quarter  of  a  grain  usually  all  that  is  necessary. 

Sudden  attacks  of  general  collapse  with  cyanosis  are  frequent  in  severe 
cases  of  broncho-pneumonia.  They  may  come  on  at  any  period  in  the 
disease.  When  occurring  in  the  early  stage,  if  promptly  and  energetically 
treated,  recovery  may  take  place,  but  when  they  come  on  in  the  late 
stages  they  are  usually  fatal.  They  may  be  due  to  acute  congestion  or 
oedema  of  the  lung  not  previously  involved.  The  most  eflficient  treatment 
is  to  put  the  child  into  a  hot  mustard  bath  (page  54),  to  use  strychnine 
and  nitroglycerin  hypodermically,  and  to  give  oxygen  continuously.  For 
a  few  hours  alcohol  should  be  given  ad  libitum.  Nitrite  of  amyl  is  some- 
times more  eflficient  than  nitroglycerin,  because  of  its  almost  instantaneous 
effect.  I  must  confess  to  have  seen  very  little  benefit  from  the  use  of 
camphor,  although  many  excellent  observers  esteem  it  very  highly. 

Treatment  of  protracted  cases. — Where  the  fever  continues  for  five 
or  six  weeks,  with  no  disposition  on  the  part  of  the  disease  to  subside, 
about  all  that  can  be  done  is  to  continue  the  sustaining  treatment  adopted 
in  the  earlier  part  of  the  disease — careful  feeding,  judicious  stimulation, 
and  proper  hygienic  means.  Many  of  these  cases  will  recover  if  the  pa- 
tient's strength  holds  out ;  but,  unfortunately,  in  the  majority  the  continu- 
ance of  the  pneumonic  process  is  in  itself  evidence  of  the  weakened  vital- 
ity of  the  patient,  and,  though  he  may  live  a  long  time,  the  attack  proves 
fatal  in  the  end. 

Where  the  fever  has  disappeared,  and  there  is  only  a  persistence  of 
the  physical  signs  and  the  general  cachexia,  the  cases  are  more  hopeful. 
Here,  a  change  of  air  is  more  important  than  all  other  means  of  treatment. 
If  in  the  winter  or  spring  the  child  can  be  removed  to  a  warm,  dry  cli- 


ACUTE   BRONCHO-PNEUMONIA.  513 

mate  where  it  can  be  kejjt  in  the  open  air,  or  if,  in  the  summer,  it  can  be 
taken  to  the  mountains,  immediate  improvement  is  often  seen,  followed 
by  rapid  recovery.  This  experience  we  see  repeated  every  year  with  hos- 
pital patients  when  they  are  transferred  from  the  city  to  the  country 
in  May  or  June.  With  the  change  of  air  a  general  tonic  plan  of  treat- 
ment should  be  followed,  cod-liver  oil,  arsenic,  iron,  and  quinine  being 
used,  according  to  the  indications  in  each  particular  case. 

In  specific  drugs  to  promote  resolution  I  have  no  faith.  Where  the 
cough  continues,  creosote  may  be  used  both  internally  and  by  inhalation, 
as  after  bronchitis.  One  should  never  declare  one  of  these  cases  of  pro- 
tracted pneumonia  to  be  hopeless,  nor  should  he  be  too  ready  to  assume 
that  tuberculosis  is  present  because  the  child  is  wasted  and  anaemic,  and 
the  physical  signs  have  persisted.  In  private  practice  the  cases  of  simple 
protracted  pneumonia  outnumber  the  tuberculous  ones,  three  to  one. 

Summary. — In  the  treatment  of  broncho-pneumonia  it  should  be 
borne  in  mind  that,  while  very  little  can  be  done  for  the  disease,  very 
much  can  be  done  for  the  patient.  The  hygienic  measures  generally 
grouped  under  the  term  "  careful  nursing  "  are  of  great  importance,  and 
many  of  the  mild  cases  need  no  other  treatment.  In  severe  cases,  the 
patient  may  be  in  great  danger  in  the  early  stage  from  two  causes  :  first, 
from  the  intensity  of  the  general  infection,  which  is  best  combatted  by  the 
use  of  alcohol  and  strychnia ;  and,  secondly,  from  the  mechanical  embar- 
rassment of  the  heart  and  respiration,  in  consequence  of  the  sudden  inter- 
ference with  the  function  of  the  lungs,  partly  from  inflammation,  but 
chiefly  from  congestion ;  this  is  best  relieved  by  counter-irritation  to  the 
chest  and  heat  to  the  extremities.  During  the  later  stage  the  principal 
danger  is  from  exhaustion ;  this  forbids  the  use  of  all  depressing  meas- 
ures, and  necessitates  the  most  careful  attention  to  the  nutrition  of 
the  patient  throughout  the  disease.  All  unnecessary  medication  is  to  be 
avoided,  particularly  the  use  of  expectorant  mixtures,  on  account  of  the 
disturbance  of  the  stomach.  Opium  is  to  be  used  very  sparingly,  and  in 
most  cases  it  should  be  withheld  altogether.  The  cough  is  best  relieved 
by  inhalations  of  creosote,  and  the  nervous  symptoms  by  phenacetine  or 
baths.  For  local  use,  the  oiled-silk  jacket  is  better  than  poultices.  Coun- 
ter-irritation by  mustard  should  be  continued  throughout  the  attack, 
when  there  is  much  bronchitis.  Where  antipyretics  are  required,  cold  is 
safer  and  more  efficient  than  the  use  of  drugs.  Of  the  cardiac  stimulants, 
alcohol  and  strychnia  are  most  to  be  depended  upon.  Care  should 
be  taken  in  all  cases  to  maintain  a  good  peripheral  circulation.  In  sudden 
general  collapse,  the  most  valuable  measures  are  hot  mustard  baths, 
strychnia  hypodermically,  alcohol  freely  by  the  mouth,  and  the  inhala- 
tion of  oxygen.  In  protracted  cases,  and  in  those  with  delayed  resolution, 
change  of  air  is  more  important  than  all  other  means  combined. 


514 


DISEASES  OF   THE   RESPIRATORY   SYSTEM. 


CHAPTER   V. 
DISEASES  OF  THE  J.UN OS.— {Continued.) 

LOBAR   PNEUMONIA. 

Synonyms :  Fibrinous  pneumonia,  croupous  pneumonia,  pneumonic  fever. 

With  our  present  knowledge,  this  may  be  best  defined  as  an  iiifectious 
disease,  caused  by  the  micrococcus  lanceohitus  (pneumococcus)  and  ac- 
companied by  a  local  lesion  in  the  lungs.  While  in  most  cases  the  gen- 
eral symptoms  correspond  with  the  extent  and  severity  of  the  local  lesion, 
they  may  be  out  of  all  proportion  to  each  other. 

Etiology. — Age. — Lobar  pneumonia  may  occur  at  any  age.  I  have 
recently  seen  a  case  in  an  infant  of  three  months  which  followed  the  typi- 
cal course.  It  may  be  seen  even  in  the  newly  born,  but  it  is  not  until 
after  the  second  year  that  it  begins  to  be  frequent.  After  the  third  year 
nearly  all  the  cases  of  primary  pneumonia  are  of  this  variety.* 

Of  160  personal  cases,  and  340  collected  from  various  sources,  the  ages 
were  as  follows : 


Age. 

Cases. 

Per  cent. 

Durinc^  the  first  year 

76 
309 
104 

11 

15 

From  the  second  to  tlie  sixth  year 

"        "    seventh  to  the  eleventh  year 

63 

31 

"       "    twelfth  to  the  fourteenth  year 

2 

Totals 

500 

100 

The  greatest  susceptibility  appears  to  be  from  the  second  to  the  sixth 
year,  and  during  this  period  it  is  most  frequent  from  the  third  to  the  fifth 
year. 

Sex. — Of  my  own  cases,  60  per  cent  were  males,  and  the  same  pro- 
portion was  noted  in  544  collected  cases.  This  predominance  of  males 
has  been  everywhere  observed,  but  is  as  yet  unexplained. 

Season. — In  my  series  of  cases,  the  seasons  were  divided  as  follows  : 


Cases. 

Per  cent. 

In  the  three  winter  months  . .    

48 

62 

6 

20 

35 

"        "      sprinsr       "        

46 

"         "      summer    "        

4 

"        "      autumn     " 

15 

Totals 

136 

100 

*  For  the  relative  frequency  of  broncho-  and  lobar  pneumonia  during  infancy,  see 
the  table  on  p.  479. 


LOBAR    PNEUMONIA. 


515 


Lobar  pneumonia,  in  children  therefore,  as  in  adults,  occurs  most  fre- 
quently during  the  spring  months.  April  showed  the  largest  number  of 
any  single  month. 

Previous  condition. — In  my  hospital  cases,  83  per  cent  of  the  children 
were  previously  in  good  condition,  and  only  18  per  cent  were  delicate, 
rachitic,  or  syphilitic.  This  observation  has  been  borne  out  by  my  ex- 
perience in  private  practice — viz.,  that  as  a  rule  lobar  pneumonia  affects 
children  who  were  previously  healthy. 

Previous  disease. — Previous  attacks  of  pneumonia  are  observed  in  but 
a  small  proportion  of  cases.  It  was  noted  only  five  times  in  160  cases. 
In  the  vast  majority  of  cases  lobar  pneumonia  is  a  primary  disease, 
although  it  occasionally  occurs  as  a  complication  of  pertussis,  measles, 
typhoid  or  scarlet  fever,  and  even  diphtheria — chiefly,  however,  in  chil- 
dren over  three  years  old. 

Epidemics  of  lobar  pneumonia  I  have  never  witnessed,  although 
on  several  occasions  I  have  seen  two  children  in  a  family  attacked  either 
simultaneously  or  in  rapid  succession.  Exhaustion,  fatigue,  and  exposure 
are  to  be  ranked  as  associated  exciting  causes. 

In  addition  to  other  causes,  there  is  required  for  the  production  of  the 
disease  the  presence  and  growth  of  the  pneumococcus. 

Lesions. —  Tlie  seat  of  the  disease. — In  950  cases  in  children  under 
fourteen  years,  this  was  as  follows : 


Seat  of  Disease. 

Personal 
cases. 

Collected 
cases. 

Totals. 

Right  lung,  upper  lobe  only 

"          "      middle  "      "     

39 

8 
26 
13 

137 
4 

142 
64 

176 
12 

"          "      lower      "      "     

168 

"          "      more  than  one  lobe 

77 

Totals,  right  lung 

86 

347 

433 

Left  lung,  upper  lobe  only 

25 

49 

9 

68 

214 

29 

93 

"        "      lower      "      "    

263 

"        "     more  than  one  lobe 

38 

Totals,  left  lung 

88 

311 

394 

Both  lungs,  upper  lobes 

3 
9 

13 
38 
60 

13 

"        "       lower     "     

41 

"        "       elsewhere 

69 

Totals,  both  lungs 

12 

111 

123 

The  right  lung  was  thus  affected  in  45'5  per  cent ;  the  left  lung  in 
415  per  cent;  both  lungs  in  13  per  cent.  In  the  order  of  frequency,  the 
disease  involves,  first,  the  left  base  ;  second,  the  right  apex ;  third,  the 
right  base;  fourth,  the  left  apex.  The  disease  affects,  as  a  rule,  a  single 
lobe,  and  often  only  a  circumscribed  portion  of  a  lobe,  stopping  sharply 

at  the  interlobar  fissure. 

34* 


516  DISEASES  OF  THE   RESPIRATORY  SYSTEM. 

Lobar  pneumonia  among  children  is  so  rarely  fatal  that  the  oppor- 
tunities for  a  study  of  the  peculiarities  of  the  lesion  have  been  somewhat 
limited.  I  have  myself  made  eleven  autopsies,  and  have  among  my  hos- 
pital records  reports  of  nine  others,  making  twenty  cases  in  all.  The 
anatomical  changes  resemble  those  seen  in  the  adult  lung.  There  is  an 
exudation  into  the  alveoli  and  smaller  bronchi  of  fibrin,  serum,  leucocytes, 
and  red  blood-cells  (Fig.  73).  There  is  usually  in  addition  an  in- 
flammation of  the  mucous  membrane  of  the  larger  bronchi  and  of  the 
pleura.  The  frequency  and  severity  of  the  pleurisy  is  a  peculiarity  of  the 
lesion  in  children. 

In  the  first  stage,  that  of  congestion,  tlie  portion  of  lung  involved  is 
dark-coloured,  heavy,  and  oedematous,  and  shows  under  the  microscope  a 
serous  and  cellular  exudation  into  the  air  vesicles,  with  swelling  of  the 
epithelial  cells  lining  the  alveoli. 

In  the  second  stage,  that  of  red  hepatization,  there  is  usually  some  ex- 
udation upon  the  pulmonary  pleura,  generally  a  thin  layer  of  fibrin,  giving 
it  a  dull,  granular  look.  The  lung  itself  is  of  a  uniform  dark-red  colour. 
It  is  solid,  and  cuts  like  liver.  It  looks  as  if  it  had  been  inflated  to  its 
utmost  extent  and  then  injected  with  a  material  which  had  solidified.  The 
consolidated  area  is  sharply  defined.  Under  the  microscope  the  air  vesi- 
cles are  seen  to  be  distended  with  an  exudation  which  is  chiefly  fibrin, 
but  with  some  leucocytes,  red  blood-cells,  and  desquamated  epithelial  cells. 
The  cells  are  chiefly  leucocytes,  and  are  usually  more  abundant  than  in 
the  pneumonia  of  adults. 

In  the  third  stage,  or  gray  hepatization,  the  lung  is  more  moist,  and 
the  inflammatory  products  are  partly  decolourized.  This  change  takes 
place  irregularly  throughout  the  lung,  giving  it  a  mottled  appearance. 

The  fourth  stage,  that  of  resolution,  follows  gray  hepatization,  and 
consists  in  the  degeneration  and  liquefaction  of  the  products  of  inflamma- 
tion, which  are  ultimately  carried  away  by  the  lymphatics,  or  pushed  out 
into  the  bronchi  and  removed  by  coughing. 

The  duration  of  the  stage  of  congestion  is  from  a  few  hours  to  several 
days ;  that  of  the  stage  of  red  hepatization  from  two  days  to  two  or  three 
weeks.  This  is  the  condition  in  which  the  lung  is  most  often  seen  at 
autopsy.  The  stage  of  gray  hepatization  is  commonly  shorter.  Resolu- 
tion usually  begins  when  the  temperature  falls  to  normal,  but  occasionally 
it  may  be  delayed  for  several  days.  It  is  generally  complete  in  about 
a  week. 

Variatio7is  in  the  lesions.— (1.)  Instead  of  clearing  up  at  the  usual  time, 
the  lung  may  remain  consolidated  for  several  weeks,  and  then  resolve. 
(2.)  The  stage  of  gray  hepatization  may  be  followed  by  a  great  exudation 
of  pus  cells,  which  may  everywhere  infiltrate  the  affected  lung ;  or  these 
may  be  circumscribed  so  as  to  form  a  single  large  abscess  or  many  small 
ones.     (3.)  There  may  be  small  areas  of  gangrene.     All  these  conditions 


LOBAR    PNEUMONIA.  51 7 

are  very  rare  in  children.  Purulent  infiltration  and  delayed  resolution 
were  not  noted  in  any  of  my  cases,  and  gangrene  but  once.  (4.)  There 
may  be  excessive  pleurisy,  or  pleuro-pneumonia.  This  was  found  in  one 
half  of  my  autopsies.     These  cases  will  be  separately  considered  elsewhere. 

Lesions  in  otlier  organs. — With  pneumonia  of  the  left  side,  if  compli- 
cated by  pleurisy,  there  may  also  be  pericarditis.  This  was  seen  in  two 
of  my  cases.  The  pericardial  inflammation  closely  resembled  that  of  the 
pleura.  There  was  a  very  abundant  exudation  of  fibrin  and  pus,  coating 
both  surfaces  of  the  pericardium.  Acute  meningitis  has  been  rarely 
observed.  It  was  met  with  twice  in  my  cases.  The  form  of  inflammation 
was  an  acute  purulent  meningitis,  with  a  very  abundant  exudation  of 
greenish-yellow  lymph,  chiefly  at  the  convexity.  In  one  of  my  cases  peri- 
tonitis was  also  seen  as  a  complication  of  pleuro-pneumonia.  As  the 
pneumococcus  is  found  in  all  these  inflammations,  they  may  be  regarded 
as  examples  of  a  more  generalized  infection  than  usually  occurs.  In  most 
of  these  the  other  processes  are  secondary  to  that  in  the  lungs,  but  some- 
times they  begin  simultaneously  with,  or  may  even  precede,  the  pulmo- 
nary lesion. 

The  heart  is  generally  found  in  diastole,  with  the  cavities,  especially 
those  of  the  right  side,  distended  with  soft  clots.  There  may  be  found 
ante-mortem  thrombi,  which  may  extend  into  the  pulmonary  artery  or 
the  aorta. 

Symptoms. — (1.)  Tlie.  tyjncal  course. — A  child  three  or  four  years  of  age, 
after  a  few  hours  of  slight  indisposition,  is  suddenly  taken  with  vomiting, 
followed  by  a  rapid  rise  in  temperature.  He  is  dull  and  heavy,  complains 
of  headache  and  general  weakness,  refuses  food,  and  is  easily  persuaded  to 
remain  in  bed.  He  has  the  appearance  of  being  quite  ill,  even  after  a  few 
hours.  Occasionally  sharp  pain  in  the  side  is  complained  of.  The  skin  is 
dry;  there  are  marked  thirst,  restlessness,  and  the  other  symptoms  which 
accompany  fever.  The  temperature  is  found  to  be  104°  F.,  or  even  higher ; 
the  respirations  40  to  50  a  minute ;  the  pulse  full,  strong,  and  120  to  130. 
On  the  second  day  the  patient  is  no  better.  The  temperature  remains 
high ;  the  tongue  is  coated ;  the  anorexia  continues ;  the  pain  is  more 
severe ;  cough  is  present  and  may  be  quite  frequent. 

After  the  second  or  third  day  the  patient  is  usually  more  comfortable, 
and  sleeps  better,  but  may  be  disturbed  by  the  cough.  At  times  there  is 
restlessness,  and  at  night  there  may  even  be  slight  delirium.  The  respi- 
ration continues  rapid  and  the  temperature  high.  These  general  symp- 
toms show  very  little  change  until  the  sixth  or  seventh  day,  when,  after  a 
long  sleep,  which  has  been  more  natural  than  before,  the  patient  wakes, 
decidedly  improved  as  to  all  his  symptoms.  There  is  less  fever,  and  the 
temperature  continues  to  fall  rapidly  until  it  touches  the  normal  line,  or 
it  may  even  go  below  this.  As  the  fever  subsides  the  pulse  drops  to  90  or 
100,  and  the  respirations  to  25  or  30  a  minute.    The  appetite  soon  returns, 


518  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

and  convalescence  is  usually  rapid.  In  a  week  the  patient  is  out  of  bed, 
and  in  a  month  from  the  beginning  of  the  illness  he  is  out  of  doors ;  but 
it  may  be  another  month  before  he  can  be  considered  to  have  entirely  re- 
covered. This  is  the  course  seen  in  fully  two  thirds  of  all  the  cases  of 
lobar  pneumonia  at  this  age. 

(2.)  Pneumonia  of  short  duration. — Instead  of  running  the  usual 
course  of  from  five  to  eight  days,  cases  are  seen  in  which  the  duration  is 
only  three  or  four  days,  although  the  physical  signs  indicate  that  the 
process  in  the  lung  passes  through  the  usual  stages.  These  are  the  cases 
of  short  pneumonia,  and  they  differ  from  the  ordinary  type  chiefly  in  their 
duration.     They  are  always  mild. 

(3.)  Abortive  pneumonia. — This  form  of  the  disease  is  rarely  seen  in 
hospitals,  but  it  is  not  infrequent  in  private  practice  where  the  physician 
is  summoned  at  the  earliest  signs  of  illness.  The  onset  is  precisely  like 
that  of  ordinary  pneumonia,  and  may  even  be  as  severe  as  the  average 
case.  The  physical  examination  of  the  chest  gives  all  the  signs  of  the 
first  stage  of  the  disease,  but  on  the  second  or  third  day  the  physician  is 
greatly  surprised  to  find  that  the  temperature  has  fallen  to  normal,  and 
that  all  the  physical  signs  have  disappeared.  The  process  in  such  cases 
does  not  seem  to  go  beyond  the  first  stage  of  congestion ;  there  is  no  evi- 
dence of  hepatization  of  the  lung.  The  course  is  often  such  as  to  lead 
the  physician  to  the  opinion  that  he  has  made  a  mistake  in  his  diagnosis. 
There  seems,  however,  to  be  no  doubt  that  these  are  cases  of  genuine 
pneumonia.  D'Espine  found  the  pueumococcus  in  the  sputum  of  such 
a  case.  This  type  of  pneumonia  corresponds  with  abortive  types  of  other 
infectious  diseases  so  frequently  met  with  in  children.  The  temperature 
curve  in  such  a  case  is  shown  in  Fig.  95,  page  521.  The  diagnosis  of  these 
cases  is  always  attended  with  some  uncertainty.  There  can  be  no  doubt 
that  very  many  of  the  unexplained  high  temperatures  of  brief  duration 
which  are  seen  in  children  are  from  this  cause.  Exactly  why  the  disease 
terminates  in  this  way  is  not  known.  It  may  be  because  the  resistance 
of  the  patient  is  greater  than  usvial,  or  the  virulence  of  the  jjneumococcus 
is  less. 

(4.)  The  2}rolonged  course. — Although  usually  lasting  about  a  week,  it 
is  not  rare  for  j^neumonia  to  continue  ten,  twelve,  or  even  fifteen  days. 
This  prolonged  course  is  often  due  to  the  fact  that  the  disease  spreads 
from  one  part  of  the  lung  to  another,  involving  in  succession  two  and 
sometimes  three  lobes ;  but  it  may  occur  when  the  process  is  limited  to 
a  single  lobe.  A  prolonged  temperature  should  always  suggest  the  pos- 
sibility of  complications,  usually  pleurisy.  Prolonged  cases  are  generally 
severe. 

(5.)  Cerebral  pneumonia. — This  term  was  first  applied  by  Eilliet  and 
Barthez  to  cases  of  pneumonia  in  wliich  the  cerebral  symptoms  predomi- 
nated.    They  will  be  considered  under  special  symptoms. 


LOBAR   PNEUMONIA.  5I9 

Onset. — Prodromal  symptoms  of  more  than  a  few  hours'  duration  are 
quite  rare.  The  onset  of  lobar  pneumonia  is  almost  invariably  sudden, 
with  well-marked  symptoms — vomiting,  diarrhoea,  chill,  or  convulsions. 
Vomiting  is  altogether  the  most  frequently  seen.  It  was  the  mode  of 
onset  in  about  one  half  my  cases.  In  summer  particularly,  there  may  be 
vomiting  and  diarrhoea.  A  distinct  chill  is  rare  in  a  child  under  five 
years  of  age,  and  is  not  very  common  even  in  older  children.  Convul- 
sions are  not  very  infrequent,  being  seen  in  about  five  per  cent  of  the 
cases.  Their  occurrence  depends  upon  the  suddenness  of  the  invasion 
and  the  susceptibility  of  the  patient. 

Cough. — This  is  present  in  most  of  the  cases  throughout  the  disease, 
but  often  is  not  marked  for  the  first  day  or  two.  It  ia  seldom  a  distress- 
ing symptom.  A  disposition  to  suppress  the  cough  on  account  of  pain  is 
very  frequently  noticed. 

Expectoration. — This  is  rarely  seen  in  childhood,  and  practically  never 
under  five  years  of  age.  Children  of  ten  or  twelve  may  have  the  same 
expectoi'ation  as  adults — white  and  viscid,  or  brownish-red  early  in  the 
disease,  yellow  and  abundant  toward  its  close. 

Pain. — Headache  and  general  muscular  pains  in  the  back  and  extremi- 
ties are  frequent  during  the  invasion.  The  characteristic  pain,  however, 
is  pleuritic.  It  is  not  necessarily  felt,  in  the  region  of  the  affected  lung, 
and  often  not  in  the  chest  at  all.  It  is  frequently  referred  to  the  loin,  the 
epigastrium,  or  to  any  region  to  which  the  intercostal  nerves  are  distrib- 
uted. In  a  recent  case,  in  a  boy  of  seven  years,  for  the  first  twelve  hours 
there  was  intense  localized  pain  in  the  right  iliac  fossa,  associated  with 
such  extreme  tenderness  as  to  lead  to  the  susj^icion  that  the  case  was  one 
of  appendicitis.  The  pain  may  last  throughout  the  disease,  and  occasion- 
ally it  is  a  most  distressing  symjitom  ;  but  usually  it  is  only  moderate,  and 
rather  more  severe  early  than  late  in  the  disease. 

Prostration. — This  is  one  of  the  characteristic  features  of  pneumonia. 
The  patient  is  generally  willing  to  go  to  bed  on  the  first  day  of  the  attack, 
and  shows  little  desire  to  leave  it  while  the  disease  continues.  "  Walking 
cases  "  are  not  common  in  children. 

Respiration. — This  is  always  accelerated,  and  generally  out  of  propor- 
tion to  the  pulse.  The  normal  ratio  of  the  respiration  to  the  pulse  is  one 
to  four;  in  pneumonia,  frequently  one  to  two.  The  respiration  is  not 
laboured  and  not  quite  panting,  although  this  term  is  sometimes  used 
to  describe  it.  It  is  jerky.  There  is  a  short  inspiration,  then  a  momen- 
tary pause,  followed  by  a  quick  expiration,  which  is  accompanied  by  a  short 
moan.  This  expiratory  moan  is  very  characteristic.  The  rapidity  of  res- 
piration is  usually  in  proportion  to  the  amount  of  lung  involved,  but  it  is 
also  modified  by  the  temperature,  as  the  respirations  often  drop  from  GO 
to  30  in  the  course  of  a  few  hours  at  the  crisis. 

Pulse. — In  the  early  part  of   the  disease  this  is  frequent,   full,  and 


520 


DISEASES   OF   THE   RESPIRATORY  SYSTEM. 


strong,  from  110  to  140  a  minute.  Later  it  may  be  weak,  small,  com- 
pressible, and  sometimes  irregular.  It  is. relatively  more  rapid  in  the  child 
than  in  the  adult.  The  frequency  of  the  pulse  is  of  less  importance  than 
its  character. 

Temperature. — The  typical  temperature  curve  of  lobar  pneumonia 
(Fig.  92)  is  characterized  by  an  abrupt  rise  usually  to  104°  or  105°  F.,  and 
by  daily  fluctuations  generally  within  the  limits  of  two  or  three  degrees 


105° 
101'- 
103° 
102° 
i01° 
100° 
99° 

1 

2 

3 

i 

5 

6 

7 

8 

A 

n 

/ 

r 

f 

A 

J 

'  /t 

- 

V 

, 

AA 

98° 

t? 

Fig.  92. — Typical  temperature  curve  of  lobar  pneumonia. 

Hidory. — Male,  three  years  old  ;  in  fair  condition ;  sudden  onset ;  sisrns  of  consolidation — 
bronchial  respiration  and  voice,  and  dulness — over  left  lower  lobe  behind,  not  distinct  until 
the  morning  of  the  fifth  day.     On  the  seventh  day  the  lung  was  resolving. 

until  the  crisis,  at  which  time  the  temperature  falls  to  normal,  usually  in 
the  course  of  twenty-four  hours.  After  this  time  it  does  not  go  above  the 
normal  line.  Such  a  curve  is  seen  in  the  majority  of  cases  over  three 
years  of  age. 

In  cases  under  three  years  of  age  it  is  not  uncommon  for  the  tempera- 
ture to  be  of  a  more  or  less  remittent  type  (Fig.  93). 


107° 

1 

2 

3 

i 

5 

6 

- 

8 

9 

10 

11 

12 

13 

11 

15 

16 

17 

18 

19 

20 

106° 
105° 
104" 
103° 
102° 
101° 
100° 
99° 

. 

A 

. 

\ 

k 

A 

/ 

'X 

1 

f 

\ 

/ 

\ 

A 

r 

\ 

1 

1  / 

1 

[I 

y  1 

\ 

/ 

1 

^' 

I 

V 

~1 

, 

98° 
97° 

\, 

^K.^ 

--* 

h^ 

V 

Y 

Fig.  93. — Lobar  pneumonia  with  remittent  temperature. 

Histori/.—Vemale,  eighteen  months  old;  in  fair  condition;  sudden  onset ;  repeated  exami- 
nations of  chest  made,  but  no  abnormal  signs  until  the  ninth  day,  when  there  were  very  rude 
respiration  and  slight  dulness  at  the  right  apex,  in  front ;  on  the  twelfth  day  all  the  signs  of 
consolidation  at  the  same  point,  no  rales ;  four  days  after  the  crisis  the  lungs  were  clear. 


These  wide  fluctuations  often  lead  to  great  difficulty  in  diagnosis,  par- 
ticularly if  the  physical  signs  appear  late,  as  they  not  infrequently  do.  It 
is  possible  that  some  of  them  are  to  be  explained  by  mixed  infection. 

The  following  chart  (Fig.  94)  illustrates  three  features  which  are 
often  seen  in  pneumonia  :  (1)  A  temperature  which  early  in  the  disease  is 
steadily  high  and  as  the  day  of  crisis  approaches  becomes  remittent ;  (2) 
a  secondary  rise  after  being  normal  for  twenty-four  hours,  which  was  due 


LOBAR    PNEUMONIA. 


521 


in  this  instance  to  an  extension  of  the  disease  to  a  new  part  of  the  lung ; 
(3)  a  fall  to  a  point  considerably  below  normal  at  the  time  of  the  crisis. 
In  this  case  the  temperature  fell  in  the  course  of  eighteen  hours  from 


J07° 

T 

!J 

3 

i 

5 

« 

7 

8 

9 

10 

11 

12 

13 

11 

15 

16 

17 

18 

19 

20 

106° 
105° 
101° 
103° 
102° 
101° 
100" 
<I9° 

1 

/ 

n 

A 

- 

. 

A 

1 

/> 

n 

\ 

1 

1 

1 

V 

1 

/ 

V 

S 

\ 

'' 

, 

1 

98° 
97  • 
96° 
95° 
91° 

1 

A 

N 

A 

^ 

r 

>r 



Fig.  94. — Lobar  pneumonia  with  subnormal  temperature  after  the  crisis. 

History. — Female,  nineteen  months  old ;  fairly  healthy ;  sudden  onset ;  symptoms  tj'pical 
but  physical  signs  delayed ;  consolidation  in  left  mammary  region  on  the  eighth  day ;  on  the 
ninth  in  right  lung  middle  lobe ;  on  the  eleventh  day  a  pseudo-critical  drop,  followed  after 
twenty-four  hours  of  apyrexia  by  a  further  rise,  which  was  accompanied  by  signs  of  extension 
of  the  disease  in  the  right  lung.     Resolution  rapid  after  crisis. 

105°  to  95°  F.,  and  later  still  lower;  it  was  two  days  before  it  finally  re- 
mained at  the  normal  point.  A  fall  to  96-5°  or  97°  F.  at  the  time  of  crisis 
is  not  uncommon. 

In  the  foregoing  cases  the  fever  terminated  by  crisis.  In  Fig.  95  is 
shown  one  ending  by  lysis.  This  is  a  mode  of  termination  much  more 
frequent  in  young  children  than  in  those  who  are  older.    Thus,  in  ninety- 


106^ 
105^ 
104° 
103' 
102' 
101° 
100' 
99  ' 

1 

2 

3 

1 

5 

6 

7 

8 

9 

10 

11 

12 

13 

11 

15 

16 

17 

y 

^ 

l\ 

V 

V 

/ 

- 

w 

^ 

v 

A 

\ 

\ 

/ 

\. 

U 

J 

\^ 

/- 

\^ 

98' 

" 

^ 

^ 

Fig.  95. — Abortive  pneumonia  in  left  lung,  followed  by  typical  pneumonia  in  right  lung,  ter- 
minating by  lysis. 

History.— W&\e,  seventeen  months  old;  healthy  ;  sudden  onset;  on  the  second  day  dissemi- 
nated fine  rales  in  both  lungs  behind,  and  over  left  lower  very  feeble  respiration,  high-pitched 
— i.  e..  some  bronchitis,  with  congestion  (?)  of  left  base.  On  the  third,  fourth,  and  fifth  days, 
general  symptoms  gone  and  signs  nearly  disappeared.  On  the  sixth  day  all  symptoms  of  pneu- 
monia, and  on  the  seventh  distinct  consolidation  of  right  base,  rest  of  chest  clear.  Subsequent 
course  typical ;  resolution  rapid  and  complete. 


three  of  my  own  cases,  nearly  all  of  which  were  under  three  years  of  age, 
the  fever  ended  by  crisis  in  forty-nine,  and  by  lysis  in  forty-four ;  while 
in  five  hundred  and  twenty-two  collected  cases,  the  majority  of  which 
were  in  older  children,  three  hundred  and  ninety-six  ended  by  crisis,  and 
one  hundred  and  twenty-six  by  lysis. 


522  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

The  following  table  shows  the  day  of  crisis  in  five  hundred  and  sixty- 
seven  cases  of  lobar  pneumonia  in  children  who  recovered  : 

The  Day  of  Crisis. 


Second  day 3  cases. 

Third      "    23  " 

Fourth    "    43  " 

Fifth       '•    88  " 

Sixth       '•    83  " 

Seventh  "    132  " 

Eighth    '•    73  " 

Ninth      "    55  '^ 

Tenth      "    22  " 


Eleventh  day 18  cases. 

Twelfth      ""   7      " 

Thirteenth  day 8      " 

Fourteenth  "    7      " 

Fifteenth      "    1  case. 

Eighteenth   "    3  cases. 

Twenty-first  day 1  case. 

Twenty-sixth  "    1     " 

5G7 


From  this  table  it  will  be  seen  that  the  most  frequent  critical  day  is 
the  seventh,  and  that  in  66  per  cent  of  the  cases  it  was  from  the  fifth  to 
the  eighth  day.  The  causes  of  a  jDOst-critical  rise  in  the  temperature  are 
chiefly  two — extension  of  the  disease  to  a  new  area,  or  the  development 
of  pleurisy,  which  is  apt  to  be  purulent.  Less  frequently  it  is  due  to 
meningitis,  pericarditis,  gastro-euteritis,  or  malaria.  In  fatal  cases  the 
temperature  is  generally  high  until  the  end.  In  general,  it  may  be  said 
that  the  temperature  is  considerably  higher  in  children  than  in  adults ; 
in  the  majority  of  cases  it  reaches  105°  F.,  the  usual  range  being  from 
102°  to  105°  F.  In  fifteen  of  one  hundred  and  thirty-seven  cases,  or  11 
per  cent,  it  reached  106"  F.  or  over. 

Gastro-enteric  symptoms. — These  are  more  common  in  infants  than  in 
older  children.  At  the  onset  there  is  frequently  vomiting,  sometimes 
also  diarrhoea.  A  continuance  of  the  vomiting  is  rare,  and  is  generally 
due  to  improper  feeding  or  medication.  It  may  be  a  very  serious  com- 
plication. Diarrhoea  is  also  rare,  except  at  the  onset  and  in  summer  cases. 
It  is  sometimes  seen  at  the  time  of  crisis.  Throughout  the  disease  there 
are  anorexia,  coated  tongue,  and  the  usual  symptoms  of  high  fever. 

Nervous  symptoms. — Cerebral  symptoms  are  frequent  and  very  often 
misleading.  In  seven  of  my  cases  the  pneumonia  was  ushered  in  by  convul- 
sions. These  differ  in  no  respect  from  convulsions  from  other  causes,  and 
may  be  repeated  two  or  three  times  in  the  course  of  the  first  twenty-four 
hours.  They  are  sometimes  followed  by  drowsiness  or  stupor,  sometimes 
by  active  delirium.  Cerebral  symptoms  may  predominate  for  several  days. 
There  may  be  opisthotonus,  dilated  or  contracted  pupils,  irregular  pulse, 
retracted  abdomen,  and,  in  fact,  almost  every  symptom  of  meningitis. 
Occasionally  the  decubitus  en  cliien  de  fusil.,  or  gun-hammer  position,  is 
assumed.  These  are  often  described  as  cases  of  cerebral  pneumonia,  Sind 
in  many  of  them  pneumonia  is  not  suspected  until  the  fourth  or  fifth  day 
of  the  disease,  sometimes  not  until  the  crisis  occurs,  when  the  rapid  dis- 
appearance of  all  these  nervous  symptoms  indicates  their  origin.     Early 


LOBAR   PNEUMONIA.  523 

convulsions  are  not  generally  followed  by  an  especially  severe  type  of  the 
disease,  only  one  of  seven  cases  beginning  in  this  way  proving  fatal.  On 
the  other  hand,  late  convulsions  are  usually  fatal.  In  two  of  the  three 
cases  in  which  I  have  noted  them,  the  convulsions  ushered  in  an  attack  of 
meningitis. 

Delirium  is  much  more  frequent  than  convulsions,  and  is  seen  in 
nearly  one  fourth  of  the  cases.  Generally  it  is  slight,  and  noticed  onlv  at 
night  or  when  the  temperature  is  very  high.  It  is  usually  mild,  but  may 
be  low  and  muttering,  like  that  of  typhoid,  or  wild  and  active,  like  that  of 
cerebro-spinal  meningitis.  It  is  most  pronounced  at  the  height  of  the 
disease.  Other  nervous  symptoms  belonging  to  the  typhoid  state,  such 
as  incontinence  of  urine  or  faeces,  muscular  twitchings,  and  tremor  of  the 
tongue  on  protrusion,  are  occasionally  seen,  but  only  in  the  worst  forms 
of  the  disease. 

There  is  no  relation  between  the  seat  of  the  disease  in  the  lungs  and  the 
occurrence  of  cerebral  symptoms.  They  are  more  frequent  in  children 
under  five  years  than  in  those-who  are  older,  and  depend  upon  the  sudden- 
ness of  the  invasion,  the  intensity  of  the  infection,  and  the  susceptibility 
of  the  child.  Late  in  the  disease  they  may  indicate  exhaustion,  toxaemia, 
or  complicating  meningitis.  They  are  frequently  associated  with  very 
high  temperature  and  extensive  disease.*  The  usual  nervous  symptoms — 
restlessness,  headache,  sleeplessness,  etc. — are  nearly  always  proportionate 
to  the  height  of  the  temperature. 

Urine. — Throughout  the  febrile  period  of  the  disease  the  urine  is 
scanty,  high-coloured,  with  a  high  sj^ecific  gravity,  and  usually  loaded 
with  urates.  In  a  small  number  of  cases  a  trace  of  albumin  may  be 
found,  and  occasionally  a  few  hyaline  casts.  Evidences  of  serious  renal 
disease  I  have  seldom  found  in  lobar  pneumonia,  and  in  the  experience  of 
all  observers  it  is  extremely  rare  in  early  life. 

Skin. — The  face,  in  pneumonia,  is  usually  flushed,  sometimes  on  both 
sides  and  sometimes  only  on  one  ;  in  other  cases  it  is  pale,  but  not  in- 
dicative of  pain.  Cyanosis  is  rare  except  toward  the  close  of  the  disease 
and  is  usually  a  sign  of  respiratory  failure.  Herpes  of  the  lips  or  face  is 
quite  frequent. 

Physical  Signs. — The  earliest  signs  in  pneumonia  are  due  to  the  acute 
congestion  of  the  affected  lung  or  lobe,  in  consequence  of  which  less  air 
enters  this  portion  and  more  air  the  rest  of  the  lungs.  Percussion  gives 
diminished  resonance  or  slight  dulness  over  the  affected  area,  and  exag- 
gerated resonance  over  the  remainder  of  this  lung  and  over  the  opposite 
lung.  Auscultation  over  the  affected  lobe  gives  feeble  respiratory  murmur, 
rather  high  in  pitch ;  sometimes  there  may  be  absence  of  all  breath-sounds 

*  For  a  fuller  discussion  of  the  cerebral  symptoms  of  pneumonia,  see  a  paper  by 
the  author,  in  the  New  York  Medical  Record,  April  7,  1888. 


524  DISEASES  OP  THE   RESPIRATORY   SYSTEM, 

so  complete  as  to  suggest  fluid.  The  normal  respiratory  murmur  over  the 
healthy  portions  of  the  lungs  is  intensified.  In  children  this  exaggerated 
breathing  is  not  infrequently  mistaken  for  bronchial  breathing,  and  the 
physician  may  be  led  into  the  error  of  locating  the  pneumonia  upon  the 
wrong  side.  Exaggerated  breathing  does  not  differ  from  normal  breathing 
except  in  intensity,  and  is  heard  only  on  inspiration.  Bronchial  breathing 
is  higher  in  pitch,  and  is  heard  with  nearly  equal  intensity  both  on  ex- 
piration and  inspiration.  If  the  chest  is  frequently  auscultated,  crepitant 
ntles  (Figs.  96  and  97)  may  usually  be  heard  at  some  period  at  the  end  of 
full  inspiration,  but  often  they  are  present  but  for  a  few  hours,  and  they 
may  be  missed  altogether. 

In  the  second  stage,  that  of  consolidation  (Fig.  98),  no  air  enters  the 
affected  part  of  the  lung.  Upon  palpation  there  is  found  here  exaggerated 
vocal  fremitus,  and  on  percussion  there  is  marked  dulness,  but  very  rarely 
flatness.  Over  the  rest  of  this  lung  there  is  exaggerated,  sometimes  even 
tympanitic,  resonance  ;  this  is  especially  frequent  at  the  apex  of  the  lung 
in  front,  when  there  is  consolidation  at  the  base  behind.  Under  these 
conditions  cracked-pot  resonance  may  sometimes  be  obtained.  Over  the 
healthy  lung  there  is  exaggerated  resonance.  On  auscultation  over  the 
consolidated  portion  there  are  bronchial  breathing  and  bronchial  voice, 
the  area  over  which  they  are  heard  being  sharply  defined.  Eales  are  usu- 
ally absent,  but  there  may  be  pleuritic  friction  sounds. 

In  the  stage  of  resolution  there  is  a  gradual  disappearance  of  the 
signs  of  consolidation.  The  pure  bronchial  is  replaced  by  broncho-vesic- 
ular breathing,  the  vesicular  element  gradually  predominating.  Moist 
rales  of  all  varieties  are  heard.  Usually  the  most  persistent  signs  are 
slight  dulness  or  diminished  resonance,  with  a  I'espiratory  murmur  which 
is  feebler  than  normal  and  a  little  higher  in  pitch ;  sometimes  there  are 
also  dry  friction  sounds.     These  signs  may  persist  for  two  or  three  weeks. 

Exceptional  liliysical  signs. — While  in  the  majority  of  cases  the  signs 
of  consolidation  are  distinct  on  or  before  the  fourth  day,  in  not  a  few  they 
may  be  delayed  much  longer.  Of  eighty-two  cases  in  which  the  day  was 
noted  on  which  consolidation  was  fou:id,  it  was  not  until  the  fifth  day  or 
later  in  one  fourth  the  number.  In  six  of  them,  although  carefully  and 
repeatedly  examined,  no  consolidation  was  found  until  the  seventh  day  or 
later  and  in  one  case  not  until  the  twelfth  day.  It  has  been  customary 
to  look  upon  these  cases  of  delayed  or  concealed  physical  signs  as  cases 
of  central  pneumonia.  That  pneumonia  may  exist  in  the  centre  of  a 
lung  for  a  number  of  days  is,  to  my  mind,  extremely  improbable.  At 
autopsy,  superficial  pneumonia  I  have  very  frequently  seen,  but  central 
pneumonia  never.  There  are  two  regions  in  which  pneumonia  may  exist 
and  yet  not  be  accessible  by  our  means  of  physical  examination,  viz.,  at 
the  apex  of  the  lung  in  the  part  covered  by  the  shoulder,  and  along  the 
posterior  border  of  the  lung  where  it  lies  against  the  vertebra?,     In  either 


PHYSICAL    SIGKS    OF    LOBAR    PXEUMOXIA. 


Fig.    96. — First   staoje.      Couirestion   of  left  lower    Fig.  97. — In  the  centre  of  the  area,  a  small  spot  of 
lobe,  with  crepitant  rales.     Feeble  breathing  pui-e  bronchial  breathing  and  voice  ;  surround- 

of  a  rude  character,  with  slight  dulness.  ing   this    an    occasional    crepitant   rale,   with 

X  broncho-vesicular   breathing  and   slight   dul- 

ness. 


Fig.  98. — Second  stage.    Complete  consolidation  of  left  lower  lobe.     Pure  bronchial  breathing  and  bron- 
chial voice;  marked  dulness  ;  increased  vocal  fremitus,  and  at  the  lower  part  a  few  friction  sounds. 


Note. — During  resolution  the  signs  take  the  inverse  order :  those  of  Fig.  98  give  place  to 
those  of  Fig.  97,  and  these  in  turn  to  those  of  Fig.  96.  In  addition,  many  coarse  rales  may 
be  heard. 

525 


526  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

of  these  situations  pneumonia  may  be  present  without  our  being  able  to 
find  it.  It  is  quite  common  in  cases  with  late  physical  signs  that  the  first 
distinctive  evidences  of  disease  are  found  high  in  the  axilla,  or  beneath 
the  clavicle  in  front,  and  these  regions  should  be  closely  watched  in  doubt- 
ful cases.  Sometimes  the  delay  is  best  explained  by  assuming  that  con- 
stitutional symptoms  due  to  the  pneumococcus  infection,  may  be  pres- 
ent for  several  days  before  the  development  of  the  local  lesion  in  the 
lung. 

Complications. — The  occurrence  of  dry  pleurisy  over  the  consolidated 
portion  of  the  lung  is  so  constant  that  it  can  hardly  be  considered  a  com- 
plication. A  slight  serous  exudation  of  two  or  three  ounces  is  not  un- 
common, but  more  than  this  is  very  rare  in  young  children.  In  the  most 
severe  cases  of  pleurisy  there  is  an  excessive  exudation  of  fibrin  and  pus. 
This  occurred  in  eight  per  cent  of  my  cases.  This  variety  is  known  clin- 
ically as  pieuro-pneumonia,  and  will  be  considered  separately.  Pericarditis 
is  rare ;  it  was  seen  in  only  two  of  my  cases  ;  in  both  it  was  associated  with 
pieuro-pneumonia  of  the  left  side,  the  exudation  resembling  that  found 
on  the  pleura.  It  rarely  gives  rise  to  any  new  symptoms.  Meningitis  was 
seen  twice,  once  with  pieuro-pneumonia.  It  is  nearly  always  ushered  in 
by  repeated  attacks  of  vomiting  or  convulsions.  Its  course  is  short  and 
progressive.  Peritonitis  was  seen  once,  also  associated  with  pieuro-pneu- 
monia.    Occasionally  there  is  gastro-enteritis. 

Course  and  Termination. — In  the  great  majority  of  cases  lobar  pneu- 
monia terminates  either  in  perfect  recovery  or  in  death.  When  ending 
in  recovery,  resolution  commonly  begins  immediately  upon  the  cessation 
of  the  fever,  and  is  complete  in  about  a  week.  Delayed  resolution  is  very 
rare ;  chronic  pneumonia  and  tuberculosis  are  also  extremely  infrequent 
as  sequela?,  but  empyema  is  quite  common.  Its  symptoms  sometimes  de- 
velop immediately  after  the  pneumonia,  the  temperature  continuing  high; 
or  there  may  be  an  interval  of  a  few  days  before  the  development  of  the 
pleural  symptoms.  Some  pleuritic  adhesions  probably  remain  in  every 
case  in  which  there  has  been  much  dry  pleurisy,  and  when  severe  and 
extensive,  these  may  be  the  cause  of  subsequent  symptoms,  like  any  other 
dry  pleurisy. 

Death  from  uncomplicated  pneumonia  may  be  due  to  exhaustion,  or 
to  heart  failure,  with  or  without  failure  of  the  respiration.  The  signs  of 
heart  failure  sometimes  develop  quite  rapidly  in  cases  which  are  apparently 
doing  well.  The  symptoms  are  :  coldness  of  the  hands  and  feet,  then  of 
the  legs  and  arms  ;  a  rapid,  compressible,  and  sometimes  irregular  pulse  ; 
muscular  weakness  and  pallor,  but  usually  no  cyanosis.  The  symptoms  of 
respiratory  failure  are  :  very  rapid  superficial  respirations,  sometimes  100 
a  minute  ;  blueness  of  the  lips  and  finger  nails ;  often  a  leaden  hue  of  the 
whole  body  ;  there  are  loud  tracheal  rales,  and  recession  of  all  the  soft 
parts  of  the  chest  on  inspiration. 


LOBAR   PNEUMONIA. 


527 


Death  may  result  early  in  the  disease,  where  the  pneumonia  has  spread 
rapidly,  involving  both  lungs.  The  earliest  deaths  I  have  seen  were  on 
the  fourth  day,  and  were  due  to  a  failure  of  the  heart  and  respiration. 
In  most  of  the  uncomplicated  fatal  cases,  death  results  from  heart  failure 
at  about  the  time  of  the  crisis.  In  the  complicated  cases  death  usually 
occurs  in  the  second  week.  I  once  knew  fatal  meningitis  to  develop  at 
the  end  of  the  fourth  week. 

Diagnosis. — The  most  characteristic  differences  between  broncho-  and 
lobar  pneumonia  are  shown  in  the  following  table  : 


BRONCHO-PNEUMONIA. 

1.  More  than  half  the  cases  secondary. 

2.  Under  three,  chiefly  under  two  years. 

3.  Occurs  more  frequently  in  delicate 
and  debilitated  children. 

4.  Bacteria — in  primary  cases,  usually 
the  pneumococeus ;  in  secondary  cases, 
chiefly  the  streptococcus,  but  usually  mixed 
infection. 

5.  Products  of  inflammation  chiefly  cel- 
lular ;  process  often  diffuse, 

6.  Onset  often  gradual,  sometimes  in- 
sidious, especially  when  secondary. 

7.  No  typical  course ;  fever  often  lasts 
three  or  four  weeks ;  rarely  terminates  by 
crisis. 

8.  Involves  both  lungs  as  a  rule,  most 
frequently  lower  lobes  posteriorly. 

9.  Signs  of  bronchitis  mingled  with 
those  of  consolidation  ;  rales  in  other  parts 
of  the  same  lung,  or  in  the  opposite  lung, 
throughout  the  disease. 

10.  Consolidation  later — fourth  to  sev- 
enth day ;  there  may  be  none  ;  apt  to  .be 

•incomplete;  shades  off  gradually. 

11.  Resolution  slow,  one  week  to  two 
months ;  often  incomplete ;  strong  tend- 
ency to  become  chronic. 

12.  Relapses  and  second  attacks  fre- 
quent. 

13.  Sequela?  :  Empyema,  chronic  inter- 
stitial pneumonia,  sometimes  tubercu- 
losis. 

14.  Prognosis  always  serious  from  the 
age  and  the  circumstances  under  which 
disease  occurs. 

15.  Hospital  mortality  50  per  cent  of 
primary  cases,  65  per  cent  of  all  cases. 

S6 


LOBAR    PNEUMONIA. 

1.  Almost  always  primary. 

2.  Most   common  between    three  and 
eight  years. 

3.  More    often    in    those    previously 
healthy. 

4.  The  pneumococeus. 


5.  Chiefly  fibrin ;  process  circumscribed. 

6.  Onset  sudden,  with  well-marked 
symptoms. 

7.  Typical  course;  crisis  usually  from 
fifth  to  eighth  day. 

8.  Usually  one  lobe  or  a  part  of  a  lobe ; 
left  base  most  frequently,  right  apex  next. 

9.  Rales  only  early,  and  during  reso- 
lution ;  frequently  no  signs  in  opposite 
lung. 

10.  Consolidation  earlier ;  second  or 
third  day.  Consolidation  complete;  area 
usually  sharply  defined. 

11.  Resolution  rapid,  usually  complete 
within  a  week. 

12.  Both  are  rare. 

13.  No  sequeliT  except  empyema. 


14.  Prognosis  good  ;  rarely  fatal  ex- 
cept from  complications — empyema,  men- 
ingitis, pericarditis. 

15.  Mortality  4  per  cent  of  all  cases. 


528  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

In  the  majority  of  cases  the  symptoms  are  plain  and  the  physical 
signs  so  typical  that  it  is  difricnlt  to  overlook  pneumonia  if  any  degree 
of  care  is  used  in  the  examination  of  the  patient.  The  characteristic 
features  are  the  sudden  onset,  with  vomiting,  convulsions,  or  chill ;  pros- 
tration ;  rapid  respiration,  with  the  expiratory  moan ;  a  temperature  of 
103°  to  105°  F. ;  cough  and  thoracic  pain  ;  and  the  physical  signs  of  a 
rapidly  developing,  circumscribed  consolidation  in  one  lobe  or  a  portion  of 
a  lobe.  The  difficulties  in  diagnosis  are  due  to  the  great  variation  that  is 
seen  in  the  general  symptoms,  and  to  the  late  appearance  of  the  physical 
signs.  The  error  usually  made  is  to  mistake  pneumonia  for  some  other 
disease,  rather  than  to  mistake  some  other  disease  for  pneumonia.  On 
account  of  its  frequency  in  children,  j^neumonia  should  always  be  ex- 
cluded before  accepting  any  other  explanation  of  a  continuously  high 
temperature.  It  is  surprising  to  find  how  often  obscure  and  indefinite 
symptoms  accompanied  by  high  fever,  are  due  to  pneumonia.  The  rule 
should  be  followed,  in  all  cases  of  acute  illness,  of  making  a  thorough 
examination  of  the  chest  daily  until  the  diagnosis  is  clear.  If  to  high 
temperature  rapid  respiration  is  added,  one  should  always  suspect  the 
lungs,  no  matter  what  the  other  symptoms  may  be.  It  not  infrequently 
happens  that  the  general  symptoms  are  quite  characteristic  and  yet  the 
physical  signs  appear  late.  In  such  cases  pneumonia  should  always  be 
looked  for  high  in  the  axilla  or  just  beneath  the  clavicle,  since  it  is  par- 
ticularly in  the  cases  of  apex  pneumonia  that  this  obscurity  is  likely  to 
exist.  If  frequent  and  thorough  examinations  of  the  chest  are  made,  very 
few  cases  will  be  overlooked. 

In  their  onset,  scarlet  fever,  tonsillitis,  and  gastro-enteritis  may  all  re- 
semble pneumonia.  Scarlet  fever  is  recognised  by  the  sore  throat  and  the 
characteristic  eruption  on  the  second  day ;  tonsillitis,  by  the  local  symp- 
toms. Pneumonia  is  distinguished  from  gastro-enteritis,  by  the  fact  that 
the  temperature  and  prostration  are  out  of  all  proportion  to  the  intestinal 
symptoms,  and  continue  even  after  these  symptoms  have  subsided.  It  is 
most  likely  to  be  mistaken  for  gastro-enteritis  in  summer,  and  in  infancy, 
when  it  often  begins  with  vomiting  and  diarrhoea.  Malaria  is  distinguished 
from  lobar  pneumonia  by  the  points  mentioned  in  the  diagnosis  of  broncho- 
pneumonia (page  507).  From  all  other  general  diseases,  pneumonia  is  to 
be  differentiated  by  the  physical  signs. 

Pneumonia  with  marked  cerebral  symptoms  sometimes  resembles  cere- 
bro-si)inal  meningitis.  In  both  we  may  have  the  abrupt  onset,  convul- 
sions, delirium  or  stupor,  opisthotonus,  and  prostration.  In  pneumonia 
the  temperature  is  usually  higher  than  in  meningitis ;  the  jiulse  is  never 
slow  and  intermittent ;  the  respiration  is  rajDid,  instead  of  slow  and  irregu- 
lar ;  and  the  stupor  is  usually  less  profound ;  and  there  are  no  localized 
paralyses.  In  meningitis  there  is  a  steady  increase  in  the  severity  of  the 
nervous  symptoms  for  the  first  three  or  four  days;  in  pneumonia  they 


LOBAR    PNEUMONIA.  529 

are  as  a  rule  most  marked  during  the  first  twenty-four  or  forty-eiglit 
hours,  and  then  gradually  diminish,  alwaj's  subsiding  completely  at  the 
crisis.  While  most  of  the  individual  symptoms  belonging  to  meningitis 
may  be  present,  they  are  usually  less  severe  and  less  persistent  in  pneu- 
monia. 

The  question  sometimes  arises,  in  a  case  of  pneumonia,  whether  the 
cerebral  symptoms  are  functional,  or  whether  meningitis  also  exists.  If 
the  nervous  symptoms  are  present  from  the  beginning,  there  is  probably 
no  meningitis.  If  they  develop  suddenly  during  the  course  or  toward  the 
close  of  the  disease,  meningitis  should  be  suspected. 

Lobar  pneumonia  is  to  be  differentiated  from  a  pleuritic  effusion. 
The  most  common  mistake  which  I  have  seen  made  is  to  confound  empy- 
ema -with  unresolved  pneumonia.  The  latter  is  very  infrequent,  so  that 
the  probabilities  are  always  strongly  in  favour  of  the  diagnosis  of  empv- 
ema.  In  pneumonia  rarely,  if  ever,  is  the  whole  lung  affected.  There 
are  increased  vocal  fremitus,  dulness,  bronchial  voice  and  breathing,  and 
occasionally  rales  or  friction  sounds.  In  empyema  the  whole  lung  is 
often  affected,  there  are  displacement  of  the  heart,  flatness  on  percus- 
sion, diminished  or  absent  vocal  fremitus,  and  although  bronchial  voice 
and  breathing  are  present,  they  are  usually  distant  and  feeble.  There 
are  no  rales  or  friction  sounds.  In  doubtful  cases  an  exploratory  punc- 
ture should  always  be  made.  Serous  effusions  are  rare,  but  are  differen- 
tiated by  the  same  signs  as  empyema. 

Prognosis. — There  is  probably  no  disease  in  which  the  patient  appears 
so  ill,  and  where  there  is  really  so  little  danger  to  life,  as  in  lobar  pneu- 
monia in  a  child  over  three  years  old.  Of  1,295  collected  cases,  chiefly 
from  hospital  practice,  there  were  but  39  deaths,  a  mortality  of  three  per 
cent.  In  187  cases  of  my  own  there  were  21  deaths,  a  mortality  of  eleven 
per  cent.  Only  one  of  the  fatal  cases  was  over  two  years  old.  The  dif- 
ference between  the  mortality  among  my  cases  and  the  general  mortality 
given,  is  due  to  the  fact  that  a  large  proportion  of  the  first  group  were 
observed  in  children  under  two  years,  while  of  the  collected  cases  the 
vast  majority  were  in  older  children.  Combining  the  above  figures,  we 
have  a  total  of  1,482  cases  with  60  deaths,  a  mortality  of  four  per  cent. 
In  nearly  all  my  cases  death  was  due  either  to  complications  or  to  very 
extensive  disease,  as  when  both  lungs  were  involved,  or  nearly  the  whole 
of  one  lung.  In  only  one  case  was  an  uncomplicated  pneumonia  of  a 
single  lobe  fatal. 

The  prognosis  depends  upon  the  age  of  the  patient,  the  presence  or 
absence  of  complications,  and  the  extent  of  the  disease.  These  factors  are 
to  be  taken  into  consideration  rather  than  any  special  symptoms.  Early 
convulsions  do  not  materially  affect  the  prognosis.  Of  seven  such  cases 
only  one  was  fatal.  Late  convulsions  are  always  very  unfavourable,  indi- 
cating either  exhaustion,  toxsemia,  or  the   development  of  meningitis. 


530  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

The  development  of  vomiting  or  diarrhcea  late  in  the  disease  is  also 
unfavourable,  especially  in  infants. 

A  temperature  range  between  102°  and  105°  F.  is  the  rule,  and 
within  these  limits  the  fever  does  not  affect  the  prognosis.  Even 
very  high  temperature  does  not  increase  the  danger  from  the  disease 
as  much  as  would  be  expected.  Of  fifteen  cases  in  which  the  tempera- 
ture touched  106°  F.  or  over,  all  but  three  recovered;  while  of  six 
cases  in  which  it  was  106-5°  or  over,  only  one  died.  The  highest  re- 
corded temperature  in  my  cases — 107*5°  F. — was  in  a  patient  who  recov- 
ered. A  transient  rise,  even  though  the  temjjerature  may  go  very  high, 
is  not  often  serious.  Much  more  serious  is  a  fever  which  remains 
steadily  above  105°  F.,  as  in  most  cases  this  accompanies  either  very  ex- 
tensive disease  or  pleuro-pneumonia.  The  continuance  of  the  fever  after 
the  tenth  day  is  a  bad  symptom,  for,  although  the  crisis  may  be  post- 
poned until  the  twelfth  day  and  occur  normally,  such  a  prolonged  tem- 
perature is  apt  to  be  an  indication  of  a  new  focus  of  disease  or  the  devel- 
opment of  complications. 

It  is  an  unfavourable  sign  for  resolution  not  to  begin  as  soon  as  the 
temperature  becomes  normal.  There  should  then  be  apprehended  a  re- 
lapse, the  development  of  empyema,  or  of  some  other  complication. 

Treatment. — In  the  treatment  of  lobar  pneumonia  in  children,  several 
cardinal  facts  are  to  be  kept  in  mind.  It  is  a  self-limited  disease,  having 
a  strong  tendency  to  recovery  in  the  great  majority  of  cases  regardless 
of  the  treatment  adopted.  The  fatal  cases  are  almost  always  in  children 
under  three  years  of  age ;  the  rare  deaths  in  older  ones  are  usually  due 
to  complications,  I  believe  that  there  is  no  means  of  treatment  by  which 
we  can  abort  pneumonia  or  shorten  its  course.  It  follows,  therefore,  that 
the  indications  are,  so  far  as  possible,  to  make  the  patient  comfortable 
during  his  illness,  to  prevent  complications,  and  to  treat  the  individual 
symptoms  as  they  arise. 

In  perhaps  the  majority  of  cases,  hygienic  treatment  is  all  that  is 
required.  The  patient  should  be  kept  in  bed,  no  matter  how  mild  the 
attack ;  he  should  be  lightly  covered,  kept  as  quiet  as  possible,  and 
allowed  plenty  of  fresh  air  in  the  room.  Food  should  be  given  at  regu- 
lar intervals,  never  oftener  than  every  two  hours,  and  usually  only 
every  four  hours.  It  should  not  be  forced  when  the  patient  is  suffering 
only  from  thirst.  These  measures,  careful  nursing,  an  occasional  dose 
of  phenacetine  when  the  patient  is  very  restless,  fretful,  or  sleepless, 
and  cold  sponging  when  the  temperature  makes  him  uncomfortable,  are 
usually  all  that  is  necessary,  except  to  keep  a  sharp  lookout  for  compli- 
cations. 

Special  symptoms  may  require  treatment.  The  nervous  symptoms  are, 
in  most  cases,  better  controlled  by  phenacetine  than  by  opiates.  Often  a 
single  dose  in  twenty-four  hours  is  enough.     Sometimes  sponging  with 


PLEURO-PNEUMONIA.  53I 

tepid  water  is  better  than  drugs.  Severe  nervous  symptoms,  such  as  delir- 
ium, stupor,  great  restlessness  with  impending  convulsions,  when  associ- 
ated with  high  temperature,  call  for  ice  to  the  head,  cold  sponging,  or  the 
cold  pack  or  bath.  Pain,  if  moderate,  may  be  relieved  by  counter-irrita- 
tion by  a  mustard  paste  or  by  a  hot  poultice  ;  if  severe,  morphine  must 
be  used  in  addition.  The  cough  is  rarely  severe  enough  to  require  treat- 
ment. When  it  is'so  severe  as  to  prevent  sleep,  small  doses  of  Dover's 
powder  or  codeia  should  be  given.  Antipyretic  measures  are  not  neces- 
sarily called  for  if  the  temperature  is  high.  This  not  infrequently  con- 
tinues for  a  few  hours  while  the  patient  may  be  quiet  and  appear  perfectly 
comfortable.  Under  such  conditions  the  temperature  should  be  closely 
watched,  but  not  necessarily  interfered  with  unless  other  symptoms  de- 
velop. The  nervous  symptoms  are  a  better  guide  than  the  thermometer 
to  the  use  of  antipyretics.  When  they  exist,  even  with  a  moderate  ele- 
vation of  temperature,  interference  is  indicated.  Cold  I  believe  to  be 
the  safest  and  most  certain  antipyretic  we  possess.  It  may  be  given  as 
a  cold  sponge  bath  or  the  cold  pack  (pages  47,  ^8).  There  is  no  objection 
to  the  bath  except  the  prejudice  of  the  laity.  While  cold  is  applied  to 
the  trunk  the  extremities  should  be  closely  watched,  and  heat  applied  if 
necessary.  The  duration  of  the  pack  or  bath, -and  the  frequency  of  their 
use,  will  depend  upon  the  individual  case.  Stimulants  are  not  required  in 
the  majority  of  cases.  They  are  called  for  when  the  pulse  is  weak,  com- 
pressible, and  rapid,  when  the  face  is  pale  and  the  extremities  are  cold. 
The  same  stimulants  are  to  be  employed,  and  in  the  same  way,  as  in 
broncho-pneumonia  (page  510).  Cardiac  stimulants  are  usually  required 
in  larger  quantity  at  the  time  of  and  just  after  the  crisis.  Respiratory 
stimulants  are  indicated  as  in  broncho-pneumonia. 

PLEURO-PNEUMONIA. 

Under  this  term  are  included  cases  of  pneumonia  with  an  excessive 
amount  of  pleurisy,  the  two  processes  uniting  to  produce  a  single  clinical 
type  of  disease. 

In  nearly  all  cases  of  lobar  pneumonia  there  is  a  certain  amount  of  in- 
flammation of  the  pulmonary  pleura,  and  also  in  those  cases  of  broncho- 
pneumonia which  are  accompanied  by  any  marked  degree  of  consolidation. 
In  both  of  these  the  pleurisy  is  usually  co-extensive  with  the  consolidation. 
But  in  certain  cases,  in  both  forms  of  pneumonia,  the  amount  of  pleurisy 
is  excessive,  and  this  so  modifies  the  symptoms  and  course  of  the  disease 
as  to  require  for  them  a  separate  consideration.  In  some  it  appears  that 
the  inflammatory  process  begins  almost  simultaneously  in  the  lung  and  in 
the  pleura;  while  in  others  the  pleurisy  follows  the  pneumonia.  These 
cases  are,  I  believe,  almost  invariably  due  to  the  pneumococcus,  although 
in  some  there  is  a  mixed  infection. 

In  398  hospital  cases  of  pneumonia  there  were  27,  or  6-8  per  cent. 


532  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

which  could  be  classed  as  pleuro-pueumonia,  the  diagnosis  being  con- 
firmed either  by  autopsy  or  operation.  Of  190  fatal  cases,  12-5  per  cent 
were  pleuro-pneumonia.  Most  of  these  hospital  patients  were  under  three 
years  of  age,  and  the  disease  is,  I  think,  more  frequent  at  this  period  than 
in  older  children. 

Lesions. — Of  these  27  cases,  17  were  classed  as  broncho-pneumonia  and 
10  as  lobar  pneumonia.  The  left  lung  was  more  frequently  affected  than 
the  right  in  the  proportion  of  three  to  two.  In  most  of  the  cases  the 
pleura  covering  the  entire  lung  was  involved,  even  though  the  pneumonia 
affected  but  a  single  lobe,  or  only  a  part  of  a  lobe.  In  nearly  half  the  cases 
both  lungs  were  involved,  but  one  to  a  very  much  less  extent  than  the 
other.  In  a  small  number  of  cases  the  pleurisy  was  limited  to  the  pos- 
terior surface  of  the  lung,  stopping  at  the  axillary  line. 

In  pleuro-pneumonia  both  the  visceral  and  the  parietal  pleura  are 
coated  with  a  layer  of  yellowish-green  fibrin,  in  thick,  shaggy  masses,  by 
which  the  lung  is  adherent  to  the  chest  wall,  the  diaphragm,  and  the 
pericardium  (Plate  XIII).  The  exudation  varies  between  one  eighth 
and  one  half  an  inch  in  thickness.  It  can  often  be  stripped  from  the 
lung  or  scraped  from  the  chest  wall  by  the  handful.  In  its  meshes  small 
pockets  may  form,  which  contain  only  a  few  drops,  or  sometimes  a 
drachm  of  pus,  or  less  frequently  serum.  This  is  the  condition  in  which 
the  lung  is  usually  found  where  death  has  occurred  at  the  height  of  the 
disease.  If  the  process  has  lasted  longer,  larger  collections  of  pus  may  be 
present.  The  lung  itself  shows  the  usual  changes  of  pneumonia,  and  if 
there  has  been  any  considerable  accumulation  of  fluid,  there  are  in  addi- 
tion the  evidences  of  compression. 

With  pleuro-pneumonia  of  the  left  side,  the  pericardium  is  occa- 
sionally involved.  This  was  seen  in  two  of  my  cases,  the  lesions  closely 
resembling  those  of  the  pleura.  In  two  cases  there  was  also  meningitis, 
and  in  one  peritonitis,  the  exudation  in  all  cases  having  the  same  charac- 
teristics. 

An  inflammation  of  the  intensity  described  is  very  often  fatal  in  the 
acute  stage,  if  the  patient  is  a  child  under  two  years  old.  Occasionally 
at  this  age,  and  very  frequently  in  older  children,  we  see  the  later  stages 
of  the  process.  The  most  frequent  course  is  for  more  and  more  pus  to  be 
poured  out  from  the  inflamed  pleura  until  the  chest  is  filled,  the  case 
becoming  thus  one  of  empyema.  Sometimes  the  fluid  is  serous  instead  of 
purulent,  but  this  is  very  rare  in  infancy.  Under  other  circumstances  the 
exudation  is  partly  absorbed,  but  the  greater  part  becomes  organized  so  as 
to  form  a  thick  jacket  of  fibrous  tissue  which  binds  the  lobe  or  lung  to 
the  chest  wall,  and  interferes  seriously  with  its  subsequent  full  expansion. 
Chronic  interstitial  pneumonia  may  follow. 

Symptoms. — There  is  little  which  distinguishes  a  case  of  pleuro-pneu- 
monia except  the  severity  of  all  the  constitutional  symptoms ;  the  tem- 


PLATE   XIII. 


43  t. 


c  <s 

o 
o:   fcJO 

cS   to 

c3 


S-^ 


5     c  S      ^ 
o    -^  o       c 


^  ^  c  ^ 

c-t;  -  ^ 

.^  a; 
_  txx:  o 

t^  ~  a;  _r 

<«  ■?;  -,  *^ 

03    ^  «>    S 


PLEURO-PNEUMONIA.  533 

perature  is  often  higher,  the  prostration  greater,  and  the  patient  in  every 
way  impresses  one  as  being  more  serionsly  ill  than  with  ordinary  pneu- 
monia. Sometimes  the  thoracic  pain  is  more  severe  and  more  constant 
than  is  nsual  in  pneumonia.  The  diagnosis,  however,  is  to  be  made  by 
the  physical  signs. 

In  the  early  stage  the  pleuritic  friction  sounds  are  unusually  promi- 
nent ;  after  two  or  three  days  the  signs  of  consolidation  come  out  clearly 
in  most  cases,  but  still  accompanied  by  loud  friction  sounds.  After  the 
fibrinous  exudation  is  very  abundant,  the  signs  are  often  obscure  and  con- 
fusing, and  there  may  be  at  no  time  well-defined  signs  of  consolidation. 
There  is  usually  a  mingling  of  the  signs  of  consolidation  with  those  of 
effusion.  There  is  marked  dulness,  and  sometimes  flatness.  The  vocal 
fremitus  is  apt  to  be  diminished,  and  it  may  be  absent.  Bronchial  voice 
and  breathing  are  heard,  but  they  are  not  distinct  as  in  consolidation ; 
they  are,  however,  feeble  and  distant,  as  over  fluid.  There  are  usually 
coarse,  moist,  crackling  pleuritic  sounds,  but  these  may  be  absent.  The 
signs  may  be  found  over  one  entire  lung,  or  they  may  be  limited  to 
the  posterior  region,  and  even  to  a  single  lobe.  They  resemble  those 
present  over  fluid,  with  one  exception — viz.,  the  heart  is  not  displaced. 
If  an  exploratory  puncture  is  made,  nothing  is  found ;  occasionally  the 
exploring  needle  happens  to  strike  one  of  the  small  pockets  of  pus 
in  the  meshes  of  the  fibrin,  and  a  few  drops  of  clear  pus  are  withdrawn. 
If  an  incision  is  made  under  the  supposition  that  the  case  is  one  of  em- 
pyema, no  more  pus  may  be  found,  the  surgeon  coming  upon  the  pul- 
monary adhesions  as  soon  as  the  chest  is  opened.  There  is  scarcely  any 
condition  in  the  chest  giving  signs  more  puzzling  than  those  just  enu- 
merated. They  are,  however,  easily  explained  by  the  pathological  con- 
ditions. 

Prognosis. — The  prognosis  in  pleuro-pneumonia  is  much  worse  than 
in  simple  pneumonia.  In  infants  the  outlook  is  very  bad,  the  majority  of 
cases  dying  during  the  acute  stage,  usually  in  the  second  week.  Very 
young  children  may  be  overwhelmed  with  the  extent  and  the  intensity  of 
the  inflammation,  and  die  in  four  or  five  days.  In  children  over  two  years 
old  the  most  frequent  result  is  for  the  case  to  go  on  to  empyema,  which 
with  proper  treatment  usually  terminates  in  recovery.  Where  there  is 
organization  of  the  fibrin  with  the  production  of  extensive  adhesions,  the 
ultimate  result  is  often  not  so  favourable  as  when  empyema  develops. 
Convalescence  is  usually  slow,  and  the  patients  are  liable  to  exacerbations  of 
pleurisy;  they  may  suffer  for  years  from  the  partial  crippling  of  one  lung. 

Diagnosis. — This  is  to  be  made  only  by  the  physical  signs.  A  differ- 
ential diagnosis  from  fluid  in  the  chest  can  in  some  cases  be  made  onlv 
by  an  exploratory  puncture. 

Treatment. — Cases  of  pleuro-pneumonia  require  no  special  treatment. 
In  general  they  are  to  be  managed  like  the  ordinary  cases  of  pneumonia 


534  DISEASES   OF  THE   RESPIRATORY   SYSTEM. 

of  the  severe  type.  In  some,  the  excessive  pain  may  call  for  more  active 
counter-irritation  and  a  freer  use  of  opium  than  in  other  forms  of  pneu- 
monia, and  the  greater  prostration  may  require  that  stimulants  be  given 
earlier  and  in  larger  quantities. 

HYPOSTATIC  PNEUMONIA. 

This  can  not  often  be  recognised  clinically,  but  it  is  very  frequently  seen 
upon  the  post-mortem  table.  It  is  present  in  some  degree  in  almost  every 
case  where  an  infant  has  died  of  chronic  disease.  It  is  particularly  fre- 
quent in  those  who  have  died  of  marasmus.  It  is  sometimes  described 
as  "  strip  pneumonia,"  on  account  of  its  position.  It  invariably  occupies 
a  strip  along  the  posterior  border  of  both  lungs,  and  usually  of  both  the 
upper  and  lower  lobes.  This  is  from  one  to  two  inches  wide,  of  a  uniform 
dark-red  colour,  and  is  sharply  outlined.  The  pleura  is  not  involved,  and 
the  remainder  of  the  lung  may  be  normal,  congested,  or  slightly  emphy- 
sematous. On  section,  it  is  seen  that  the  pneumonic  area  is  quite  super- 
ficial, rarely  involving  the  lung  to  a  greater  depth  than  half  an  inch.  Un- 
der the  microscope  there  is  found  a  distention  of  the  small  blood-vessels  in 
the  affected  area,  and  the  air  vesicles  are  filled  with  many  red  blood -glob- 
ules, epithelial  cells,  and  a  few  leucocytes.  Between  the  areas  of  consoli- 
dation are  groups  of  air  vesicles  which  are  normal,  congested,  or  collapsed. 
It  is  a  lobular  rather  than  a  broncho-pneumonia.  The  lesions  in  this 
form  of  pneumonia  are  probably  the  result  of  venous  stasis,  owing  to  the 
child's  recumbent  position. 

At  autopsy  the  condition  may  be  confounded  with  atelectasis ;  this, 
however,  is  almost  invariably  more  marked  in  the  interior  of  the  lung, 
while  pneumonia  is  always  more  marked  upon  the  surface.  The  two  con- 
ditions are  sometimes  associated.  Little  significance  is  to  be  attached 
to  the  finding  of  hypostatic  pneumonia  at  autopsy,  and  it  alone  should 
never  be  regarded  as  a  sufficient  cause  of  death,  although  it  is  perhaps  the 
only  lesion  present.  During  life  it  may  give  rise  to  fine  moist  rales,  which 
are  heard  along  the  spine,  usually  upon  both  sides ;  but  there  is  neither 
dulness  nor  bronchial  breathing. 

The  treatment  is  that  of  the  primary  disease. 

CHRONIC   BRONCHO-PXEUMONIA— CHRONIC  INTERSTITIAL 
PNEUMONIA— BRONCHIECTASIS. 

This  is  an  inflammation  of  the  connective-tissue  framework  of  the 
lung,  involving  the  stroma,  the  alveolar  septa,  the  walls  of  the  bronchi, 
and  the  pleura.  It  is  usually  accompanied  by  cylindrical  dilatation  of  the 
bronchi — bronchiectasis. 

Etiology. — In  children,  as  in  adults,  this  process  is  most  frequently 
associated  with  pulmonary  tuberculosis;  but  in  early  life  it  is  not  an  in- 


PLATE    XIV 


Chronic  Broncho-Pneumonia. 

In  the  greater  jiart  of  the  specimen  the  disease  is  limited  to  the  vicinity  of  the 
small  bronchi,  A  A  A,  each  of  which  is  surrounded  by  a  zone  of  new  connective 
tissue,  the  result  of  the  inflammatory  process,  the  intervening  king  tissue,  B  B,  being 
normal.  In  the  lower  left-hand  portion,  the  disease  is  more  diffuse;  the  air  vesicles, 
C,  between  the  areas  of  new  connective  tissue  are  greatly  compressed,  and  in  some 
places  entirely  obliterated.  (After  I)elafield.) 


CHRONIC  BRONCHO-PNEUMONIA.  535 

frequent  condition  apart  from  tuberculosis.  The  non-tuberculous  cases, 
as  a  rule,  are  preceded  by  an  attack  of  acute  broncho-pneumonia,  some- 
times by  several  such  attacks,  separated  by  longer  or  shorter  intervals. 

Lesions. — The  part  of  the  lung  affected  may  be  an  entire  lobe,  but 
usually  it  is  a  portion  of  one  lobe,  or  there  are  areas  in  more  than  one 
lobe.  There  are  dense  connective-tissue  adhesions  binding  the  diseased 
part  to  the  chest  wall,  to  the  diaphragm  and  to  the  pericardium,  often 
so  firmly  that  the  lung  is  torn  on  removal.  The  affected  lung  is  smaller 
than  in  health ;  it  is  hard,  tough,  and  fibrous.  Surrounding  the  fibrous 
portions  are  emphysematous  areas.  On  section,  the  process  is  seen  to 
be  somewhat  irregularly  distributed  through  the  lung,  the  lesion  being 
usually  most  marked  in  the  vicinity  of  the  smaller  bronchi,  and  some- 
times seen  only  there,  the  intervening  lung  being  nearly  normal  (Plate 
XIV).  In  some  portions,  where  the  process  is  most  advanced,  almost 
all  trace  of  lung  tissue  has  disappeared,  the  part  resembling  a  solid  fibrous 
tumour,  through  which  run  the  bronchial  tubes,  usually  much  dilated. 
In  places  this  dilatation  may  be  sufficient  to  form  cavities  of  consid- 
erable size.  The  bronchial  glands  are  often  enlarged  to  the  size  of  a 
hazelnut,  and  they  may  be  tuberculous. 

Upon  examination  with  the  microscope,  the  pleura  is  found  greatly 
thickened,  with  bands  of  new  fibrous  tissue  passing  from  it  into  the 
lung.  The  walls  of  the  small  bronchi  are  generally  thickened,  but  in 
some  places  they  have  undergone  cylindrical  dilatation,  and  are  filled 
with  pus.  The  walls  of  the  alveoli  are  greatly  thickened  from  the  pro- 
liferation of  the  connective-tissue  elements,  and  the  alveoli  are  filled 
with  organized  inflammatory  products,  so  that  they  are  nearly  or  quite 
obliterated.  The  stroma  is  greatly  increased  in  amount  throughout  the 
affected  lung. 

Symptoms. — In  most  of  the  cases  there  is  a  history  of  an  attack  of 
acute  broncho-pneumonia,  from  which  the  child  made  a  slow  convales- 
cence, remaining  pale,  anaemic,  and  sometimes  wasted  for  several  months. 
Improvement  then  takes  place  in  the  general  symptoms,  the  appetite  and 
strength  return,  and  in  many  cases  the  lost  weight  is  nearly  or  quite  re- 
gained. However,  neither  the  pulmonary  symptoms  nor  the  physical  signs 
entirely  disappear.  There  remains  a  dry,  hard  cough,  which  at  times  is 
severe.  Pains  in  the  chest  are  occasionally  complained  of,  and  perhaps 
shortness  of  breath  on  exertion  is  noticed.  Examination  shows  a  per- 
sistence of  the  dulness  on  percussion,  with  a  rude  or  broncho-vesicular 
respiratory  murmur  of  very  feeble  intensity.  Little  change  may  take  place 
in  these  signs  for  months ;  then  an  acute  attack  of  bronchitis  or  broncho- 
pneumonia may  occur.  If  the  latter,  the  same  lung  is  affected,  and  a  fresh 
consolidation  is  added  to  the  previous  disease.  This  attack  may  not  be 
very  severe,  but  it  drags  on  for  several  weeks,  with  slight  fever  and  little 
or  no  change  in  the  physical  signs.     Partial  resolution  may  then  take 


536  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

place,  but  the  lung  is  left  much  more  seriously  crippled  than  before.  In 
many  cases  there  is  a  history  of  several  such  attacks,  each  one  leaving  the 
lung  a  little  vi^orse  than  it  found  it. 

The  characteristic  physical  signs  of  chronic  broncho-pneumonia  are 
not  usually  present  until  the  process  has  continued  for  many  months, 
sometimes  for  several  years.  They  may  involve  part  of  a  lobe,  or  they  may 
be  present  over  an  entire  lobe,  or  even  an  entire  lung.  On  inspection, 
there  is  seen  in  a  well-marked  case,  a  retraction  of  the  chest,  which  is 
especially  noticeable  when  the  disease  is  situated  at  the  apex  of  the 
lung.  The  vocal  fremitus  is  usually  increased,  but  it  may  not  be  abnor- 
mal. There  is  marked  dulness,  often  flatness,  over  the  affected  area, 
with  exaggerated  resonance  over  the  rest  of  the  lung.  The  area  of  flat- 
nessis  not  sharply  circumscribed,  but  shades  off  gradually.  The  most 
striking  thing  on  auscultation  is  the  very  feeble  respiratory  murmur ;  in 
many  cases  the  lung  is  almost  silent.  In  other  cases  the  respiration  is 
distinctly  bronchial  in  character,  and,  if  marked  bronchiectasis  exists, 
it  may  be  cavernous.  Eales  and  friction  sounds  are  usually  absent  ex- 
cept during  an  acute  exacerbation  of  the  symptoms,  when  they  may  be 
heard  as  in  any  attack  of  broncho-pneumonia.  There  is  no  displacement 
of  the  heart. 

The  course  of  these  cases  is  always  uncertain.  When  once  present 
the  lesions  are  permanent,  and  there  is  always  a  tendency  to  increase 
rapidly  or  slowly,  according  to  the  child's  vigour  of  constitution,  its  sur- 
roundings, and,  most  of  all,  the  frequency  with  which  exacerbations  occur. 
If  the  disease  is  extensive  the  general  health  is  so  undermined  that  the  pa- 
tient succumbs  either  to  some  intercurrent  disease  or  to  an  acute  attack 
of  pneumonia ;  if  limited  in  area,  the  process  may  be  arrested  and  the 
patient  recover,  always,  however,  to  be  more  or  less  embarrassed  because 
of  the  crippling  of  a  part  of  one  lung.  Not  a  small  number  of  these  chil- 
dren ultimately  die  of  tuberculosis,  and  in  such  cases  it  is  always  a  diffi- 
cult matter  to  decide  whether  tuberculosis  was  present  from  the  begin- 
ing,  or  whether  there  was  subsequent  infection.  The  classical  symptoms 
which  are  presented  by  adults  with  bronchiectasis  are  rarely  seen  in 
young  children. 

Prognosis. — From  what  has  already  been  said,  it  will  be  evident  that 
the  prognosis  in  these  cases  is  always  doubtful  as  to  the  ultimate  result. 
It  depends  on  the  extent  of  the  disease,  the  patient's  age  and  constitu- 
tion, and  on  our  ability  to  prevent  by  treatment,  climatic  and  otherwise, 
the  occurrence  of  acute  exacerbations.  Under  the  most  favourable  con- 
ditions, a  few  patients  may  recover  completely  so  far  as  symptoms  are 
concerned ;  but  the  majority  at  best  remain  delicate  during  childhood,  or 
even  throughout  life. 

Diagnosis. — The  most  important  thing  is  to  distinguish  between  the 
simple  and  the  tuberculous  cases,  and  this,  it  must  be  confessed,  is  in  tlie 


GANGRENE  OF  THE   LUNG. 


537 


majorit}'  impossible.  Repeatedly  have  I  seen  a  process  proved  at  autopsy 
to  be  simple,  which  all  who  had  observed  the  case  had  unhesitatingly  pro- 
nounced to  be  tuberculous,  and  quite  as  often  the  opposite  has  been  true. 
If  the  family  history  is  good,  if  the  patient  lives  in  the  country,  if  his 
symptoms  began  with  a  well-defined  acute  attack  of  pneumonia,  if  the 
seat  of  disease  is  the  base  of  one  lung,  and  if  the  examination  of  the 
sputum  is  negative,  the  process  is  probably  simple.  If  the  family  history 
is  doubtful  or  is  positively  tuberculous,  if  the  patient  lives  in  the  city,  and 
especially  if  he  is  an  inmate  of  an  institution  or  if  his  home  is  among 
the  tenements,  if  the  initial  symptoms  were  indefinite,  if  the  seat  of  dis- 
ease is  the  axilla,  the  mammary  region,  or  the  apex  in  front,  the  process 
is  probably  tuberculous.  The  discovery  of  tubercle  bacilli  in  the  sputum 
is,  of  course,  conclusive.  Even  the  course  of  the  disease  may  not  settle 
the  diagnosis,  unless  there  develop  in  the  bones  or  in  other  viscera,  lesions 
undoubtedly  tuberculous. 

Treatment. — Xothing  has  any  essential  influence  upon  the  disease 
except  change  of  climate.  This  should  be  the  same  as  for  tuberculous 
cases.  The  treatment  of  the  patient  has  for  its  object  the  maintenance 
of  the  general  nutrition  at  its  highest  point,  by  careful  feeding,  judicious 
exercise,  and  by  most  of  the  measures  enumerated  in  the  chapter  on  Mal- 
nutrition. Cod-liver  oil  should  be  given  throughout  every  winter  season. 
The  cough  may  be  treated  as  in  cases  of  chronic  bronchitis. 

GANGRENE   OF   THE    LUNG. 

Pulmonary  gangrene  is  quite  rare  in  children,  although  it  is  probably 
more  common  than  in  adults.  It  is  most  frequently  associated  with 
pneumonia.  It  is  usually  circumscribed,  and  in  the  majority  of  cases  it  is 
latent. 

Etiology. — Children  of  all  ages  may  be  affected  ;  all  of  my  own  cases 
have  been  under  three  years  old,  the  youngest  being  an  infant  of  four 
months.  It  occurs  for  the  most  part  in  children  who  are  ill-conditioned, 
feeble,  or  cachectic,  and  often  follows  one  of  the  infectious  diseases,  par- 
ticularly measles.  In  such  cases  it  may  be  associated  with  gangrene  of  the 
mouth  or  of  the  vulva.  It  is  seen  in  general  pyemia,  and  has  followed 
caries  of  the  petrous  bone.  Of  the  local  causes,  altogether  the  most  fre- 
quent is  broncho-pneumonia.  Of  nine  cases  which  have  come  under 
my  personal  observation,  six  complicated  acute  broncho-pneumonia  and 
one  lobar  pneumonia.  It  has  been  present  in  three  per  cent  of  my  autop- 
sies upon  cases  of  pneumonia.  It  may  accompany  pulmonary  tubercu- 
losis, bronchiectasis,  and  pulmonary  apoplexy,  or  it  may  be  due  to  a  for- 
eign body  in  one  of  the  bronchi.  The  immediate  cause  of  the  necrotic 
process  is  interference  with  the  circulation  in  a  part  of  the  lung,  which 
is  usually  due  to  thrombosis  or  embolism  of  some  of  the  branches  of  the 
jiulmonary  artery.     To  this  there  is  added  the  entrance  of  putrefactive 


538  DISEASES  OF  THE   RESPIRATORY  SYSTEM. 

bacteria.  In  some  cases  the  process  may  begin  as  a  septic  thrombosis,  this 
infection  originating  in  some  process  in  a  distant  part  of  the  body. 

Lesions. — According  to  general  experience,  the  lower  lobes  are  more 
frequently  affected  than  the  upper,  and  this  is  borne  out  by  my  own  cases. 
The  surface  of  the  lung,  rather  than  the  central  portions,  are  most  often 
involved. 

Two  forms  of  gangrene  may  be  seen  :  the  diffuse  form,  which  affects  a 
whole  lobe,  or  even  a  whole  lung ;  and  the  circumscribed  form,  which 
occurs  in  a  number  of  small  scattered  areas,  usually  from  half  an  inch  to 
two  inches  in  diameter.  The  latter  is  the  variety  usually  seen  in  children. 
In  the  diffuse  form  the  lung  is  of  a  dirty  green  or  brown  colour,  moist, 
and  emits  a  gangrenous  odour.  In  the  circumscribed  form,  when  occur- 
ring in  pneumonia,  the  parts  affected  are  of  a  gray  or  green  colour,  usually 
wedge-shaped,  with  the  base  at  the  surface  of  the  lung.  In  the  early  stage 
they  are  not  softened,  and  have  no  gangrenous  odour ;  later,  both  these 
conditions  may  be  present,  and  masses  of  necrotic  lung  tissue  may  be 
found  in  a  cavity  with  ragged  walls,  partly  filled  with  fetid  pus.  Careful 
dissection  will  reveal,  in  many  cases,  the  presence  of  thrombi  in  the  ves- 
sels leading  to  the  gangrenous  parts.  The  later  stages  of  the  process  are 
very  rarely  seen.  However,  in  some  cases  the  gangrenous  masses  may  be 
coughed  up  and  the  cavity  closed  by  cicatrization.  This  is  more  likely  to 
happen  where  there  is  but  one  area,  as  when  the  process  is  due  to  the 
presence  of  a  foreign  body.  Sometimes  rupture  into  the  pleura  takes 
place,  and  empyema  or  pneumothorax  follows. 

Two  unique  cases  of  necrosis  of  the  lung  have  come  to  my  notice ; 
they  were  in  all  respects  similar.  The  surface  of  the  lung  was  of  a  uni- 
form dark  reddish-brown,  and  seemed  to  be  slightly  softened.  On  section, 
a  large  part  of  the  lower  lobe  was  of  a  dark-red  colour  and  of  a  semifluid 
consistency,  the  pulmonary  tissue  being  so  completely  disintegrated  that  it 
could  be  washed  away  with  a  stream  of  water.  There  was  no  gangrenous 
odour.  No  thrombosis  was  found  in  these  cases,  and  no  explanation  of 
their  origin  was  discovered  even  by  microscopical  examination.  There  was 
some  broncho-pneumonia  present.  Both  cases  occurred  in  infants  suf- 
ering  from  marasmus.  These  are  perhaps  to  be  classed  as  examples  of 
diffuse  gangrene,  although  they  differed  very  markedly  from  the  form 
usually  seen. 

Symptoms. — There  are  but  two  distinctive  symptoms  of  pulmonary 
gangrene  :  the  gangrenous  odour  of  the  breath,  and  the  expectoration  of 
masses  of  necrotic  lung  tissue.  In  the  cases  associated  with  acute  pneu- 
monia, which  include  the  majority  of  those  seen,  death  nearly  always 
takes  place  before  there  is  any  separation  of  the  sloughs,  and  even  before 
very  active  decomposition  in  the  necrotic  areas  has  occurred.  Both  the 
peculiar  symptoms  are  therefore  wanting,  and  the  diagnosis  is  made  only 
at  the  autopsy.     This  has  been  true  of  all  the  cases  which  have  come 


PULMONARY  COLLAPSE.  539 

under  my  own  observation.  But  these  patients,  with  one  exception,  were 
infants.  In  older  children,  particularly  in  cases  secondary  to  the  en- 
trance of  a  foreign  body,  the  characteristic  symptoms  are  more  fre- 
quently seen,  and  there  may  be  a  third  symptom — hgemorrhage.  This 
is  present  in  about  one  fourth  of  the  cases  (Rilliet  and  Barthez),  and 
may  be  fatal.  The  general  symptoms  associated  with  gangrene  are  those 
of  profound  depression,  and  often  all  the  signs  of  the  typhoid  condition 
are  present. 

From  what  has  already  been  said,  it  will  be  evident  that  the  diagnosis 
is  very  difficult  in  children,  and  that  most  cases  of  gangrene  of  the  lung 
are  overlooked.  Wlien  the  characteristic  odour  of  the  breath  is  present, 
conditions  in  the  mouth  from  which  it  might  arise  must  first  be  ex- 
cluded. The  physical  signs  differ  in  no  respect  from  those  of  ordinary 
cases  of  pneumonia.  The  termination  is  almost  always  in  death.  This 
is  due  not  only  to  the  condition  itself,  but  to  the  circumstances  in  which 
it  is  seen. 

Treatment. — The  general  treatment  is  supporting  and  stimulating,  as 
in  all  very  severe  cases  of  pneumonia.  For  the  local  process  but  little  can 
be  done,  except  the  inhalation  of  antiseptics,  of  which  creosote  and  tur- 
pentine are  undoubtedly  the  best. 

ACQUIRED   ATELECTASIS— PULMONARY   COLLAPSE. 

These  terms  are  applied  to  a  state  of  the  lung  resembling  the  foetal 
condition,  but  which  occurs  in  a  lung  which  has  once  been  expanded. 
Two  varieties  are  met  with  :  collapse  from  compression  and  collapse  from 
obstruction. 

Collapse  from  Compression. — The  principal  cause  of  this  form  is  pleu- 
ritic effusion.  It  may  also  be  produced  by  pneumothorax,  enlargement 
of  the  heart,  pericardial  effusion,  deformities  of  the  chest  from  rickets 
or  Pott's  disease,  and  tumours  of  the  mediastinum  or  thoracic  wall.  In 
these  conditions,  on  account  of  the  external  pressure,  the  air  vesicles  are 
not  filled,  although  the  bronchi  are  pervious.  The  elasticity  of  the  vesi- 
cles tends  to  exj^el  the  air  which  they  contain.  This  form  of  collapse 
may  be  complete  or  partial,  according  to  the  cause.  After  it  has  existed 
for  a  considerable  time,  changes  may  take  place  in  the  lung  which  ren- 
der expansion  difficult  or  impossible.  Unless,  however,  there  are  thick 
pleuritic  adhesions,  expansion  often  takes  place  readily  after  many  weeks 
and  even  months,  as  in  most  cases  it  is  the  condition  of  the  pleura,  rather 
than  of  the  lung  itself,  which  interferes  with  it.  In  recent  cases  only 
moderate  force  is  required  at  autopsy  to  produce  expansion  ;  in  old  cases 
it  is  more  difficult  and  may  be  impossible.  The  symptoms  and  signs  are 
those  of  the  original  disease. 

Treatment  is  available  chiefly  in  that  form  which  follows  pleuritic 
effusion,  and  will  be  considered  in  the  chapter  on  Empyema. 


540  DISEASES  OP   THE  RESPIRATORY  SYSTEM. 

Collapse  from  Obstruction. — This  is  due  to  two  factors :  blocking  of 
either  the  large  or  small  bronchial  tubes,  and  feeble  insj^iratory  force. 
The  importance  of  collapse  from  obstruction  as  a  factor  in  the  acute  dis- 
eases of  the  lung  in  infancy  has,  I  think,  been  very  much  exaggerated. 
It  is  well  known  that  whenever  a  large  or  small  bronchus  is  completely 
obstructed  by  a  foreign  body  so  that  the  entrance  of  air  is  prevented,  the 
portion  of  the  lung  to  which  the  bronchus  is  distributed  gradually  becomes 
collapsed.  If  it  is  one  of  the  primary  bronchi  which  is  occluded,  a  whole 
lung  may  be  collapsed ;  if  one  of  the  lobar  divisions,  an  entire  lobe ;  if 
one  of  the  smaller  divisions,  a  small  area,  usually  somewhat  wedge-shaped. 
The  collapse  does  not  take  place  immediately,  but  the  contents  of  the  air 
vesicles  are  gradually  absorbed  by  the  blood,  requiring  perhaps  twenty- 
four  hours,  or  even  longer.  According  to  Lichtheim,  the  oxygen  is  first 
absorbed,  then  the  carbon  dioxide,  and  finally  the  nitrogen.  The  collapsed 
portion  of  the  lung  is  smaller  than  the  inflated  portions,  and  consequently 
is  slightly  depressed  below  the  surface.  It  is  of  a  dark-red  colour,  very 
vascular,  and  to  the  naked  eye  resembles  a  pneumonic  area,  which  it 
may  subsequently  become. 

It  has  been  the  fashion  since  the  writings  of  Gairdner  to  explain 
the  development  of  broncho-pneumonia  from  bronchitis  of  the  smaller 
tubes,  through  the  intervention  of  pulmonary  collapse.  It  has  been 
assumed  that  the  obstruction  of  the  small  bronchi  from  swelling  of 
their  walls  and  the  accumulation  of  secretion,  produced  the  same  re- 
sult as  the  plugging  of  a  bronchus  by  a  foreign  body.  Without  going 
into  a  full  discussion  of  the  subject,  I  will  only  say  that  from  personal 
observations  upon  nearly  one  thousand  autopsies  upon  infants,  in  which 
are  included  a  very  large  number  of  the  acute  pulmonary  diseases  of 
all  varieties,  I  have  found  very  little  support  for  this  theory.  In  acute 
bronchitis  of  the  smaller  tubes  the  lumen  is  narrowed,  but  not  often 
to  such  a  degree  as  entirely  to  prevent  the  entrance  of  air.  This  con- 
dition of  stenosis  results,  as  a  rule,  in  the  production  of  emphysema, 
not  atelectasis.  Such,  at  least,  has  been  the  condition  in  the  cases 
in  which  I  have  had  an  opportunity  to  make  autopsies  in  the  ear- 
liest stage  of  broncho-pneumonia,  when  it  has  developed  from  a  gener- 
alized bronchitis  of  the  fine  tubes.  It  is  certainly  true  that  there  are 
very  often  groups  of  collapsed  air  vesicles  found  surrounding  those  which 
are  the  seat  of  pneumonia,  but  these  are  neither  an  essential  nor  a  very 
important  part  of  the  lesion.  Anything  approaching  collapse  of  a 
large  part  of  the  lung,  or  even  of  a  lobe,  I  have  never  seen,  either  in 
pertussis  or  in  acute  bronchitis,  nor  do  I  believe  that  it  occurs  in  ^the 
way  mentioned. 

There  is  occasionally  seen,  usually  in  very  delicate  infants  or  ia  those 
who  are  markedly  rachitic,  a  form  of  collapse  which  comes  on  very 
gradually.     It  is  accompanied  by  bronchitis  affecting  the  tubes  in  the 


EMPHYSEMA.  54I 

dependent  part  of  the  lung.  Its  seat  is  the  lower  lobes  posteriorly, 
sometimes  also  the  posterior  border  of  the  upper  lobes.  In  general 
appearance  it  may  resemble  the  congenital  form  of  atelectasis.  Under  the 
microscope  there  is  almost  invariably  found  accompanying  the  collapse, 
lobular  pneumonia  and  bronchitis  of  the  tubes  in  the  affected  regions. 

The  symptoms  are  much  the  same  as  in  persistent  congenital  atelec- 
tasis. In  marked  cases  the  respiration  is  rapid,  and  there  may  be  in- 
spiratory dyspncea  with  deep  recession  of  the  chest  walls,  especially 
if  there  is  rickets.  There  is  also  cyanosis  of  variable  intensity,  which 
may  be  constant  or  intermittent.  There  are  usually  present  a  short 
cough,  feeble  cry,  and  poor  circulation  with  cold  extremities.  The  tem- 
perature is  not  elevated,  but  frequently  is  subnormal.  The  physical  signs 
are  very  uncertain.  There  may  be  slight  dulness  and  very  feeble  respira- 
tory murmur  over  the  affected  areas,  occasionally  accompanied  by  moist 
rales.  '  The  course  and  termination  are  the  same  as  those  seen  in  some 
of  the  cases  of  congenital  atelectasis.  The  essential  point  of  difference 
is,  that  in  the  acquired  cases  the  patients  are  often  strong  at  birth,  crying 
and  breathing  well,  giving  no  signs  of  anything  wrong  in  the  lungs  until 
the  general  nutrition  has  suffered  from  some  other  cause.  The  symptoms 
come  on  gradually. 

The  following  is  a  fairly  typical  case  :  A  female  infant  thirteen  months 
old  had  been  under  observation  in  the  Nursery  and  Child's  Hospital  for 
several  months  before  death.  During  this  period  she  suffered  a  great  jDart 
of  the  time  from  mild  bronchitis.  The  child  was  extremely  rachitic,  and 
the  chest  showed  deep  lateral  furrows.  The  respiration  was  always  accel- 
erated, and  on  inspiration  the  lateral  recession  of  the  chest  was  at  times 
extreme.  There  was  occasionally  seen  slight  cyanosis,  and  during  the  last 
few  weeks  it  was  constant.  Death  occurred  quite  suddenly.  At  autopsy 
there  was  found  very  marked  vesicular  emphysema  of  both  lungs  in 
front.  Nearly  the  whole  of  both  lower  lobes  were  in  a  condition  of  col- 
lapse, and  of  a  uniform  grayish-purple  colour.  The  posterior  portion  of 
the  upper  lobes  was^  similarly  affected,  but  to  a  less  degree.  With  mod- 
erate force  all  of  the  collapsed  areas  could  be  completely  inflated.  Bron- 
chitis was  present,  but  the  pleura  was  normal. 

The  treatment  of  these  cases  is  the  same  as  that  outlined  in  the  chapter 
upon  Congenital  Atelectasis  (page  75). 

ExMPHYSEMA. 

Pulmonary  emphysema  consists  primarily  in  overdistention  of  the  air 
vesicles.  It  may  result  in  their  rupture  and  the  escape  of  air  into  the 
interlobular  connective  tissue  of  the  lung.  In  infancy  and  childhood  em- 
physema is  usually  associated  with  acute  processes. 

Etiology. — Cases  of  emphysema  are  divided  into  two  groups  which  are 
due  to  quite  different  causes.    In  one  group  it  is  compensatory,  and  consists 


542  DISEASES  OP  THE  RESPIRATORY  SYSTEM. 

in  overdistention  of  the  air  vesicles  in  certain  parts  of  the  lungs  because 
the  full  expansion  of  other  parts  is  prevented  either  because  they  are  con- 
solidated, as  in  pneumonia  or  tuberculosis,  bound  down  by  adhesions 
from  old  pleurisy,  or  subjected  to  external  pressure,  as  from  chest  de- 
formities due  to  Pott's  disease  or  rickets.  In  these  conditions  it  is  prob- 
able that  the  emphysema  is  produced  during  inspiration.  It  may  also  be 
produced  by  the  artificial  inflation  of  the  lungs  of  the  newly  born. 

In  the  second  group  of  cases  emphysema  is  produced  by  obstructive 
expiratory  dyspnoea  or  cough.  It  is  seen  in  all  forms  of  laryngeal  stenosis, 
in  acute  bronchitis  and  broncho-pneumonia,  in  asthma,  pertussis,  and 
occasionally  it  is  produced  by  any  condition  which  requires  deep  inspira- 
tion and  holding  the  breath.  A  case  has  been  reported  to  me  which 
occurred  in  a  little  boy,  who,  while  playing  that  he  was  a  steam  engine, 
would  hold  his  breath  for  a  long  time  and  then  issue  short,  forcible  ex- 
piratory puffs.  In  bronchitis  the  obstruction  may  be  caused  by  swelling 
of  the  mucous  membrane  or  by  an  accumulation  of  secretion.  In  this 
group  of  cases  air  enters  the  lung,  but  as  it  can  not  readily  escape,  the  air 
vesicles  are  distended,  sometimes  to  such  a  degree  that  their  resiliency  is 
almost  entirely  lost. 

Lesions. — The  most  common  form  in  early  life  is  acute  vesicular 
emphysema,  which  occurs  when  the  force  distending  the  air  cells  is  only 
moderate.  In  this  form  there  is  dilatation  of  the  vesicles  with  very  slight 
structural  changes,  there  being  usually  rupture  of  a  few  alveolar  septa 
only  (Fig.  77).  Although  the  dilatation  may  be  quite  marked,  the  emphy- 
sema is  not  permanent.  The  parts  most  affected  are  the  upper  lobes,  par- 
ticularly the  anterior  borders.  In  appearance  the  emphysematous  lung  is 
pale,  sometimes  almost  white.  The  areas  are  prominent,  and  do  not  col- 
lapse upon  opening  the  chest.  With  a  lens,  or  even  with  the  naked  eye, 
the  individual  air  vesicles  can  often  be  distinguished  as  minute  pearly 
bodies,  at  times  resembling  miliary  tubercles.  When  the  disease  is 
secondary  to  acute  bronchitis  or  laryngeal  stenosis  it  may  affect  nearly  the 
whole  of  both  lungs. 

AYith  a  greater  distending  force  rupture  of  many  of  the  air  vesicles 
results,  and  this'  may  give  rise  to  interstitial  or  interlobular  emphysema. 
At  times  blebs  are  formed,  varying  in  size  from  a  pin's  head  to  a  cherry. 
These  are  usually  seen  at  the  anterior  border  or  at  the  root  of  the  lung  on 
its  inner  surface.  Again,  the  air  finds  its  way  between  the  lobules,  dis- 
secting them  apart  in  all  directions  throughout  the  lung.  Sometimes  a 
large  part  of  the  surface  of  both  lungs  is  seamed  with  irregular  deep 
crevasses  containing  air,  the  largest  being'an  inch  or  more  in  length  and 
nearly  one  fourth  of  an  inch  wide.  The  most  severe  cases  occur  in  per- 
tussis. On  two  or  three  occasions  I  have  seen  this  form  of  emphysema, 
once  to  an  extreme  degree,  where  children  had  died  from  diseases  uncon- 
nected with  the  respiratory  tract,  and  where  no  history  could  be  obtained 


PLEURISY.  543 

which  threw  any  light  upon  the  etiology  of  the  emphysema.  Rupture  of 
the  blebs  which  form  at  the  root  of  the  lung  may  lead  to  emphysema  of 
the  mediastinum,  or  even  of  the  subcutaneous  connective  tissue  of  the  body. 
This  is  occasionally  seen  in  whooping-cough  and  in  laryngeal  stenosis. 
The  primary  or  substantive  form  of  emphysema  seen  in  adult  life  rarelv 
if  ever  occurs  in  childhood. 

Symptoms. — Emphysema  occurring  in  acute  pulmonary  diseases  gives 
rise  to  no  peculiar  symptoms  and  to  no  physical  signs  except  exag- 
gerated resonance  upon  percussion.  If  the  patients  recover  from  the 
original  disease,  the  emphysema  undoubtedly  disappears  completely  in 
the  course  of  a  few  weeks  or  months.  Acute  interlobular  emphysema 
can  not  be  diagnosticated  during  life.  The  lesion  is  of  such  a  nature 
that  complete  recovery  is  impossible,  although  improvement  often  takes 
place. 

The  treatment  of  emphysema  is  that  of  the  original  disease. 


CHAPTER   VI. 

PLEURISY. 

All  the  common  forms  of  inflammation  of  the  pleura  are  seen  in 
childhood.  In  the  great  majority  of  cases  they  are  secondary  to  disease 
of  the  lung  itself.  Serous  effusions  are  much  less  frequent  than  in 
adults,  and  under  three  years  they  are  extremely  rare.  Purulent  effu- 
sion (empyema)  is,  however,  much  more  often  seen  than  in  adult  life, 
and  it  is  the  most  important  variety  of  jjleurisy  with  which  the  physi- 
cian has  to  deal. 

Whether  inflammation  of  the  pleura  ever  occurs  as  a  strictly  primary 
disease  is  still  a  mooted  point.  Cases  are  occasionally  observed  clinically 
in  which  both  the  serous  and  purulent  forms  of  the  disease  appear  to  be 
primary,  but  these  are  extremely  rare.  Acute  pleurisy  may,  however,  fol- 
low inflammation  of  the  lung  so  rapidly  that  it  is  not  easy  to  determine 
that  the  lung  was  first  aifected.  In  infants,  extension  from  the  lung  is 
almost  the  sole  cause.  It  occurs  both  with  lobar  and  broncho-pneumonia, 
existing  to  some  degree  in  nearly  every  case  in  which  there  is  consolida- 
tion of  the  lung.  Xext  in  frequency  to  simple  pneumonia  as  a  cause  of 
pleurisy  are  the  tuberculous  processes  of  the  lung.  Tuberculous  pleurisy 
without  tuberculosis  of  the  lungs  or  the  bronchial  glands  is  of  doubtful 
occurrence.  Acute  pleurisy  is  not  an  infrequent  complication  of  the 
infectious  diseases,  particularly  scarlet  and  typhoid  fevers,  measles,  and 
influenza.  In  most  of  these  cases  also  it  is  secondary  to  disease  of  the 
lung.  Pleurisy  in  older  children  occasionally  follows  cold  and  exposure, 
36 


544  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

although  it  is  doubtful  whether  in  any  case  this  is  the  only  cause.     In 
them  also  it  may  occur  as  a  complication  of  rheumatism. 

The  most  important  cause  of  acute  pleurisy  being  extension  from 
pneumonia,  it  follows  that  it  is  most  frequent  in  the  cold  season,  that  it 
occurs  more  often  in  males  than  in  females,  and  between  the  ages  of  one 
and  five  years.  It  may,  however,  be  seen  at  all  ages,  and  may  even  occur 
in  intra-nterine  life.  The  youngest  case  in  which  I  have  found  extensive 
pleuritic  adhesions  as  an  evidence  of  previous  inflammation  was  in  an  in- 
fant of  three  months,  who  died  at  the  Randall's  Island  Hospital.  In  this 
case  firm  connective  tissue  adhesions  were  found  over  the  whole  of  both 

lungs. 

DRY   PLEURISY. 

In  infants  and  young  children  this  usually  accompanies  pneumonia  or 
tuberculous  processes  in  the  lung.     In  older  children  it  may  be  primary. 

Lesions. — On  account  of  the  frequency  with  which  this  occurs  in 
pneumonia  we  have  an  opportunity  of  observing  it  in  all  stages.  In  the 
mildest  varieties  it  affects  only  the  pulmonary  pleura,  and  occurs  over  the 
pneumonic  areas.  The  pleura  is  injected,  has  lost  its  lustre,  and  appears 
dull  or  roughened.  This  is  due  to  an  exudation  of  fibrin  upon  its  surface. 
If  the  process  continues,  more  fibrin  is  poured  out,  and  there  are  in  addition 
swelling  and  a  proliferation  of  the  connective-tissue  cells,  and  an  exuda- 
tion of  leucocytes  from  the  blood-vessels.  The  pleura  is  then  coated  with 
a  layer  of  fibrin  of  variable  thickness,  in  which  are  entangled  pus  cells 
and  new  connective-tissue  cells.  The  layer  of  fibrin  varies  from  the  thick- 
ness of  tissue  paper  to  that  of  an  ordinary  book  cover.  In  recent  cases  it 
may  easily  be  stripped  off,  while  in  older  ones  it  becomes  organized  and  is 
firmly  adherent.  The  colour  of  the  exudate  varies  with  the  number  of 
pus  cells.  It  is  gray,  grayish-yellow,  or  yellowish-green,  according  as 
these  cells  are  few  or  numerous.  As  a  rule,  dry  pleurisy  is  localized,  but 
the  two  opposing  surfaces  are  affected.  Part  of  the  exudate  is  usually 
absorbed,  but  it  is  doubtful  if  complete  recovery  occurs,  there  being  left 
behind  some  adhesions  between  the  visceral  and  parietal  layers. 

In  some  cases  of  dry  pleurisy  there  is  an  excessive  exudation  of  pus  cells. 
These  cases  are  most  common  in  young  children,  and  usually  occur  with 
pneumonia,  constituting  what  is  known  as  "  pleuro-pneumonia."  The 
process  is  essentially  the  same  as  in  the  cases  just  mentioned,  yet  the 
gross  appearance  differs  very  much  from  ordinary  dry  pleurisy.  The  le- 
sions have  already  been  described  under  the  head  of  Pleuro-Pneumonia 
(page  532). 

In  the  dry  form  of  tuberculous  pleurisy  there  may  be  only  an  exudation 
of  fibrin,  or  the  pleura  may  be  covered  with  gray  tubercles  and  yellow 
tuberculous  nodules.  These  are  not  only  seen  upon  the  pleura,  but  develop 
in  the  exudation.  In  this  form,  which  is  usually  chronic,  great  thickening 
of  the  pleura  may  take  place.     Both  the  serous  and  purulent  effusions 


PLEURISY  WITH  SEROUS  EFFUSION.  545 

occurring  in  conjunction  with  tuberculosis  are  likely  to  be  sacculated  be- 
cause of  the  previous  existence  of  adhesions. 

After  nearly  every  case  of  dry  pleurisy  there  probably  remains  some 
slight  thickening  of  the  pleura.  In  certain  cases  there  follows  a  chronic 
inflammation  of  the  pleura  with  the  production  of  new  connective  tissue, 
which  results  in  thickening  and  adhesions,  which  may  be  so  extensive  as 
to  entirely  obliterate  the  pleural  cavity.  Either  one  or  botli  sides  may  be 
affected.     This  form  is  extremely  rare  in  childhood. 

Symptoms. — As  an  independent  clinical  disease,  acute  dry  pleurisy  has 
no  existence  in  infancy  or  early  childhood.  The  cases  which  are  occa- 
sionally so  diagnosticated  have  in  my  experience  invariably  proven  to  be 
broncho-pneumonia.  In  children  from  ten  to  fourteen  years  old,  dry 
pleurisy  may  occur  under  the  same  conditions  as  in  adults. 

The  symptoms  are  sharp,  localized  pain,  increased  by  full  inspiration, 
sometimes  tenderness  upon  pressure,  and  a  short,  teasing  cough.  The  pain 
is  not  always  felt  upon  the  affected  side,  and  it  may  be  referred  to  the  ab- 
domen. Upon  physical  examination,  dry  jjleurisy  is  recognised  by  the  pres- 
ence of  a  pleuritic  frictioji  sound.  This  is  usually  of  a  moist,  crackling 
♦.character,  generally  localized,  and  heard  both  on  inspiration  and  expira- 
tion. It  is  quite  superficial,  and  not  changed  by  coughing.  This  form 
of  pleurisy,  as  a  rule,  runs  a  course  of  a  few  days  or  a  week,  without  con- 
stitutional symptoms.  When  dry  pleurisy  occurs  as  a  complication  of 
pneumonia  it  is  recognised  by  the  signs  just  mentioned  ;  but  it  usnall}' 
causes  no  new  symptoms  except  pain. 

Treatment. — The  treatment  consists  in  counter-irritation  by  mustard, 
iodine,  or  blisters,  according  to  the  severity  of  the  inflammation,  and  in 
the  use  of  opium.  Severe  pain  can  sometimes  be  relieved  by  firmly  en- 
circling the  chest  with  a  broad  band  of  adhesive  plaster. 

PLEURISY    WITH   SEROUS   EFFUSION. 

This  form  of  pleurisy  is  infrequent  in  children,  and  under  three  years 
it  is  very  rare.  It  may  occur  as  a  complication  of  pneumonia,  nephritis, 
acute  rheumatism,  scai'let  fever,  or  any  of  the  other  acute  infectious  dis- 
eases. It  may  be  tuberculous.  In  rare  cases  it  appears  to  be  primary. 
Bacteria  are  occasionally  present  in  the  exudation,  even  in  cases  which  do 
not  become  purulent,  but  their  number  is  usually  small.  The  pneiimo 
coccus,  the  streptococcus,  and  the  tubercle  bacillus  are  the  forms  most 
often  seen. 

Lesions. — The  early  changes  are  much  the  same  as  in  dry  pleurisy, 
but  in  addition  serum  is  poured  out  from  the  blood-vessels,  in  some  cases 
almost  from  the  beginning  of  the  inflammation.  This  may  be  small  in 
amount,  or  it  may  fill  the  pleural  cavity.  The  lesions  are  similar  to  those 
seen  in  adults,  except  that  there  is  apt  to  be  more  fibrin  in  children.  The 
process  usually  terminates  in  absorption  of  the  serum,  but,  as  in  dry  pleurisy, 


546  DISEASES  OP   THE   RESPIRATORY   SYSTEM. 

more  or  less  extensive  adhesions  are  left  behind  from  the  fibrinous  exu- 
dation. 

Symptoms. — The  small  serous  effusions  of  one  or  two  ounces,  occurring 
with  the  dry  pleurisy  that  complicates  pneumonia,  rarely  cause  either 
symptoms  or  physical  signs  by  which  they  can  be  recognised.  In  the 
present  connection  only  those  cases  will  be  discussed  in  which  the  amount 
of  effusion  is  considerable.  This  form  of  pleurisy  sometimes  follows  a 
well-defined  attack  of  pneumonia.  Other  cases  come  on  with  acute  febrile 
symptoms  somewhat  resembling  those  of  pneumonia,  but  with  all  the 
symptoms  less  severe,  except  the  pain.  After  an  illness  of  only  two  or 
three  days  the  chest  may  be  found  full  of  fluid.  In  a  third  class  the  dis- 
ease comes  on  insidiously,  with  little  or  no  fever,  and  often  with  no  dis- 
tinct pulmonary  symptoms  except  shortness  of  breath.  There  are  general 
weakness,  sometimes  loss  of  flesh,  anasmia,  and  moderate  prostration ;  but 
usually  the  patients  are  not  sick  enough  to  go  to  bed.  The  symptoms 
of  pleurisy  with  effusion  vary  greatly.  When  it  occurs  as  a  complication  of 
some  acute  infectious  disease,  it  is  often  latent,  and  the  diagnosis  is  to  be 
made  only  by  the  physical  examination  of  the  chest. 

The  usual  course  of  the  disease  is  for  the  fluid  to  disappear  gradually 
by  absorption,  the  case  going  on  to  spontaneous  recovery.  Serious  symp- 
toms resulting  from  pressure  upon  the  heart  and  lungs  are  not  common, 
but  may  occur  when  the  fluid  accumulates  rapidly ;  hence  they  are  most 
likely  to  be  seen  early  in  the  attack.  There  may  be  great  dys2:)ncea,  some- 
times orthopnoea,  cyanosis,  weak  pulse,  and  even  attacks  of  syncope. 
Death  may  occur  with  these  symptoms.  In  certain  cases  there  is  seen  no 
tendency  to  spontaneous  absorption,  and  the  exudation  may  remain  sta- 
tionary for  months.  There  may  then  be  fever,  usually  slight  but  some- 
times quite  regular,  with  a  decline  in  the  general  health,  pallor  and 
ana?mia,  which  may  strongly  suggest  the  existence  of  pus,  although  this 
is  not  present.     Others  are  regarded  as  cases  of  tuberculosis. 

Physical  Signs.- — The  signs  in  the  chest  are  essentially  the  same  whether 
the  fluid  is  serous  or  purulent.  On  inspection,  there  is  diminished  move- 
ment of  the  affected  side,  sometimes  bulging  of  the  intercostal  spaces,  and 
if  the  effusion  is  large,  an  increase  in  the  measurement  of  the  affected  side 
of  the  chest.  The  apex  beat  of  the  heart  Avill  usually  be  considerably  dis- 
placed if  the  effusion  is  upon  the  left  side.  It  may  be  found  at  the  epi- 
gastrium, at  the  right  border  of  the  sternum,  or  even  in  the  right  mam- 
mary line.  In  disease  of  the  right  side  the  displacement  is  less,  and 
occurs  only  with  a  large  effusion.  It  may  then  be  found  in  or  near  the 
left  axillary  line.  On  palpation,  the  vocal  fremitus  is  usually  diminished 
or  absent,  but  it  may  be  but  little  changed.  Percussion  gives  marked  dul- 
ness  or  flatness.  In  a  large  effusion  this  is  over  the  entire  lung.  There 
is  also  a  sensation  of  increased  resistance  appreciable  by  the  percussing 
finger.     AVitli  a  smaller  effusion  there  is  usually  flatness  over  the  lower 


PLEURISY   WITH   SEROUS  EFFUSION.  547 

part  of  the  chest  and  dulness  or  tympanitic  resonance  above ;  sometimes 
■dulness  is  fonnd  behind  and  tympanitic  resonance  at  the  apex  in  front. 
The  line  of  flatness  may  change  with  the  position  of  the  patient.  The 
signs  on  auscultation  are  variable,  and  probably  lead  to  more  frequent 
mistakes  in  diagnosis  than  in  any  other  pulmonary  affection.  Bronchial 
breathing  and  bronchial  voice  over  the  fluid  are  the  rule  in  children ;  they 
are  generally  more  distinct  the  greater  the  effusion.  Absence  of  both  voice 
and  breathing  is  sometimes  met  with,  but  it  is  exceptional.  The  bronchial 
breathing  over  fluid  usually  differs  from  that  over  consolidation,  in  that  it 
is  feebler  and  distant ;  in  some  cases,  however,  it  is  indistinguishable  from 
that  heard  over  consolidation.  Friction  sounds  may  be  heard  above  the 
level  of  the  fluid,  or  when  the  fluid  is  subsiding,  and  there  may  be  bron- 
chial rales. 

Diagnosis. — The  most  reliable  signs  for  diagnosis  are  displacement  of 
the  heart,  flatness  on  percussion,  absence  of  rales  and  friction  sounds,  and 
(usually  distant)  bronchial  breathing.  In  an  infant,  flatness  should  always 
lead  one  to  suspect  fluid.  If  there  is  flatness  over  one  entire  lung,  the 
existence  of  fluid  is  almost  certain.  Between  serous  and  purulent  effusions 
a  positive  diagnosis  is  possible  only  by  the  use  of  the  exploring  needle. 
This  should  be  employed  in  every  case,  as  for  treatment  it  is  important  to 
know  at  once  whether  or  not  we  have  a  purulent  effusion  to  deal  with. 
The  amount  of  fluid  in  serous  pleurisy  is  generally  less  than  in  the  puru- 
lent variety. 

Pleurisy  is  further  to  be  differentiated  from  pneumonia,  and  from  tuber- 
culosis. From  pneumonia,  the  acute  cases  are  distinguished  by  the  lower 
temperature,  the  less  severe  prostration,  and  the  fact  that  all  the  general 
symptoms  are  milder,  but  especially  by  the  physical  signs.  The  differential 
diagnosis  by  the  physical  signs  between  effusion  and  the  various  forms  of 
consolidation  is  considered  under  the  head  of  Empyema  (page  552). 

Prognosis. — These  cases,  as  a  rule,  terminate  in  recovery,  death  being 
very  infrequent.  In  cases  coming  on  without  definite  cause  there  should 
always  exist  a  suspicion  of  tuberculosis,  and  hence  every  patient  should  be 
closely  watched  for  the  development  of  the  other  signs  of  that  disease. 

Treatment. — In  the  great  majority  of  cases,  only  symptomatic  treat- 
ment is  requited  during  the  acute  period.  The  patient  should  be  kept 
in  bed,  and  pain  relieved  by  opium,  counter-irritation,  or  hot  poultices. 
After  the  fever  has  ceased  the  patient  may  be  allowed  to  sit  up,  but  all 
exertion  should  be  carefully  avoided  if  the  effusion  is  large.  Sudden 
death  has  often  occurred  when  this  rule  has  been  violated.  The  patient 
should  in  suitable  weather  be  kept  in  the  open  air  as  much  as  possible. 
In  the  course  of  a  few  weeks  the  effusion  usually  subsides  under  simple 
tonic  treatment.  Absorption  may  sometimes  be  hastened  by  counter- 
irritation  and  diuretics ;  but  convalescence  is  apt  to  be  slow,  and  it  may 
be  several  months  before  the  health  is  entirely  restored. 


548  DISEASES  OP  THE   RESPIRATORY   SYSTEM. 

The  removal  of  the  fluid  by  operation  is  indicated  in  the  acute  stage 
when  it  is  accumulating  so  rapidly  as  to  endanger  life  from  the  pressure 
upon  the  heart  and  lungs ;  also  when  there  is  no  tendency  to  absorption 
after  from  two  to  three  weeks  of  constitutional  treatment.  In  such  cases 
nothing  is  to  be  gained  by  waiting,  and  harm  may  be  done  to  the  lung  by 
the  delay.  The  usual  method  is  by  aspiration.  In  the  acute  stage  enough 
should  be  removed  to  relieve  the  patient's  symptoms,  aspiration  being  re- 
peated if  necessary  in  twelve  or  twenty-four  hours.  In  the  sub-acute  stage 
the  removal  of  a  portion  of  the  fluid  may  be  all  that  is  required,  spontaneous 
absorption  of  the  remainder  often  taking  place  then  quite  promptly.  A 
few  cases  of  serous  pleurisy  have  been  incised  and  drained  as  cases  of 
empyema.  Scharlau  (New  York)  operated  in  such  a  case  in  an  infant 
two  years  old.  The  effusion  came  on  acutely  and  was  excessive,  the  chest 
having  refilled  very  quickly  after  aspiration.  The  chest  was  incised  and 
drained  and  the  patient  recovered  in  five  days.  In  chronic  cases,  in  which 
there  are  slight  fever  and  a  gradual  failure  of  general  health,  the  opera- 
tion of  incision  is  by  some  preferred  to  aspiration. 

EMPYEMA. 

Fully  nine  tenths  of  the  cases  of  empyema  in  children  under  five  years 
either  occur  with  or  follow  pneumonia,  being  usually  the  sequel  of  the 
form  described  as  pleuro-pneumonia.  In  some  of  these  cases,  however, 
the  pleurisy  masks  the  pneumonia,  so  that  the  former  appears  to  be  the 
primary  disease.  Tuberculosis  is  a  rare  cause  in  early  childhood,  but  be- 
comes more  frequent  after  the  seventh  year.  Empyema  may  complicate 
scarlet  fever,  measles,  or  any  of  the  other  acute  infectious  diseases.  It  is 
met  with  in  pyemia  from  all  causes.  It  may  occur  in  the  newly  born  as 
the  result  of  infection  through  the  umbilical  wound  or  the  skin.  It  is 
seen  with  suppurative  inflammations  of  the  joints  and  in  osteo-myelitis. 
It  may  complicate  suppurative  processes  in  the  abdomen,  such  as  ap- 
pendicitis or  purulent  peritonitis.  Among  the  local  causes  may  be  men- 
tioned traumatism,  necrosis  of  a  rib,  and  the  rupture  into  the  pleural  cav- 
ity of  abscesses  originating  in  the  mediastinum,  in  the  thoracic  wall,  or 
below  the  diaphragm. 

Bacteriology. — Much  light  upon  the  etiology  of  empyema  has  been 
thrown  by  the  bacteriological  investigations  of  the  past  few  years,  espe- 
cially by  the  work  of  Fraenkel,  Weichselbaum,  Levy,  and  Netter  in 
Europe,  and  Prudden  and  Koplik  in  this  country.  Bacteriologically,  we 
may  divide  the  cases  into  several  groups  : 

1.  Those  containing  the  pneumococcus  (micrococcus  lanceolatus),  usu- 
ally in  pure  culture.  This  is  the  largest  group,  and  includes  nearly  all  the 
cases  secondary  to  pneumonia.  The  pleura  is  usually  involved  by  direct 
infection  from  the  lung. 

2.  Those  containing  other  pyogenic  germs,  particularly  the  strepto- 


EMPYEMA.  549 

COCCUS  pyogenes  and  tlie  stupliylococcus.  Of  tliese  the  streptococcus  is 
the  most  important.  It  may  be  found  alone,  but  is  usually  associated 
with  the  pneumococcus.  This  combination  is  likely  to  be  found  in  cases 
secondary  to  the  pneumonia  which  occurs  with  the  infectious  diseases. 
The  streptococcus  and  staphylococcus  occur  in  the  pleurisy  of  pyaemia, 
and  usually  also  when  the  disease  is  due  to  the  rupture  of  abscesses  into 
the  pleural  cavity. 

3.  The  cases  due  to  tuberculosis.  In  this  group  the  presence  of  the 
tubercle  bacillus  is  very  often  difficult  to  demonstrate,  and  it  may  be 
absent.  From  this  fact  the  statement  is  made  by  Levy  that,  if  no  biic- 
teria  can  be  found  in  a  purulent  exudate,  tuberculosis  should  always  be 
suspected.  It  is  not,  however,  safe  to  conclude  that  under  these  circum- 
stances tuberculosis  is  always  present. 

Of  nineteen  successive  cases  of  empyema  occurring  in  my  own  prac- 
tice, the  pneumococcus  was  found  alone  in  fourteen ;  the  streptococcus 
alone  in  three ;  the  pneumococcus  and  streptococcus  in  one  ;  and  the  staphy- 
lococcus alone  in  one. 

Lesions. — This  is  an  inflammation  with  the  production  of  serum,  fibrin, 
and  pus.  In  most  of  the  cases — and  the  younger  the  child  the  more  fre- 
quent its  occurrence— empyema  succeeds  the  form  of  pleurisy  in  which 
there  is  first  an  exudation  of  fibrin  with  an  excess  of  pus  cells  [vide 
supra).  As  the  process  continues,  more  and  more  pus  is  poured  out, 
with  serum.  At  first  the  fluid  collects  in  small  pockets  formed  by  the 
slight  adhesions.  As  it  accumulates  these  are  broken  down,  and  the  pleu- 
ral cavity  may  be  filled  with  pus.  If  the  original  inflammation  involved 
but  a  portion  of  the  pleura  the  empyema  may  be  sacculated.  This  is  often 
seen  even  in  infants.  Sacculated  empyema  is  usually  posterior,  but  may  be 
in  any  part  of  the  chest.  In  very  rare  cases  there  may  be  several  sacs 
containing  pus,  separated  by  septa.  This  I  have  never  seen  in  empyema 
following  pneumonia.  The  cases  just  described  are  those  in  which,  in  in- 
fants and  young  children,  the  pneumococcus  is  regularly  found.  The 
amount  of  fibrin  is  large,  covers  both  surfaces  of  the  pleura,  and  many 
large  masses  float  in  the  fluid.  The  pus  is  usually  thick,  creamy,  and 
odourless.  In  another  group  of  cases  the  evidences  of  inflammation  of  the 
pleura  are  much  less  marked,  and  in  some  they  may  be  slight.  There  is 
but  little  fibrin  in  the  exudate,  and  adhesions  are  rare.  In  this  form  the 
streptococcus  or  the  staphylococcus  are  the  organisms  usually  found.  In 
these  cases  the  inflammation  may  be  purulent  from  the  outset,  and  the 
pus  is  thinner  than  the  preceding  variety.  It  is  rare  that  empyema  in  a 
young  child  results  from  a  serous  effusion  which  has  been  gradually  con- 
verted into  a  purulent  one.     I  can  recall  but  a  single  instance. 

Even  when  the  fluid  is  moderate  in  quantity  it  is  not  all  at  the  bottom 
of  the  chest,  but  is  generally  distributed  over  a  considerable  part  of  its 
surface,  and  its  depth  at  the  middle  and  upper  part  of  the  chest  may  be 


550 


DISEASES   OF   THE   RESPIRATORY   SYSTEM. 


only  half  an  inch,  or  even  less.  When  the  accnmnlation  is  larger,  the 
lung  does  not  float  on  the  surface  of  the  fluid,  hut  the  fluid  surrounds 
the  lung,  which  is  compressed  on  all  sides  (Fig.  99).  The  heart  is  dis- 
placed ;  the  diaphragm  and 
the  abdominal  viscera  are 
somewhat  depressed,  and 
there  may  be  bulging  of 
the  chest  on  the  affected 
side.  The  amount  of  fluid 
in  ordinary  cases  is  from 
half  a  pint  to  two  pints, 
although  in  neglected  cases 
it  may  accumulate  until  it 
amounts  to  four  or  five 
pints.  The  effect  upon  the 
lung  will  depend  upon  the 
amount  of  fliiid  and  the 
duration  of  the  compres- 
sion. When  the  quantity 
is  small,  or  when  the  pres- 
sure is  removed  early,  the 
lung  in  most  cases  readily 
expands,  air  being  forced 
into  it  from  the  opposite 
lung,  especially  during  the 
act  of  coughing.  If  the 
pressure  is  great  and  has 
been  long  continued,  the 
adhesions  over  the  lung 
may  become  so  dense  and  firm  that  expansion  is  difficult,  and  can  at  best 
be  only  partial.  In  such  cases  recession  of  the  chest  wall  occurs.  In  very 
old  cases,  expansion  is  still  further  interfered  with  by  the  changes  taking 
jilace  in  the  lung  itself,  usually  a  low  grade  of  interstitial  pneumonia. 

In  cases  of  empyema  receiving  proper  surgical  treatment  reasonably 
early,  full  expansion  of  the  lung  occurs,  and,  with  the  exception  of  adhe- 
sions, recovery  may  be  complete.  Although  wide  in  extent,  the  adhesions 
are  not  usually  strong  enough  to  interfere  seriously  with  the  function  of 
the  lung.  In  cases  receiving  no  treatment,  absorption  of  the  pus  is  pos- 
sible, but  is  not  to  be  expected.  It  generally  seeks  an  external  outlet ;  the 
lung  may  be  perforated  and  the  pus  evacuated  through  the  bronchi,  or 
external  rupture  may  occur,  generally  in  the  neighbourhood  of  the  nipple. 
In  still  other  cases  the  pus  may  burrow  along  the  sjjine,  or  through  the 
diaphragm  may  reach  the  peritonaeum. 

Empyema  is  more  often  of  the  left  than  of  the  right  side,  the  propor- 


Tio.  99. — Section  of  a  lung  to  illuHtrate  the  distribution  of 
the  fluid  in  the  chest  in  a  moderately  large  ettusion 
(diagrammatic). 


EMPYEMA.  551 

tion  being  about  tlirce  to  two.  It  is  double  in  about  three  per  cent  of  the 
cases.  The  most  serious  complication  in  young  children  is  pericarditis, 
which  usually  occurs  with  empyema  of  the  left  side.  In  older  children 
the  most  frequent  complication  is  pulmonary  tuberculosis. 

Sjrmptoms. — When  it  occurs  as  a  sequel  of  pneumonia,  the  symptoms 
of  empyema  may  follow  those  of  the  original  disease  without  any  inter- 
mission ;  or  after  the  temperature  has  been  normal  or  nearly  so  for  sev- 
eral days  it  may  rise  again,  sometimes  quite  suddenly,  but  more  often 
gradually.  With  this  accession  of  fever  there  are  other  symptoms  point- 
ing to  an  increase  in  the  thoracic  disease.  After  scarlet  fever  or  other  in- 
fectious diseases,  the  onset  of  empyema  is  often  signalized  by  cough,  rapid 
breathing,  and  the  other  usual  symptoms  of  pulmonary  disease.  In  the 
cases  where  emjiyema  appears  to  be  primary,  the  onset  is  sudden,  with 
high  temperature  and  general  and  local  symptoms  resembling  those  of 
pneumonia.  After  such  a  beginning,  the  chest  may  be  found  full  of  pus 
by  the  third  or  fourth  day.  In  rare  cases  emjiyema  may  come  on  with 
gradual,  and  even  insidious,  symptoms,  there  being  only  slight  fever,  dysp- 
noea, and  cachexia.     This  is  usually  seen  in  older  children. 

Whatever  may  have  been  the  mode  of  onset,  when  the  pus  has  been 
in  the  chest  for  some  time  the  symptoms  are  fairly  uniform.  There  are 
cachexia,  pallor,  amemia,  and  prostration  which  is  generally  sufficient  to 
keep  the  child  in  bed.  The  respirations  are  always  accelerated,  being 
usually  from  forty  to  seventy  a  minute.  Cough  is  present ;  there  is  dysp- 
noea, sometimes  marked,  but  more  often  it  is  scarcely  noticeable.  Fever 
is  exceedingly  variable;  it  is  rarely  high,  not  often  above  102°  or  103°  F. ; 
in  many  cases  it  is  not  over  100°  F.,  and  it  may  be  absent  altogether.  A 
typical  hectic  temperature  with  sweating,  is  in  my  experience  very  rare. 
The  pulse  is  rapid  but  of  fair  strength.  There  is  loss  of  flesh,  sometimes 
even  emaciation  and  anorexia;  occasionally  there  is  diarrhea.  In  chronic 
cases  the  general  symptoms  may  closely  resemble  those  of  tuberculosis. 
There  may  be  clubbing  of  the  fingers,  albuminuria,  and  even  swelling  of 
the  feet. 

Diagnosis. — The  physical  signs  do  not  differ  essentially  from  those 
present  in  serous  effusions  (page  516).  Usually  the  history  and  the  con- 
stitutional symptoms  enable  us  to  make  a  diagnosis  between  serous  and 
jiurulent  effusions  with  tolerable  certainty.  If  the  patient  is  under  three 
vears  of  age,  the  fluid  is  almost  certain  to  be  purulent ;  and  from  the  third 
to  the  seventh  year,  pus  is  much  more  often  found  than  serum.  In  every 
case  in  which  fluid  is  suspected  the  exploring  needle  should  be  used,  be- 
cause of  the  great  importance  of  an  early  diagnosis.  The  skin  should  be 
washed,  the  needle  sterilized,  and  the  arm  raised  so  as  to  separate  the  ribs. 
Pus  may  not  be  found  because  the  needle  is  too  small,  too  short,  or  because 
it  is  introduced  too  far  into  the  chest ;  for  when  the  layer  of  pus  is  thin 
the  needle  may  be  pushed  through  this  into  the  lung.     If  the  physical 


552  DISEASES  OP  THE  RESPIRATORY   SYSTEM. 

signs  point  to  fluid,  and  if  it  is  not  found  at  the  first  trial,  repeated  punc- 
tures should  be  made  until  the  presence  or  absence  of  fluid  is  definitely 
settled.  In  some  cases  eight  or  ten  punctures  may  be  necessary  to  decide 
the  matter. 

Empyema  is  most  frequently  confounded  with  nnresolved  pneumo- 
nia. The  mistake  of  regarding  empyema  as  nnresolved  pneumonia  is 
much  more  common  than  the  reverse.  The  history  may  be  the  same  in 
both  cases,  and  the  general  symptoms  may  closely  resemble  each  other. 
The  differential  points  are,  that  in  unresolved  pneumonia  there  is  dulness, 
usually  over  a  single  lobe,  rales  or  friction  sounds  are  heard,  and  there  is  no 
displacement  of  the  heart.  Empyema  gives  flatness  over  the  whole  lung, 
or  over  the  lower  half  of  the  chest  in  front  and  behind,  with  no  rales  or 
friction  sounds,  and  the  heart  is  displaced  ;  and  when  empyema  is  sacculated, 
it  is  generally,  but  not  always,  at  the  base  behind.  In  both  conditions  we 
may  get  bronchial  breathing  and  voice.  The  difficulty  in  differentiating 
consolidation  due  to  acute  pneumonia  or  tuberculosis  from  empyema, 
generally  arises  from  placing  too  much  reliance  upon  the  auscultatory 
signs.  Here  also  the  flatness,  displacement  of  the  heart,  and  the  feeble, 
distant  character  of  the  bronchial  breathing  usually  suffice  to  make  clear 
the  diagnosis.  In  pleuro-pneumonia,  with  an  excessive  exudation  of  fibrin, 
the  signs  may  be  identical  with  those  of  empyema,  except  that  the  heart 
is  not  displaced.  I  have  once  seen  pulmonary  tuberculosis  with  caseation 
of  an  entire  lobe  which  gave  signs  that  were  identical  with  those  of  a  saccu- 
lated empyema.  It  is  by  the  exploring  needle,  and  by  that  alone,  that 
empyema  is  positively  differentiated  from  other  pulmonary  diseases.  Oth- 
er diseases  than  those  of  the  lung  may  be  confounded  with  empyema, 
particularly  typhoid  fever  and  malaria ;  but  from  these  empyema  is  dis- 
tinguished by  the  physical  examination  of  the  chest. 

Prognosis. — The  outcome  of  a  case  of  empyema  depends  upon  four 
factors  :  the  cause,  the  age  of  the  patient,  the  duration  of  the  symptoms, 
and  the  treatment.  The  best  results  are  obtained  in  the  cases  that  follow 
pneumonia.  Tuberculosis  before  the  seventh  year  is  an  exceedingly  infre- 
quent cause,  and  gangrene  of  the  lung  and  general  pysemia  are  both  rare 
causes  in  early  life.  The  three  etiological  factors  last  mentioned  are  those 
which  make  the  prognosis  of  the  disease  in  adults  so  serious.  I  can  recall 
but  two  deaths  in  children  over  two  years  old  which  were  due  to  empyema. 
In  one  case  operation  was  refused,  and  in  the  other  death  was  due  to  mul- 
tiple abscesses  of  the  lung.  The  mortality  in  hospital  cases  in  infants 
under  one  year  is  high — fully  50  per  cent — not  only  because  of  the  ten- 
der age,  but  because  of  the  wretched  general  condition  of  the  patients. 
Empyema  in  older  children,  seen  reasonably  early — i.  e.,  within  six  or 
eight  weeks — and  receiving  proper  treatment,  almost  invariably  termi- 
nates in  recovery,  unless  the  disease  is  double  or  complications  exist. 
The  longer  operation  is  delayed  the  worse  the  prognosis,  because  the  more 


EMPYEMA.  -  553 

difficult  the  expansion  of  the  lung,  the  more  tedious  the  disease,  and  the 
greater  the  likelihood  of  a  sinus  remaining.  With  proper  early  treatment 
these  patients  not  only  recover,  but  they  recover  perfectly,  and  in  most 
cases  rapidly.  Retraction  of  the  chest  and  its  resulting  lateral  curvature 
of  the  spine  are  extremely  rare,  and  seen  only  in  neglected  cases.  In  the 
great  majority  of  the  cases  I  have  seen,  in  which  a  reasonably  early  oper- 
ation was  done,  it  was  impossible,  after  the  lapse  of  one  or  two  years,  to 
detect  any  difference  whatever  in  the  physical  signs  of  the  two  sides  of 
the  chest.  There  is  no  serious  disease  the  treatment  of  which  is  usually 
more  satisfactory  than  that  of  acute  empyema  in  a  young  child. 

Spontaneous  recovery  in  empyema  may  take  place  by  absorption  ;  but 
this  is  so  rare  that  it  is  never  to  be  expected,  although  there  is  conclusive 
evidence  that  it  is  possible.  The  pus  may  be  evacuated  spontaneously 
through  a  bronchus,  rupture  having  taken  place  through  the  visceral 
pleura.  When  this  occurs,  a  large  amount  of  pus  may  be  coughed  up  in  a 
few  hours,  usually  followed  by  immediate,  but  not  always  lasting,  improve- 
ment. This  is  the  most  favourable  of  the  natural  terminations.  External 
opening  may  take  place,  usually  about  the  nipple.  There  is  an  area  of 
redness,  then  a  fluctuating  tumour,  and  finally  the  pointing  of  an  abscess. 
The  discharge  may  continue  for  months,  or  even  for  years.  External 
opening  rarely  occurs  until  the  disease  has  lasted  several  months.  Of  19 
cases  of  empyema  in  children  collected  by  Schmidt,  in  which  a  spontaneous 
discharge  of  pus  occurred  either  externally  or  through  a  bronchus,  there 
were  17  deaths  and  2  recoveries.  Empyema  may  burrow  behind  the  dia- 
phragm into  the  abdominal  cavity,  appearing  as  a  psoas  abscess ;  it  may 
burrow  posteriorly  into  the  lumbar  region  ;  it  may  rupture  into  the  oesoph- 
agus, or  through  the  diaphragm  into  the  peritoneal  cavity.  All  these 
conditions,  however,  are  very  rare.  The  chances  of  spontaneous  cure  in 
empyema  are  small.  Of  32  cases,  reported  by  Eilliet  and  Barthez,  which 
received  no  surgical  treatment,  21  proved  fatal.  The  statistics  of  empyema 
before  the  general  adoption  of  surgical  treatment  are  simply  appalling. 
Patients  were  either  worn  out  by  the  protracted  suppuration,  or  died  from 
amyloid  degeneration,  pneumonia,  or  tuberculosis. 

Treatment. — The  medical  treatment  relates  to  the  patient  only ;  the 
disease  is  always  to  be  treated  surgically.  Like  any  other  acute  abscess, 
empyema  requires  free  incision  and  drainage  with  proper  antiseptic  pre- 
cautions. 

Aspiratio7i  as  a  means  of  cure  has  been  almost  entirely  given  up  in 
New  York.  Unquestionably  it  sometimes  suffices  to  cure  empyema,  most 
frequently  when  it  is  localized.  How  often  this  occurs  is  shown  by  the 
following  statistics :  Of  139  cases  which  I  collected  that  were  treated  by 
aspiration,  25  were  cured,  8  of  these  by  a  single  aspiration  ;  13  died,  and  the 
remaining  101  were  afterward  subjected  to  other  treatment.  The  objections 
to  aspiration  are :  Tliat  it  is  not  possible  to  remove  all  the  pus ;  that  it 


554  DISEASES   OP   THE   RESPIRATORY   SYSTEM. 

affords  no  opportunity  for  the  removal  of  the  fibrinous  masses  usually  pres- 
ent in  large  quantities  in  the  exudate  ;  and,  finally,  that  it  is  only  a  possi- 
ble means  of  cure.  The  terror  caused  by  repeated  aspirations  is  almost  as 
great  as  that  of  incision  without  anaesthesia.  In  this  way  valuable  time 
is  lost,  the  disease  is  unduly  prolonged,  and  the  chances  of  success  by 
subsequent  incision  are  greatly  diminished.  Aspiration,  therefore,  is  to  be 
advised  only  for  temporary  relief  when  the  amount  of  fluid  is  large  and 
the  symptoms  are  urgent.  Enough  pus  may  thus  be  removed  to  relieve 
the  immediate  symptoms,  incision  being  deferred  for  a  day  or  two.  Even 
under  these  conditions  its  advantages  over  a  primary  incision  are  open 
to  question. 

Puncture  with  a  trocar  and  camda  was  formerly  much  practised,  but 
it  has  almost  entirely  passed  into  disuse. 

Simple  incision  and  drainage. — Incision  is  usually  advisable  as  soon 
as  the  diagnosis  is  made.  There  is  no  advantage  in  delay,  provided  the 
patient's  general  condition  be  such  as  to  stand  the  slight  shock  of  the 
operation.  The  dangers  attendant  upon  general  anesthesia  are  so  great 
that  it  is  better  not  to  employ  it  at  all.  I  have  known  four  deaths  to 
occur  on  the  table  during  the  operation,  and  in  several  other  cases  have 
seen  very  dangerous  symptoms  from  general  ana?sthesia.  Chloroform  is 
more  to  be  feared  than  ether.  We  should,  then,  rely  upon  the  local 
anesthesia  obtained  by  a  spray  of  chloride  of  ethyl  or  ether,  or,  better  still, 
by  cocaine.  The  most  favourable  point  for  incision  is  the  posterior  axillary 
line  in  the  seventh  intercostal  space  upon  the  right  side,  the  eighth  upon 
the  left.  In  a  case  of  a  localized  empyema,  the  lowest  point  at  which  pus 
can  be  obtained  by  puncture  should  be  chosen.  The  incision  is  made  in 
the  middle  of  the  intercostal  space.  No  matter  what  has  been  found  by 
puncture  on  previous  occasions,  the  exploring  needle  should  always  be 
used  at  the  time  of  operation  and  at  the  site  of  the  incision  before  the 
latter  is  made.  The  cutaneous  incision  should  be  an  inch  and  a  half  long, 
and  the  opening  in  the  pleura  made  large  enough  to  allow  the  little  finger 
of  the  operator  to  pass  into  the  pleural  cavity.  The  haemorrhage  is  very 
rarely  sufficient  to  require  a  ligature.  Masses  of  fibrin  presenting  at  the 
opening  should  be  removed  with  forceps.  The  wound  may  be  held  open 
by  forceps  or  a  tracheal  dilator,  and  as  much  of  the  fibrin  as  possible  re- 
moved at  the  time;  or,  if  the  patient's  condition  is  bad,  the  tube  may 
be  immediately  inserted  and  the  dressings  applied.  The  drainage  tube 
should  be  of  heavy  rubber,  fenestrated,  three  eighths  or  half  an  inch  in 
diameter  and  four  or  five  inches  long.  It  is  passed  into  the  deepest  pocket 
of  the  empyema.  To  secure  it  from  slipping  into  the  cavity,  its  outer  end 
should  be  transfixed  by  a  large  safety-pin  before  its  introduction.  It  is 
often  advisable  to  insert  two  tubes  side  by  side.  This  diminishes  the  dan- 
ger of  stopping  the  discharge  by  the  plugging  of  the  tube  with  fibrin. 
Iodoform  gauze  is  placed  over  the  wound  beneath  the  safety-pin,  and  a 


EMPYEMA. 


555 


compress  of  the  same  over  the  opening  of  the  tube,  the  dressing  being 
completed  by  a  large  mass  of  absorbent  cotton  and  a  snug  roller  bandage. 
The  pus  now  slowly  escapes  into  the  dressing  as  the  lung  expands.  The 
pad  of  gauze  placed  over  the  end 
of  the  tube  acts  as  a  valve,  prevent- 
ing air  from  entering  the  chest,  al- 
though permitting  pus  to  escape  as 
the  lung  is  expanded  by  inspiration 
or  by  the  act  of  coughing.  When 
there  is  no  reason  for  haste  during 
the  operation,  a  larger  part  of  the 
pus  may  be  removed  before  the  ap- 
plication of  the  dressing.  This 
should  be  allowed  to  escape  slowly, 
the  opening  being  closed  from  time 
to  time  by  a  compress.  From  ten 
to  twenty  minutes  should  be  con- 
sumed in  evacuating  the  pus. 

For  the  first  two  days  the  dress- 
ings should  be  changed  twice  daily, 
then  once  a  day  for  ten  days  or  two 
weeks,  and  later  at  longer  intervals. 
The  tube  is  gradually  shortened  at 
each  dressing,  until,  at  the  end  of  a 
week  or  ten  days,  it  is  reduced  to 
the  length  of  two  inches.  After 
the  fourth  or  fifth  day  a  smaller 
tube  may  be  substituted.  Usually 
by  the  end  of  the  third  week,  and 
often  by  the  end  of  the  second,  the 
tube  may  be  dispensed  with  alto- 
gether, the  tract  being  kept  open 
by  the  introduction  of  a  narrow 
strip  of  iodoform  gauze.  The  time 
of  redressing  and  the  removal  of  the 
tube  is  determined  by  the  amount 
of  discharge  and  by  the  temperature, 
after  the  second  day,  unless  the  drainage  is  imperfect,  it  may  do  so  when 
the  lung  does  not  expand  properly,  or  when  there  is  still  active  disease 
in  the  lung  itself,  as  is  not  very  uncommon  in  the  cases  coming  on  most 
acutely.  The  drainage  tube  is  very  liable  to  be  blocked  by  masses  of 
fibrin,  even  when  one  of  large  size  is  used.  This  is  the  first  thing  to  be 
suspected  if  the  temperature  rises.  At  each  dressing  it  is  well  to  remove 
the  tube  to  see  if  it  is  clear.     The  mistake  is  often  made  of  allowing  the 


Fig.  100. — Deformity  at'ter  an  old  empyema  of 
the  left  side  for  "which  Estlauder's  operation 
was  performed.  Portions  of  five  ribs  were 
removed.  ( From  a  photograph  seven  years 
after  operation.) 

While  this  does  not  usuallv  rise 


556 


DISEASES  OP  THE    RESPIRATORY  SYSTEM. 


drainage  tube  to  remain  too  long  a  time,  so  that  a  sinus  is  kept  open 
which  would  otherwise  heal.  Another  is  that  of  allowing  a  very  large 
tube  to  remain  for  a  long  time;  this  may  cause  erosion  of  the  periosteum 
and  even  necrosis  of  a  rib.  Washing  out  the  pleural  cavity  is  indicated 
only  in  cases  in  which  the  pus  is  in  a  putrid  condition.  A  single  washing 
for  the  purpose  of  removing  fibrin  is  the  routine  practice  of  some  surgeons. 
For  this  a  warm  sterilized  salt  solution  should  be  used.  Personally  I  have 
not  found  this  necessary.  Repeated  irrigations  should  on  no  account  be 
employed.  The  usual  duration  of  the  discharge  in  cases  treated  by  simple 
incision  is  from  three  to  six  weeks,  the  average  being  about  five  weeks. 
The  earlier  the  operation  the  shorter  the  course,  because  of  the  facility 
with  which  the  lung  expands. 

Resection  of  a  rib. — Many  of  the  best  surgeons  favour  this  as  a  routine 
procedure,  with  the  belief  that  with  the  larger  opening  which  is  thus 

made,  more  perfect  drainage 
is  secured,  that  masses  of 
fibrin  can  be  removed  with 
greater  facility,  and  that  it 
is  altogether  a  more  certain 
and  efficient  means  of  treat- 
ment than  is  a  simple  incis- 
ion. While  admitting  some 
of  the  advantages  claimed, 
my  own  experience  has  been 
that  in  the  great  majority  of 
recent  cases  in  young  chil- 
dren simple  incision  with 
drainage  is  all  that  is  re- 
quired. Rib  resection  is  ne- 
cessary if  there  is  overlap- 
ping of  the  ribs,  or  if  the  in- 
tercostal spaces  are  so  nar- 
row as  not  to  allow  the  in- 
troduction of  a  good-sized 
drainage  tube.  These  are 
usually  the  cases  in  which  the  disease  has  lasted  much  longer  than  the 
average  time.  One  inch  of  rib  is  all  that  it  is  necessary  to  remove.  The 
periosteum  is  preserved,  and  there  is  rarely  any  permanent  deformity. 

In  chronic  cases,  or  those  which  have  been  long  neglected,  some  fur- 
ther operative  treatment  is  often  necessary.  Some  of  these  are  cases 
which  have  opened  spontaneously  and  discharged  for  many  months  before 
coming  under  observation.  The  lung  is  so  bound  down  by  firm  adhesions 
that  further  expansion  is  impossible,  and  even  after  the  chest  has  receded 
to  its  utmost,  so  that  the  ribs  are  in  contact,  there  still   remains  a  cavity 


Fig.  101. — Junios'  apparatus  for  expanding  the  lung 
after  empyema. 


EMPYEMA.  557 

which  can  not  close.  For  such  cases  the  only  hope  is  in  an  operation  by 
which  portions  of  several  ribs  are  removed,  thus  allowing  a  greater  collapse 
of  the  chest.  This  is  known  as  thoracoplasty,  or  Estlander's  operation. 
The  operation  is  of  itself  a  serious  one,  and  only  to  be  advised  as  a  last 
resort  in  inveterate  cases.  By  it,  however,  life  may  be  saved  in  some  that 
are  otherwise  hopeless.  Such  an  operation  is,  of  course,  always  followed 
by  very  great  deformity  (Fig.  100). 

Methods  of  inducing  expansion  of  the,  lung. — In  most  of  the  cases, 
particularly  the  recent  ones,  complete  expansion  of  the  lung  takes  place 
without  any  difficulty,  the  chief  agent  being  the  cough.  In  some  cases 
this  may  be  insufficient.  The  apparatus  shown  in  the  accompanying  cut 
(Fig.  101),  devised  by  James  (New  York),  serves  at  the  same  time  as  a  toy 
for  the  child's  amusement  and  as  a  most  efficient  means  of  inducing  forced 
expiration.  One  bottle  is  jilaced  a  few  inches  higher  than  the  other,  and 
the  child  blows  a  coloured  fluid  from  the  lower  into  the  higher  bottle, 
allowing  it  to  siphon  back.  By  raising  the  second  bottle,  a  greater  ex- 
piratory force  is  required.  This  may  be  regulated  at  will.  The  apparatus 
may  be  used  for  a  few  minutes  several  times  a  day,  and  particularly  in 
cases  of  long  standing  it  is  of  great  assistance  in  producing  pulmonary 
expansion.     Blowing  soap  bubbles  often  answers  the  same  purpose. 


SECTION  Y. 

DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

CHAPTER   I. 

PECULIARITIES   OF    THE   HEART  A^D    CIRCULATION  IN  EARLY 

LIFE. 

The  Fcetal  Circulation. — During  the  latter  part  of  ftetal  life  the  circu- 
lation may  be  briefly  described  as  follows :  The  purified  blood  comes  from 
the  placenta  through  the  umbilical  vein.  Entering  the  body,  it  divides  at 
the  under  surface  of  the  liver  into  two  branches,  the  smaller  one,  the  ductus 
venosus,  communicating  directly  with  the  inferior  vena  cava ;  the  larger 
branch  Joining  the  portal  vein,  so  that  its  blood  traverses  the  liver,  and 
then  enters  the  inferior  vena  cava  through  the  hepatic  vein.  From  the 
iiiferior  vena  cava  the  blood  enters  the  right  auricle,  like  that  returned 
from  the  head  and  upper  extremities  by  the  superior  vena  cava.  A  part 
of  the  blood  now  passes  directly  into  the  left  auricle  through  the  foramen 
ovale ;  the  remainder,  through  the  tricuspid  orifice  into  the  right  ventricle. 
As  the  requirements  of  the  pulmonary  circulation  are  not  great,  only  a 
small  part  of  the  blood  is  sent  through  the  j)ulmonary  artery  to  the 
lungs ;  the  greater  portion  passes  from  the  pulmonary  artery  through  the 
ductus  arteriosus  into  the  aorta,  joining  here  the  blood  from  the  left  ven- 
tricle. The  blood  thus  finds  its  way  from  the  right  heart  to  the  left,  only 
in  small  part  by  way  of  the  lungs,  the  greater  part  passing  directly  from 
the  right  auricle  to  the  left,  or  from  the  right  ventricle  into  the  aorta 
through  the  ductus  arteriosus.  From  the  aorta,  the  blood  reaches  the 
placenta  through  the  umbilical  arteries,  which  are  a  continuation  of  the 
hypogastric  arteries,  which  in  turn  are  given  off  from  the  internal  iliacs. 

Changes  in  the  Circulation  at  Birth. — With  the  ligature  of  the  umbil- 
ical cord,  the  circulation  through  the  umbilical  vein  and  arteries  and  the 
ductus  venosus  ceases.  With  the  establishment  of  respiration  and  the 
consequent  increased  demands  made  by  the  pulmonary  circulation,  the 
blood  ceases  almost  at  once  to  pass  through  the  ductus  arteriosus,  and  very 
soon  through  the  foramen  ovale.  The  umbilical  vessels  during  the  first 
few  days  of  life  are  filled  with  small  thrombi,  which  become  organized. 
By  the  end  of  the  first  week,  these  vessels,  as  well  as  the  ductus  venosus, 
are  usually  closed  at  their  extremities,  although  they  may  remain  patulous 
throughout  the  greater  part  of  their  extent  for  several  weeks.  They  sub- 
sequently atrophy  to  the  condition  of  small  fibrous  cords.    For  some  weeks 

558 


THE    HEART   AND   CIRCULATION   IN   EARLY    LIFP]. 


559 


before  birth  the  circulation  through  the  foramen  ovale  is  slight,  it  being 
gradually  obstructed  by  the  growth  of  a  septum  which  nearly  fills  the  space 
at  birth.  After  the  first  week  of  extra-uterine  life  \ery  little,  if  any,  blood 
passes  through  it,  although  complete  closure  of  the  foramen  often  does 
not  take  place  until  the  middle  of  the  first  year.  In  fully  one  fourth  of 
the  autopsies  I  have  made  upon  infants  under  six  months  old,  there  have 
been  found  minute  openings  at  the  margin  of  the  foramen  ovale,  but  they 
are  usually  oblique,  and  closed  by  the  valvular  curtain  so  as  effectually  to 
obstruct  the  current  of  blood.  The  ductus  arteriosus  is  first  closed  by  a 
clot,  which  becomes  organized  and  blends  with  the  products  of  a  prolif- 
erating arteritis.  It  is  rarely  found  open  after  the  tenth  day,  and  by  the 
twentieth  it  is  almost  invariably  obliterated. 

The  Pulse. — The  pulse  in  early  life  is  not  only  more  frequent,  but  it  is 
very  much  more  variable  than  in  adults.  The  following  is  the  average 
pulse-rate  in  healthy  children  during  sleep  or  perfect  quiet : 

Six  to  twelve  months 105  to  115  per  minute. 

Two  to  six  years 90  •'   105   ■• 

Seven  to  ten  years 80  "     90   " 

Eleven  to  fourteen  years    75  "     85   '■ 

The  pulse  is  a  little  more  frequent  in  females  than  in  males,  and  more 
frequent  when  sitting  than  when  lying  down.  Muscular  exercise  or  ex- 
citement increases  the  pulse-rate  by  from  twenty  to  fifty  beats.  Very 
trivial  causes  disturb  not  only  the  frequency  but  the  force  of  the  pulse. 
The  pulse  in  young  infants  may  be  irregular  even  in  health  and  duiing 
sleep.  When  rapid,  it  is  frequently  irregular  without  any  meaning.  No 
dicrotism  is  seen  in  the  pulse  wave  of  early  infancy,  according  to  Blanche.* 

The  circulation  is  much  more  active  in  infancy  than  in  later  childhood  ; 
thus,  according  to  Vierordt,  the  entire  round  of  the  circulation  is  accom- 
plished in  the  newly  born  in  twelve  seconds ;  at  three  years,  in  fifteen  sec- 
onds ;  in  the  adult,  in  twenty-two  seconds. 

Size  and  Growth. — The  relative  size  of  the  heart  is  slightly  greater  in 
infancy  than  in  later  life,  it  being  smallest  at  about  the  seventh  year. 
The  average  weight  at  the  different  periods  of  life  is  as  follows :  f 


Age. 

Ounees. 

Grammes. 

Ratio  to  body 
weight. 

Birth.             

0-50 
1-25      . 

1-87 
2-25 

2-80 
5-84 
8-50 

141 
35  ! 
53  f 
64  J 
80 

166 

241 

1  year       .          

1  to  225 

2  vears 

3  '   •'       

7      "       

1  to  280 

14    "                     

1  to  222 

Adult 

1  to  226 

*  See  tracings  in  Archives  of  Paxliatrics,  vol.  v,  p.  732. 

f  The  figures  in  infancy  are  from  one  hundred  and  fifty-five  observations  made  in 
the  New  York  Infant  Asylum ;  the  others  are  taken  from  Salili. 
37 


560  DISEASES  OP  THE  CIRCULATORY  SYSTEM. 

The  growth  of  the  heart  is  rapid  during  the  first  three  years,  and 
nearly  proportionate  to  that  of  the  body.  It  is  slowest  from  the  third 
to  the  tenth  year,  and  most  rapid  from  the  eleventh  to  the  fifteenth 
year.  At  birth,  the  thickness  of  the  right  ventricle  is  very  nearly  the 
same  as  that  of  the  left,  the  ratio  being  6  :  7.  The  left  ventricle,  how- 
ever, grows  very  much  more  rapidly  than  the  right,  so  that  at  the  end 
of  the  second  year  the  ratio  is  1:2,  which  is  nearly  that  of  the  rest  of 
childhood. 

Position  of  the  Apex  Beat. — ^In  the  infant  the  heart  is  placed  some- 
what higher,  and  occupies  a  position  a  little  nearer  the  horizontal  than  in 
the  adult.  This  is  partly  due  to  the  higher  position  of  the  diaphragm. 
The  apex  beat  is  therefore  higher  and  farther  to  the  left  than  in  adult 
life.  According  to  the  observations  of  Wassilewski  and  Starck,  whose 
combined  examinations  with  reference  to  this  point  were  made  upon  over 
2,100  children,  the  apex  beat  is,  as  a  rule,  outside  the  mammary  line  until 
the  fourth  year ;  if  it  is  less  than  one  third  of  an  inch  beyond  the  nipple, 
it  can"  not  be  considered  abnormal.  From  the  fourth  to  the  ninth  year, 
the  apex  beat  is  in  or  near  the  mammary  line.  After  the  thirteenth  year, 
under  normal  conditions,  it  is  invariably  within  that  line.  During  the 
first  year  the  apex  beat  is  usually  found  in  the  fourth  intercostal  space; 
from  the  first  to  the  seventh  year,  it  is  found  with  about  equal  frequency 
in  the  fourth  and  the  fifth  spaces ;  after  the  seventh  it  is  usually,  and  after 
the  thirteenth  year  it  is  always,  when  normal,  in  the  fifth  space.  The 
position  of  the  apex  beat  may  be  considerably  modified  by  severe  deformi- 
ties of  the  chest  resulting  from  rickets.  Pott's  disease,  or  lateral  curvature 
of  the  spine. 

Examination  of  the  Heart. — Inspection. — Bulging  of  the  prtecordia  is 
a  frequent  and  important  sign  of  cardiac  disease  during  childhood.  The 
cardiac  impulse  is  generally  weaker  than  in  the  adult,  and  often  it  is  diffi- 
cult to  locate  the  apex  beat  owing  to  the  thick  layer  of  adipose  tissue 
covering  the  chest. 

Palpation. — This  is  usually  a  much  more  satisfactory  method  than  is 
inspection  for  determining  the  position  of  the  apex  beat.  For  this  pur- 
pose the  child  should  be  in  the  sitting  posture,  with  the  body  inclined 
slightly  forward.  Great  displacement  of  the  apex  beat  is  always  signifi- 
cant, and  should  lead  one  to  suspect  pleuritic  effusion ;  lesser  degrees  of 
displacement  to  the  left  indicate  hypertrophy,  especially  of  the  left  ven- 
tricle ;  to  the  right,  hypertrophy  of  the  right  ventricle,  usually  with  a  con- 
genital malformation. 

Percussion. — This  is  best  done  by  means  of  the  percussion  hammer. 
A  light  blow  should  be  used,  on  account  of  the  thinness  and  elasticity  of 
the  chest  walls.  The  outline  of  the  area  of  "  relative  cardiac  dulness," 
especially  in  small  children,  is  proportionately  larger  than  in  the  adult. 
This  may  lead  to  the  mistaken  opinion  that  the  heart  is  enlarged,  when  it 


THE   HEART   AND   CIRCULATION   IN   EARLY   LIFE. 


561 


is  really  of  normal  size.  According  to  Sahli,*  the  limits  of  this  area  are  as 
follows  :  Above,  the  second  space  or  lower  border  of  the  second  costal  car- 
tilage ;  to  the  right,  at  the  para-sternal  line,  sometimes  slightly  beyond  it ;  to 
the  left,  at  or  slightly  beyond  the  mammary  line,  this  depending  upon  the 
age  of  the  child.    The  lower  border  is  indeterminable  on  account  of  the  liver. 

The  area  of  "  absolute  cardiac  dulness,"  or  that  part  of  the  heart  un- 
covered by  the  lung,  resembles  in  shape  the  same  area  in  the  adult,  but  it 
is  relatively  larger.  Its  upper 
limit  is  the  upper  border  of  the 
third  intercostal  space,  some- 
times the  third  costal  cartilage  ; 
it  extends  to  the  left  to  a  point 
between  the  para-sternal  and  the 
mammary  lines,  and  to  the  right 
as  far  as  the  left  border  of  the 
sternum.  These  two  areas  will 
be  readily  understood  by  refer- 
ence to  the  accompanying  dia- 
gram (Fig.  102). 

Auscultation. — This  is  of  lit- 
tle value  unless  the  child  is  quiet. 
The  preferable  position  is  the 
sitting  posture.  For  an  accu- 
rate diagnosis  the  stethoscope  is 
indispensable,  but  auscultation 
should  always  be  practised  with 
the  naked  ear  as  well.  The 
rhythm  and  rapidity  of  the 
child's  heart .  action  are  much 
more  easily  disturbed  than  are 
the  adult's,  and  such  disturbances  are  consequently  much  less  significant. 
The  rapidity  of  the  heart  in  infancy  is  ordinarily  so  great  as  to  make  it 
practically  impossible  to  distinguish  between  diastolic  and  presystolic  mur- 
murs. Normally,  the  loudest  sound  is  the  first  sound  at  the  apex ;  the 
weakest  sound  is  the  second  sound  at  the  aortic  orifice.  According  to 
Hochsinger,  the  accentuation  of  the  child's  heart-sounds  is  upon  the  first 
sound,  and  not  upon  the  second,  as  in  the  adult. 

In  consequence  of  the  small  size  and  the  thin  walls  of  the  chest,  all 
sounds,  both  normal  and  pathological,  appear  relatively  louder  than  in  the 
adult,  and  the  area  of  diffusion  is  therefore  much  greater.  Thus  it  is  a 
frequent  occurrence  for  murmurs  to  be  heard  all  over  the  chest  both  in 
front  and  behind. 


Fig.  102. — Showing  areas  of  cardiac  dulness :  a  is 
the  mammary  line ;  6,  the  para-sternal  line  ;  Z, 
the  upper  border  of  the  liver.  The  space  en- 
closed by  the  dotted  line  represents  the  area  of 
relative  dulness  ;  the  heavily  shaded  area,  that 
of  absolute  dulness.  (After  Sahli,  slightly  modi- 
tied  by  linger.) 


*  Topographisehe  Percussion  iin  Kindesalter,  1882. 


5f52  DISEASES   OF   THE   CIRCULATORY  SYSTEM. 

Reduplication  of  the  heart  sounds,  in  consequence  of  the  valves  of  the 
two  sides  not  closing  exactly  together,  is  not  uncommon  in  children,  and 
may  be  due  simply  to  excitement.  During  the  fir.st  four  years  of  life 
nearly  all  the  abnormal  murmurs  heard  are  systolic. 

Accidental  murmurs  may  be  due  to  anemia  and  other  blood  condi- 
tions, and,  although  not  so  common  as  in  older  patients,  they  are  by  no 
means  rare  even  in  infants. 


CHAPTER   II. 

CONGENITAL   ANOMALIES   OF   THE  HEART. 

Etiology. — The  causes  of  congenital  anomalies  of  the  heart  may  be 
grouped  under  three  general  heads  : 

1.  Malformations  resulting  from  imperfect  development  of  certain 
parts  of  the  heart,  most  frequently  one  of  the  septa.  Either  the  ventricu- 
lar or  the  auricular  septum  may  be  affected,  or  that  dividing  the  pulmo- 
nary artery  from  the  aorta.  Such  failure  in  development  perpetuates  condi- 
tions which  are  normal  in  the  early  months  of  foetal  life.  There  may  also 
be  atresia  of  any  one  of  the  orifices,  absence  of  one  or  more  of  the  valvular 
leaflets,  or  of  any  one  of  the  large  vessels. 

2.  Foetal  endocarditis.  The  effects  of  this  condition  vary  according  to 
the  time  of  its  occurrence.  It  is  almost  invariably  of  the  right  side,  most 
frequently  affecting  the  pulmonic  valves.  Valvular  disease  in  foetal  life 
leads  not  only  to  hypertrophy  and  dilatation,  but  also  interferes  with 
the  normal  development  of  the  heart  by  preventing  the  closure  of  the 
auricular  or  ventricular  septum  or  the  ductus  arteriosus,  these  being  kept 
open  by  way  of  compensation. 

3.  Persistence  of  foetal  conditions,  such  as  the  foramen  ovale  or  ductus 
arteriosus.  This  may  be  the  result  of  valvular  disease,  as  previously 
stated,  or  of  some  condition  of  the  lungs,  such  as  atelectasis. 

Lesions. — In  the  following  table  are  given  the  lesions  found  in  two 
hundred  and  forty-two  cases,  which  I  have  collected  from  medical  litera- 
tu  re  : 

Frequency  of  the  different  lesions  in  2J^2  autopsies  upon  cases  of  congenital 

cardiac  anomaly. 

Defect  in  the  ventricular  septum 149  cases ;  the  only  lesion  in  5  eases. 

Defect  in  the  auricular  septum  or  pjitent  foramon 

ovale 126     "  '•  "  9      " 

Pulmonic  stenosis  or  atresia 108     "  "  '■  6      " 

Patent  ductus  arteriosus G8     "  "  "  3     " 


CONGENITAL   ANOMALIES   OP   THE   UEART.  5^33 

Abnormalities  in  the  origin  of  the  great  vessels.  45  eases;  the  only  lesion  in  0  cases. 

.  Pulmonic  insufficiency 17  "  ••  "  0 

Tricuspid  insufficiency 0  "  ••  ••  q 

Tricuspid  stenosis  or  atresia ;j  "  "  "  q 

Mitral  insufficiency. 1  "  "  "  0 

Mitral  stenosis  or  atresia 0  "  "  "  () 

Aortic  insufficiency 1  "  •■  "  q 

Aortic  stenosis  or  atresia (5  "  "  •'  0     .' 

Transposition  of  the  heart 3  "  "  >•  q 

Ectocardia 1  ••  "  "  q 

The  most  frequent  associated  lesions. 

Pulmonic  stenosis,  with  defect  in  the  ventricular 

septum ))2  cases  ;  the  oidy  lesion  in  20  cases. 

Pulmonic  stenosis,  with  defect   in   th(!   aiiricidar 

septum 52      "  "  "  8     •' 

Defects  in  both  septa S2      "  "  ■'  17     " 

Pulmonic  stenosis  and  defects  in  both  septa ;^(j      ■*  "  •'  21     •' 

From   tliis  table  it  will  be  seen  that,  in  the  great  majority  of  eases, 
several  lesions  are  present,  the  most  frequent  combinations  being  pul- 
monary stenosis  with  defective  ven- 
tricular septum,  pulmonic  stenosis 
with  defective    auricular    septum, 
the  three  lesions  associated,  or  the 
first  two  with  a  patent  ductus  arte-     ^^      ^^me^ 
riosus.  ^KSBK^K      S  ^' 

Defect  in  the   ventricular  sep-     |p"*^^Hfp^.-^^^ 
turn. — This  is  the   most   frequent     Jk^^Hll  j'^i^J^S^/''  "^C 
lesion  in  congenital  cardiac  disease, 
and  in  half  the  cases  was  associated     ^^hbttj' 
with  pulmonic  stenosis.     The  de-     ^Hi''t'*#a  ^'^^^^ 

feet  is  generally  at  the  upper  part     ^^E'^^vl  \V.  v*  ,       '"^^ 
of  the  septum    (Fig.    103).     Ttis     ^»^#vSV-.V'     % 
usually  from  one  fourth  to  one  half     ^^H^  \'^'^^  -^ y.^^MJ^i 
an  inch  in  diameter,  but  not  infre-      t^^HL'  *" '^\ 
quently  there  is  a  large  defect,  and 
the  septum  may  be  entirely  absent, 
the   heart   then    consisting  of  but      „  ,      ,.     , 

.  rm.  103. — Congenital  cardiac  disease.     The  lelt 

three     cavities — two     auricles    and  ventricle  is  shown  with  a  defect  iu  the  veu- 

one  ventriclp      Tf  fhp  flnricnlar  spti  tricular  septum,  the  opening  being  just  be- 

oue  ventricle.      11  tne  auriCUiai  sep-  ^eath  the  aortic  valve.    (From  a  patient  dy- 

tum  also  is  wanting,  as  is  often  the  '"?  "^  *''  Babies'  Hospital.) 

case,  the  heart  has  but  two  cavities. 

Frequently  there  are  also  abnormalities  in  the  origin  of  the  great  vessels. 

The  pulmonary  artery  and  the  aorta  may  be  given  off  from  the  common 

ventricle,  or  the  aorta  may  arise  partly  from  one  ventricle  and  partly  from 

the  other.     If  pulmonic  stenosis  or  atresia  is  present,  the  opening  in  the 


501:  DISEASES   OF   THE   CIRCULATORY  SYSTEM. 

ventricular  septum  is  conservative,  affording  a  channel  for  the  passage  of 
blood  from  the  right  to  the  left  side  of  the  heart. 

Patent  foramen  ovale,  or  defect  in  the  auricular  sejjtiwi. — Although 
this  is  one  of  the  most  common  congenital  malformations,  it  is  not  one  of 
the  most  important.  It  rarely  occurs  alone,  but  is  frequently  found  with 
pulmonic  stenosis  or  a  defect  in  the  ventricular  septum.  Small  oblique 
openings  in  the  auricular  septum — usually  at  the  foramen  ovale — are  not 
infrequently  met  with  in  autopsies  upon  young  infants,  but  they  are  of  no 
importance.  In  pathological  conditions  the  opening  is  from  one  fourth 
to  one  inch  in  diameter,  and  there  may  be  more  than  on(5  opening.  A  de- 
fect in  this  septum  is  frequently  secondary  to  pulmonic  stenosis,  or  it  may 
be  a  failure  in  development.  A  patent  foramen  ovale  may  be  due  to 
atelectasis. 

Patent  dnctus  arteriosus. — As  a  solitary  lesion  this  is  rare,  but  it  is 
frequently  associated  with  pulmonic  stenosis,  usually  with  a  defect  in  one 
or  both  septa.  It  is  then  one  of  the  channels  by  which  the  blood  may  find 
its  way  to  the  lungs  when  the  pulmonary  orifice  is  obstructed.  It  is  not 
a  malformation,  but  simply  the  persistence  of  a  foetal  condition  usually 
necessitated  by  other  changes  in  the  heart. 

Pulmonic  stenosis. — This  is  one  of  the  most  frequent  and  most  im- 
portant lesions.  It  may  be  due  to  foetal  endocarditis,  or  to  a  mal- 
formation. If  the  former,  there  is  usually  stenosis ;  if  the  latter,  there 
may  be  atresia.  It  is  often  a  primary  lesion,  and  when  marked  it  is 
always  accompanied  by  other  changes,  most  frequently  by  a  defect  in  one 
or  both  septa  or  by  a  patent  ductus  arteriosus.  This  is  important,  as  be- 
ing more  constantly  associated  with  cyanosis  than  is  any  other  congeni- 
tal lesion.  The  amount  of  obstruction  varies  from  a  slight  narrowing 
of  the  orifice  to  complete  atresia.  If  there  is  atresia,  the  pulmonary  artery 
is  very  small,  and  may  be  rudimentary. 

Pulmonic  insufficiency. — This  lesion  is  relatively  rare.  It  is  usually 
the  result  of  foetal  endocarditis,  but  there  may  be  absence  of  the  pulmo- 
nary valve.  It  is  most  frequently  associated  with  a  defect  in  the  ven- 
tricular septum. 

Tricuspid,  mitral,  and  aortic  disease  are  all  very  infrequent  and  usu- 
ally seen  in  cases  with  multiple  defects.  Atresia  or  stenosis  is  much  more 
common  than  insufficiency. 

AhnormaUties  in  the  origin  of  the  large  vessels. — These  are  quite  fre- 
quent ;  but,  as  will  be  seen  from  the  table,  they  are  always  associated  with 
other  lesions.  Three  forms  are  seen  :  (1)  Transposition  of  the  large  vessels 
— the  pulmonary  artery  is  given  off  from  the  left,  and  the  aorta  from  the 
right  ventricle.  (2)  Both  arteries  arise  from  a  common  trunk.  This  is 
usually  due  to  an  incomplete  develojDment  of  the  lower  part  of  the  sep- 
tum dividing  the  two  arteries.  Usually  the  pulmonary  artery  appears  to 
be  a  branch  of  the  aorta.     This  condition  is  frequently  associated  with 


CONGENITAL   ANOMALIES   OF   THE   HEART.  565 

other  abnormalities,  often  with  so  large  a  defect  in  the  ventricular  septum 
that  there  is  really  but  one  ventricle.  (3)  The  aorta  has  an  abnormal 
origin,  arising  from  the  right  ventricle,  or  partly  from  both  ventricles. 
This  also  is  associated  with  a  large  defect  in  the  ventricular  septum. 
When  described  as  arising  from  both  ventricles,  the  aorta  is  usually  given 
oft"  directly  above  the  line  of  the  septum. 

In  addition  to  these  main  deformities,  there  are  many  others  which 
need  not  be  more  than  mentioned.  An  abnormality  in  the  number  of 
valvular  segments  is  quite  a  frequent  occurrence,  but  does  not  usually 
impair  the  valve's  function.  In  rare  cases  a  valve  is  rudimentary,  and 
it  may  be  entirely  absent,  generally  at  the  pulmonic  or  tricuspid  orifice. 
Absence  of  the  right  auricle  and  absence  of  the  pericardium  have  been 
recorded  ;  also  opening  of  the  pulmonary  veins  into  the  right  auricle,  and 
a  single  pulmonary  artery.  In  one  case  in  the  series  there  was  ectocardia, 
this  being  associated  with  a  congenital  fissure  of  the  sternum. 

Transpositio}i  of  the  heart,  or  true  dextro-cardia,  was  recorded  but 
twice  in  this  series  of  cases.  It  was,  however,  simulated  in  several  others, 
including  one  of  my  own,  where  the  apex  beat  was  to  the  right  of  the 
sternum.  There  was  in  this  case  great  hypertrophy  of  the  right  ventricle 
with  a  rudimentary  ventricular  septum. 

Secondary  lesions. — Since  the  one  condition  which  nearly  all  of  the 
oougenital  malformations  of  the  heart  have  in  common  is  a  persistence  of 
one  or  more  of  the  fcetal  conditions  in  which  the  right  ventricle  does 
most  of  the  work,  it  is  usually  found  hypertrophied.  It  is  in  most 
cases  accompanied  by  some  dilatation,  and  often  there  is  dilatation  of  the 
right  auricle.  Changes  in  the  wall  of  the  left  heart  alone  are  exceedingly 
rare.  In  four  cases  there  was  evidence  of  malignant  endocarditis,  which 
was  the  cause  of  death,  all  but  one  of  these  patients  being  adults. 

Symptoms. — The  symptoms  of  congenital  cardiac  disease  are  usually 
manifested  soon  after  birth,  although  this  is  not  always  the  case.  Of  128 
■cases  in  which  the  time  of  the  first  symptoms  was  noted,  they  were  con- 
genital, or  appeared  during  the  first  month,  in  85 ;  after  one  month  and 
■during  the  first  year,  in  18 ;  from  one  to  sixteen  years,  in  15  ;  while  in  10 
no  symptoms  were  observed  until  after  puberty.  Congenital  cardiac  dis- 
ease is  one  of  the  causes,  but  not  a -frequent  one,  of  death  during  the  first 
few  days  of  life.  This  may  be  directly  due  to  convulsions,  asphyxia,  or 
syncope. 

The  most  striking  objective  symptom  is  cyanosis.  This  was  noted  in 
88  per  cent  of  the  cases  in  which  histories  were  given.  Congenital  cardiac 
disease  is  very  apt  to  be  overlooked  when  cyanosis  is  absent,  as  it  may  be 
even  with  very  serious  lesions.  Cyanosis  may  be  slight  and  noticed  only 
upon  exertion,  as  upon  coughing  or  crying,  or  it  may  be  intense  and  con- 
stant, giving  the  skin  a  dark,  leaden  colour,  and  the  mucous  membrane 
of  the  mouth  a  raspberry  hue.     The  view  that  cyanosis  depends  upon  an 


560 


DISEASES   OF   THE  CIRCULATORY   SYSTEM. 


admixture  of  arterial  and  venous  blood  is  generally  discredited.  In  the 
great  majority  of  the  cases  at  least,  the  explanation  is  a  deficient  oxi- 
dation of  tlie  blood 
in  the  lungs,  owing 
to  some  interference 
with  the  pulmonary 
circulation.  In  63 
per  cent  of  the  cases 
of  cyanosis  in  the  se- 
ries, there  was  found 
pulmonic  stenosis  or 
atresia,  or  a  small 
pulmonary  artery. 
Cyanosis  is  of  much 
value  in  diagnosis,  as 
it  is  rarely  seen  in 
acquired  cardiac  dis- 
ease. The  degree  of 
cyanosis  and  its  con- 
stancy are  of  some 
importance  in  deter- 
mining  the    gravity 


1(14. — Clubbing  of  the  fingers  in  congenital   heart  disease. 
(From  a  boy  five  years  old.) 


of  the  lesion,  altliough  these  alone  are  not  to  be  depended  upon.  Another 
frequent  symptom  is  the  enlargement  of  the  terminal  phalanges  known 
as  clubbing  of  the  fingers  (Fig.  104)  and  toes.  This  enlargement,  which 
usually  involves  all  the  phalanges,  is  probably  due  to  venous  obstruction. 
Occasionally  there  are  seen  dyspnoea,  oedema  of  the  lower  extremities, 
dropsy  of  the  serous  cavities,  and  haemorrhages,  particularly  hemoptysis 
and  epistaxis. 

Diagnosis. — The  most  diagnostic  features  of  congenital  cardiac  disease 
are  cyanosis,  the  presence  of  cardiac  murmurs,  and  signs  of  enlargement 
of  the  right  heart. 

Murmurs  were  present  in  four  fifths  of  the  cases  in  which  histories 
were  given.  Tlie  most  characteristic  is  a  systolic  murmur,  loudest  at  the 
left  base  and  diffused  over  a  large  area.  A  systolic  murmur  only  was 
heard  in  GO  cases,  a  double  murmur  in  11,  a  diastolic  and  a  presystolic 
in  one  case  each.  A  systolic  murmur  may  be  due  to  pulmonic  stenosis, 
deficient  ventricular  septum,  patent  ductus  arteriosus,  mitral  regurgitation, 
tricuspid  regurgitation,  or  aortic  stenosis.  Since  these  conditions  are  very 
often  associated,  it  is  difficult  to  tell  upon  which  one  the  murmur  depends. 
In  over  two  thirds  of  the  cases  in  which  the  murmur  was  localized  it  was 
at  the  base  of  the  heart,  and  in  the  great  majority  of  these  it  was  loudest 
at  the  left  base,  in  the  second  or  third  space  at  the  border  of  the  sternum 
and  transmitted  toward  the  left  slioulder.     Apex  murmurs  were  heard  in 


CONGENITAL   ANOMALIES   OF   THE   HEART.  507 

bat  one  fourth  of  tlie  cases.  The  murmurs  are  usually  loud,  rough,  and 
often  out  of  proportion  to  the  other  signs  present.  Frequently  they  may 
1)6  heard  all  over  the  chest,  both  in  front  and  behind.  In  a  young  child, 
a  very  loud  murmur  with  cyanosis  is  almost  diagnostic  of  congenital  dis- 
ease, since  in  acquired  disease  loud  murmurs  are  nearly  always  at  the  apex, 
and  are  accompanied  by  marked  hypertrophy. 

Enlargement  of  the  right  heart,  chiefly  from  ventricular  hypertrophy, 
was  present  in  86-5  per  cent  of  the  cases.  In  about  one  half  of  these  there 
was  hypertrophy  of  the  left  ventricle,  but  this  was  rarely  seen  aloue.  The 
signs  of  hypertrophy  of  the  right  ventricle  are  :  dnlness  extending  to  the 
right  of  the  sternum,  displacement  of  the  apex  beat  to  the  right,  epigastric 
pulsation,  and  sometimes  bulging  of  the  lower  portion  of  the  sternum. 

A  diagnosis  of  the  precise  nature  of  the  malformation  is  very  difficult, 
and  in  the  great  majority  of  cases  only  a  probable  diagnosis  is  possible. 
Nearly  all  the  cases  are  complex,  and  the  variety  of  combinations  is  very 
great.  A  study  of  the  histories  and  autopsies  of  the  cases  in  this  series 
reveals  many  apparently  contradictory  facts.  Loud  murmurs  are  some- 
times heard  which  are  difficult  to  explain  by  the  lesions,  and  murmurs 
may  be  absent  where  there  is  every  reason  for  expecting  their  presence, 
as  in  a  case  recently  under  my  observation.  Certain  lesions  like  aortic 
stenosis,  mitral  stenosis,  and  mitral  regurgitation  may  be  accompanied  by 
the  same  signs  as  in  acquired  disease.  With  reference  to  the  other  con- 
ditions, I  can  not  do  better  than  give  the  more  frequent  clinical  symp- 
toms with  the  results  of  the  autopsies  in  the  series  of  cases  which  I  have 
collected. 

A  systolic  murmur  at  the  base,  with  cyanosis. — This  is  the  most  com- 
mon combination  met  with,  and  was  present  in  about  one  third  of  all  the 
cases.  In  over  80  per  cent  of  the  cases  with  these  symptoms,  pulmonic 
stenosis  was  found.  The  remainder  were  complicated  cases  of  quite  a 
wide  variety.  Pulmonic  stenosis  was  usually  associated  with  a  defect  in 
one  of  the  cardiac  septa,  or  a  patent  ductus  arteriosus. 

A  systolic  muriitur  without  cyanosis. — In  the  cases  followed  to  autopsy 
this  was  not  a  frequent  combination,  being  noted  but  six  times,  and  usu- 
ally dependent  upon  a  defect  in  the  ventricular  septum  without  pulmonic 
stenosis,  or  upon  tricuspid  regurgitation.  Judging  from  my  own  clinical 
experience,  a  systolic  murmur  without  cyanosis  is  more  common  than  is 
indicated  by  these  figures. 

A  systolic  murmur  at  the  apex  with  cyanosis. — Of  the  six  cases  with 
this  combination,  all  were  examples  of  complex  malformation,  the  most 
frequent  lesions  being  a  defect  in  the  auricular  septum,  transposition  of 
the  great  vessels,  and  patent  ductus  arteriosus. 

Cyanosis  without  rnunnurs  was  noted  fourteen  times.  It  indicates 
either  pulmonic  atresia  or  the  transposition  or  irregular  origin  of  the  great 
vessels. 


56S  DISEASES   OF  THE   CIRCULATORY   SYSTEM. 

Diastolic  inurmurs  were  heard  in  two  cases,  and  depended  upon  pul- 
monic insufficiency. 

A  presystolic  murmur  was  noted  in  a  single  case.  It  was  localized  at 
the  right  base,  and  the  only  lesion  was  a  patent  foramen  ovale. 

Absence  of  both  cyayiosis  and  murmurs  was  recorded  in  five  cases. 
The  lesions  found  were :  atresia  of  the  aorta,  both  arteries  arising  from 
the  right  ventricle,  or  defective  septa. 

It  will  be  seen  that  about  the  only  cases  in  which  a  fairly  positive 
diagnosis  can  be  made  are  those  of  pulmonic  stenosis  with  a  deficient  ven- 
tricular septum.  Enlargement  of  the  right  heart,  being  common  to 
nearly  all  the  varieties,  is  of  no  diagnostic  value. 

Diagnosis  of  congenital  from  acquired  disease. — Congenital  disease 
may  be  suspected  if  the  patient  is  under  two  years  of  age;  if  there  is  no 
history  of  previous  rheumatism  ;  if  the  murmur  is  atypical  in  its  location, 
character,  or  transmission ;  if  there  is  a  very  loud  murmur  at  the  base ;  if 
there  is  cyanosis ;  and  if  there  is  evidence  of  enlargement  of  the  right 
heart. 

Diagnosis  of  congenital  from  anmmic  ynurmurs. — This  is  often  a  more 
difficult  matter  than  to  decide  between  congenital  and  acquired  disease. 
From  a  murmur  alone  one  should  be  very  cautious  in  making  a  diagnosis 
of  cardiac  malformation  in  a  very  ansemic  infant.  Anaemic  murmurs  are 
systolic,  basic,  unaccompanied  by  enlargement  of  the  heart ;  usually  heard 
in  the  carotids,  often  in  the  subclavian  arteries,  but  are  seldom  so  loud  as 
those  due  to  malformations.  In  some  cases  it  may  be  necessary  to  watch 
the  effect  of  treatment  or  the  course  of  the  disease  before  deciding  the, 
question. 

Prognosis. — Of  225  cases,  60  per  cent  were  fatal  before  the  end  of  the 
fifth  year,  and  nearly  one  half  of  these  during  the  first  two  months ;  while 
16  per  cent  of  the  cases  lived  over  sixteen  years,  and  8  per  cent  over  thirty 
years.  The  prognosis  in  any  given  case  is  to  be  made  from  the  general 
condition  of  the  patient  and  how  well  the  circulation  is  carried  on,  rather 
than  from  the  intensity  of  the  cyanosis  or  the  character  of  the  murmur, 
although  extreme  cyanosis  is  always  unfavourable. 

In  the  cases  fatal  soon  after  birth  the  usual  lesions  are  large  defects  in 
the  septa,  transposition  of  the  great  vessels,  or  pulmonic  atresia.  In  five 
of  twenty-three  cases  dying  thus  early,  the  heart  had  but  two  cavities.  Le- 
sions which  are  compatible  with  the  longest  life  are  minor  septum  defects, 
and  pulmonic  stenosis  which  can  be  compensated  for  by  hypertrophy  of  the 
right  ventricle.  Many  exceptional  instances  are  recorded  in  which  patients 
have  lived  a  long  time  in  spite  of  extreme  deformities.  One  child  with 
transposition  of  the  pulmonary  artery  and  aorta  lived  two  and  a  half  years. 
Tiedmann's  case  lived  eleven  years  with  a  heart  consisting  of  three  cavities 
— two  auricles  and  one  ventricle — and  with  constant  cyanosis.  In  three 
cases  reported  by  Rokitansky,  the  patients  lived  over  forty  years  with  rudi- 


PERICARDITIS.  559 

mentary  auricular  septa  and  no  cyanosis  mentioned.  Gelpke's  case  had 
cyanosis,  and  lived  twenty-seven  years  with  rudimentary  auricular  and 
ventricular  septa,  and  with  no  tricuspid  opening. 

Treatment. — No  treatment  is  of  the  slightest  avail  in  diminishing  the 
amount  of  deformity  or  promoting  the  closure  of  any  of  the  abnormal 
openings.     All  cases  are  to  be  treated  symptomatically. 


CHAPTER   III. 
PERICARDITIS. 

Inflammation  of  the  pericardium  is  a  rare  disease  in  infancy  and 
early  childhood,  only  two  cases  being  seen  in  seven  hundred  and  twenty- 
six  consecutive  autopsies  at  the  New  York  Infant  Asylum.  In  later 
childhood  the  disease  is  more  frequent.  In  its  etiology,  symptoms,  and 
course  it  resembles  quite  closely  the  same  disease  in  adults. 

Etiology.— Of  69  cases  of  pericarditis  in  children  under  fourteen  years 
of  age,  24  occurred  before  the  third  year,  12  between  the  third  and  sev- 
enth years,  and  33  between  the  seventh  and  fourteenth  years.  It  has  been 
seen  in  the  newly  born,  and  has  been  found  even  in  the  foetus. 

Pericarditis  is  almost  invariably  a  secondary  disease,  following  (1) 
pleurisy  or  pleuro-pneumonia ;  (2)  acute  rheumatism  ;  (3)  acute  infec- 
tious diseases,  especially  scarlet  fever ;  (4)  pygemia ;  (5)  tuberculosis ;  (6) 
local  causes.  The  relative  importance  of  these  causes  differs  with  the  age 
of  the  child.  In  infancy  and  early  childhood  most  of  the  cases  compli- 
cate disease  of  the  lung  or  pleura,  usually  of  the  left  side.  After  the  fourth 
year  rheumatism  takes  the  first  place  as  an  etiological  factor.  Pericar- 
ditis is  then  generally  associated  with  endocarditis,  and  may  precede  or 
follow  the  articular  manifestations  of  rheumatism.  Following  scarlet  fever, 
pericarditis  generally  occurs  in  connection  with  nephritis  or  multiple  joint 
inflammations.  In  typhoid  fever,  also,  it  is  usually  associated  with  pneu- 
monia or  joint  lesions.  Pyemia  may  be  a  cause  in  the  newly  born,  or  it 
may  occur  in  connection  with  disease  of  the  bones  or  joints  in  older  chil- 
dren ;  in  both  it  is  usually  associated  with  similar  lesions  of  other  serous 
membranes.  Tuberculous  pericarditis  is  more  frequent  after  the  third 
year,  and  is  generally  secondary  to  pulmonary  tuberculosis.  Among  the 
local  causes  may  be  mentioned  traumatism,  ulceration  of  a  foreign  body 
from  the  oesophagus  into  the  pericardium,  disease  of  the  sternum,  ribs,  or 
vertebra^,  and  abscesses  resulting  from  cheesy  bronchial  lymph  nodes. 

Lesions. — 1.  Pericardial  transudations,  or  an  increase  in  the  normal 
pericardial  fluid,  are  met  with  in  many  conditions  in  which  there  is  a 


570  DISEASES   OF  THE   CIRCULATORY   SYSTEM. 

very  marked  degree  of  anaemia,  general  dropsy,  or  a  weak  heart,  particu- 
larly of  the  right  side.  Generally  from  one  and  a  half  to  two  ounces  of  a 
clear  serum  are  found  in  the  pericardial  sac. 

2.  External  or  mediastinal  pericai'ditis  is  always  associated  with 
mediastinal  pleurisy,  and  results  in  more  or  less  extensive  adhesions  of 
the  pericardial  and  pleural  surfaces,  with  an  increase  in  the  connective 
tissue  of  the  mediastinum.  It  is  often  a  tuberculous  process.  When 
severe,  it  may  cause  compression  of  the  large  blood-vessels,  and  seldom  in 
any  other  way  produces  symptoms.  Witli  this  form  there  may  be  inflam- 
mation of  the  internal  layer  of  the  pericardium.  It  is  only  inflammation 
of  the  internal  layer  which  is  ordinarily  considered  as  pericarditis,  the 
other  form  being  preferably  classed  as  mediastinitis. 

3.  Dry  'pericarditis. — Tliis  may  be  either  general  or  localized.  If  the 
latter,  it  is  more  often  seen  at  the  base  than  at  the  apex  of  the  heart.  The 
two  opposing  surfaces  are  usually  involved.  As  a  result  of  the  inflamma- 
tion they  are  coated  with  fibrin,  which  may  be  partly  absorbed,  but  usu- 
ally leaves  behind  bands  of  adhesions  of  greater  or  less  extent.  From  re- 
peated attacks  there  may  result  complete  obliteration  of  the  pericardial  sac. 

4.  The  sero-fihrinons  form— pericarditis  ivith  effusion. — This  is  the 
most  common  variety.  The  heart  appears  roughened  from  the  exudate 
which  often  completely  covers  it,  forming  bands  which  extend  from  one 
surface  to  the  other.  The  serum  may  be  clear,  or  contain  flakes  of  lymph, 
and  varies  in  amount  from  a  few  ounces  to  a  pint.  In  cases  terminating 
in  recovery  there  is  gradual  absorption  of  the  serum  and  part  of  the 
fibrin,  but  adhesions  more  or  less  extensive  always  remain. 

5.  Purulent  pericarditis. — If  the  inflammation  is  set  up  by  a  foreign 
body  ulcerating  into  the  sac,  by  the  rupture  of  a  mediastinal  abscess,  or 
by  general  pyaemia,  the  process  may  be  purulent  from  the  outset.  More 
frequently,  however,  in  purulent  pericarditis  there  is  first  an  abundant 
exudation  of  fibrin  with  pus  cells  in  its  meshes,  and  subsequently  the 
pouring  out  of  fluid  pus,  precisely  as  in  empyema,  with  which  it  is  very 
often  associated.  If  death  occurs  in  the  early  stage,  both  surfaces  of  the 
pericardium  are  found  coated  with  a  thick  exudate  of  greenish-yellow 
lymph,  but  little  or  no  fluid  pus  may  be  present.  At  a  later  period  the 
pericardial  sac  contains  pus,  which  may  vary  in  amount  from  a  few 
ounces  to  one  or  two  pints.  Purulent  pericarditis,  which  is  secondary  to 
pneumonia  or  pleurisy,  is  usually  due  to  the  pneumococcus.  In  other  cases 
any  of  the  pyogenic  germs  may  be  found. 

G.  Pericarditis  with  an  effusion  of  blood  is  very  rare  in  children.  It 
may  occur  from  the  rupture  of  organized  adhesions  or  in  certain  blood 
states  such  as  purpura,  and  very  rarely  in  tuberculosis. 

Pericarditis  complicating  pneumonia  and  pleurisy  is  generally  fibrinous 
or  fibrino-purulent ;  that  with  rheumatism  is  sero-fibrinous,  and  often 
accompanied  by  endocarditis.     With  acute  tuberculosis  there  is  usually 


PERICARDITIS.  5  71 

only  a  deposit  of  miliary  tubercles,  or  there  may  be  a  small  serous  or  sero- 
sanguinolent  effusion,  in  chronic  cases  there  may  be  a  tuberculous  in- 
flammation with  the  formation  of  caseous  nodules,  new  connective  tissue, 
and  extensive  adhesions.  This  generally  occurs  in  connection  with  pul- 
monary tuberculosis — sometimes  with  tuberculous  peritonitis. 

In  any  form  of  pericarditis  complete  recovery,  so  far  as  pathological 
conditions  are  concerned,  is  rare — if,  indeed,  it  ever  occurs.  Generally 
adhesions  remain,  which  may  be  in  the  form  of  a  few  thin  connective- 
tissue  bands,  or  so  extensive  as  to  produce  almost  entire  obliteration  of 
the  pericardial  sac.  Such  adhesions  are  usually  followed  by  secondarv 
changes.  The  growth  and  development  of  the  heart  are  interfered  with, 
and  there  may  be  sufficient  pressure  upon  the  coronary  vessels  to  lead  to 
degeneration  of  the  muscular  walls  and  dilatation  of  the  heart.  With 
large  fluid  exudations  there  may  be  an  interference  with  the  systemic  circu- 
lation, enlargement  of  the  spleen  and  liver,  and  sometimes  general  dropsy. 

Symptoms. — A  pericardial  transudation,  or  dropsy  of  the  pericardium, 
is  very  rarely  large  enough  to  make  a  diagnosis  possible. 

External  pericarditis  is  seldom  recognised  during  life,  there  being  no 
symptoms  except  those  of  the  pleurisy  with  which  it  is  associated.  Occa- 
sionally there  may  be  heard,  particularly  if  the  inflammation  is  anterior, 
a  pleuritic  friction  sound  which  is  increased  with  the  systole  of  the  heart. 
The  pulse  may  be  weak  during  inspiration,  and  there  may  be  an  increased 
area  of  cardiac  dulness.  If  the  inflammation  is  chiefly  posterior,  it  causes 
only  the  symptoms  of  mediastinitis,  which  is  recognised  principally  by  its 
pressure  effects  upon  the  great  vessels.  It  may  produce  oedema  of  the 
face  or  of  the  lower  extremities,  ascites,  enlargement  of  the  liver  and 
spleen,  but  rarely  albuminuria.  It  is  usually  j^rogressive,  and  lasts  from  a 
few  mouths  to  two  or  three  years,  according  to  its  cause. 

Inflammation  of  the  internal  layer  is  the  only  form  usually  described 
as  pericarditis.  This  is  very  frequently  overlooked,  not  only  on  account 
of  its  rarity,  but  from  the  obscurity  of  its  symptoms.  The  difficulty  in 
diagnosis  is  particularly  great  in  young  children.  The  symptoms  are  few, 
and  many  of  them  are  equivocal.  As  this  disease  is  nearly  always  second- 
ary, the  physician  should  be  on  the  watch  for  it  in  infants  with  pleurisy 
or  pleuro-pneumonia  of  the  left  side,  and  in  older  children  in  the  course 
of  articular  rheumatism.  Localized  pain  and  tenderness  may  be  present, 
and  also  a  certain  amount  of  embarrassment  of  the  heart's  action,  usually 
manifested  by  prsecordial  distress,  palpitation,  and  slight  irregularity  of 
the  pulse.  There  may  be  dyspnoea,  and  if  there  is  a  large  effusion  present 
there  may  be  orthopncea  and  cyanosis.  Sometimes  there  is  delirium. 
When  pericarditis  follows  pleurisy  or  pleuro-pneumonia  there  are  fre- 
quently no  new  symptoms  added. 

The  physical  signs  in  older  children  resemble  those  in  adults.  In  dry 
pericarditis  there  is  usually  heard  a  double  friction  sound  over  the  pra?cor- 


572  DISEASES  OF   THE   CIRCULATORY   SYSTEM. 

dial  space,  the  area  being  generally  small  and  near  the  base  of  the  heart. 
The  sound  is  not  transmitted,  and  bears  no  relation  to  the  respiratory 
movements.  After  effusion  has  taken  place  the  apex  beat  may  be  dis- 
placed upward,  diffused,  and  somewhat  indistinct,  or  it  may  not  be  found 
at  all.  There  may  be  bulging  of  the  chest  wall.  On  palpation,  there  is  an 
absence  of  vocal  fremitus  over  an  area  usually  occupied  by  the  lung.  Per- 
cussion gives  an  area  of  marked  dulness  or  flatness  of  triangular  shape, 
the  base  being  below  and  the  apex  above.  The  normal  area  of  cardiac 
dulness  is  increased  in  all  directions,  and  this  dulness  extends  beyond  the 
limits  of  the  heart.  On  auscultation,  the  heart  sounds  are  feeble  and  dis- 
tant. Friction  sounds  disappear  as  serum  is  poured  out,  and  reappear  as 
it  is  absorbed.  Endocardial  murmurs  may  also  be  present.  In  infants, 
physical  signs  are  often  entirely  wanting,  or  the  normal  sounds  may  be 
feeble,  distant,  or  absent. 

The  usual  duration  of  acute  pericarditis  is  from  one  to  three  weeks. 
The  ordinary  dry  form,  with  its  resulting  adhesions,  may  be  followed  by  a 
subacute  or  chronic  form  of  the  disease.  In  the  sero-fibrinous  form  the 
serum  is  usually  absorbed  quite  promptly,  and  only  adhesions  are  left,  or 
a  chronic  inflammation  follows,  with  exacerbations  in  each  recurrence 
of  rheumatism.  In  the  purulent  form  of  the  disease  in  young  children, 
death  is  the  most  frequent  termination.  If  the  pus  is  evacuated,  or  spon- 
taneous opening  takes  place,  there  may  be  recovery,  but  always  with  more 
or  less  extensive  adhesions  remaining. 

Prognosis. — Of  thirty-five  cases  in  Steffen's  collection,  only  six  recov- 
ered. This  statement  is  to  be  taken  rather  as  evidence  of  the  great  difficulty 
of  diagnosis  than  of  a  very  high  mortality,  although  the  disease  is  always 
a  serious  one.  The  prognosis  depends  chiefly  upon  the  exciting  cause. 
Wiien  due  to  pyaemia  or  the  acute  infectious  diseases,  or  when  extending 
from  pleurisy  or  pneumonia,  the  prognosis  is  bad.  Here  it  is  usually  the 
primary  disease  rather  than  the  pericarditis  which  is  the  cause  of  death ; 
the  latter  may  be  the  case,  however,  if  the  effusion  is  large.  The  cases  in 
which  the  pericarditis  itself  is  the  most  important  disease  are  those  de- 
pending upon  rheumatism.  Although  immediate  danger  to  life  may  not 
often  be  great,  yet  convalescence  is  slow,  and  the  remote  consequences  of 
the  disease,  by  reason  of  adhesions,  may  be  very  serious. 

Diagnosis. ^0 wing  to  the  very  rapid  action  of  the  heart  in  children, 
acute  dry  pericarditis  presents  difficulties  of  diagnosis  in  early  life  which 
are  not  met  with  in  the  adult.  The  disease  is  fortunately  so  rare  under 
three  years,  that  in  ordinary  practice  it  need  seldom  be  considered.  In 
older  children  the  diagnosis  is  to  be  made  by  essentially  the  same  signs  as 
in  adults.  Pericarditis  with  effusion  is  to  be  diagnosticated  from  dilata- 
tion of  the  heart  and  from  pleuritic  effusions.  From  dilatation,  the  diag- 
nosis is  not  often  difficult  in  childhood,  for  this  is  not  a  common  con- 
dition, and  is  rarely  extreme  except  in  advanced  valvular  disease.     From 


CHRONIC   PERICARDITIS   WITH   ADHP]SIONS.  573 

pleuritic  effusions  the  diagnosis  is  at  times  almost  impossible.  Signs 
pointing  to  a  sacculated  empyema  of  the  left  side  anteriorly  should  always 
be  regarded  with  suspicion,  particularly  if  the  apex  beat  is  not  displaced 
to  the  right,  and  if  the  heart  sounds  are  very  feeble.  When  empyema  and 
pericarditis  coexist,  it  may  be  impossible  to  recognise  the  condition.  The 
diagnosis  between  serous  and  purulent  effusions  can  be  made  only  by  aspi- 
ration. Fluid  effusions  in  infants  are  almost  invariably  purulent,  and  so 
also  are  they  in  the  majority  of  cases  in  older  children,  unless  due  to  rheu- 
matism. 

Treatment. — In  the  early  part  of  an  attack  of  acute  pericarditis  the 
patient  should  be  kept  in  bed  and  as  quiet  as  possible,  and  hot  poultices  or 
counter-irritation  by  mustard  used  over  the  heart.  Sometimes  an  ice  bag 
may  with  advantage  be  substituted.  Excessive  heart  action  may  be  con- 
trolled by  aconite,  and  severe  pain  may  require  opium.  If  the  disease  is 
due  to  rheumatism,  anti-rheumatic  remedies  should  be  employed.  Serous 
effusions  usually  subside  under  simple  tonic  treatment.  If  absorption  is 
slow,  it  may  be  hastened  by  counter-irritation.  When  a  large  effusion 
forms  rapidly  there  may  be  danger  of  death  from  syncope.  Symptoms 
which  indicate  an  unfavourable  termination  are  cyanosis,  weak,  irregular 
pulse,  and  great  dyspnoea,  or  orthopnea.  Under  these  conditions  aspiration 
may  afford  temporary  relief,  and  free  diuresis  should  be  induced  by  citrate 
of  potash  and  caffein.  The  inhalation  of  oxygen  is  at  times  of  great  value 
in  cases  presenting  such  urgent  symptoms.  If  pus  is  shown  to  be  present 
by  puncture,  incision  and  drainage  should  be  practised,  as  in  empyema. 
The  results  of  aspiration  in  such  cases  are  extremely  unfavourable.  Of 
eighteen  cases  of  aspiration  of  the  pericardium  collected  by  Keating,  only 
four  recovered.  In  puncturing  the  pericardium  the  point  usually  selected 
is  a  little  to  the  left  of  the  border  of  the  sternum  in  the  fifth  intercostal 
space,  the  needle  being  directed  upward  and  outward. 

CHRONIC   PERICARDITIS  WITH   ADHESIONS. 

This  is  not  a  very  uncommon  condition.  It  may  be  general  or  local- 
ized. The  youngest  case  which  has  come  under  my  observation  was  in  a 
female  child  sixteen  months  old,  who  died  from  acute  broncho-pneumonia. 
The  adhesions  were  old  and  general,  the  pericardial  sac  being  completely 
obliterated.  There  was  also  some  old  pleurisy  present.  The  history 
threw  no  light  upon  the  lesions.  As  already  stated,  such  adhesions  may 
follow  single,  but  more  frequently  recurrent,  attacks  of  rheumatic  peri- 
carditis. Sometimes  the  process  may  be  tuberculous.  The  adhesions  may 
increase  until  they  are  one  eighth  or  even  one  fourth  of  an  inch  in  thick- 
ness. Adhesive  pericarditis  is  usually  accompanied  by  some  dilatation  of 
the  heart,  which  may  be  preceded  by  hypertrophy,  and  there  may  or  may 
not  be  valvular  disease. 

Partial  adhesions  cause  no  symptoms  by  which  they  can  be  recognised, 


574  DISEASES   OF  THE  CIRCULATORY   SYSTEM. 

and  even  general  adhesions  sufficient  to  obliterate  the  pericardial  sac  are 
found  at  autopsy  where  not  suspected  during  life.  This  is  one  of  the 
conditions  in  which,  after  it  has  led  to  considerable  dilatation  of  the 
heart,  sudden  death  sometimes  occurs.  It  often  happens  that  the  only 
cardiac  symptoms  present  are  such  as  could  be  explained  by  functional 
disturbance.  The  heart  is  almost  invariably  enlarged.  On  inspection, 
there  is  seen  bulging  of  the  chest  wall,  with  a  strong  and  somewhat  dif- 
fused apex  beat.  One  of  the  most  characteristic  signs  is  that  during  sys- 
tole there  occurs  a  retraction  of  the  chest  over  a  small  area  at  or  near  the 
apex  of  the  heart,  sometimes  at  the  tip  of  the  sternum,  and  sometimes  at 
the  epigastrium.  This  is  often  better  appreciated  by  palpation  than  by 
inspection.  It  is  followed  by  a  rapid  rebound,  associated  with  diastolic 
collapse  of  the  jugular  veins.  A  similar  retraction,  according  to  Broad- 
bent,  is  to  be  seen  behind  in  the  infrascapular  region,  sometimes  on  the  left 
and  sometimes  on  the  right  side.  Percussion  shows  an  increase  in  the  car- 
diac dulness  in  all  directions,  but  particularly  upward.  Hale  White  has 
called  attention  to  the  frequency  of  a  presystolic  nuirmur  of  a  "  blubber- 
ing" character  in  these  cases.  The  diagnosis  of  adherent  pericardium 
always  presents  difficulties,  but  it  can  be  made  with  tolerable  certainty  in 
a  considerable  proportion  of  the  cases.  On  account  of  the  enlargement 
of  the  heart  and  the  frequency  of  the  murmurs,  it  is  usually  mistaken  for 
valvular  disease.  The  lesion  is  a  permanent  one,  and  tends  to  increase. 
The  treatment  is  symptomatic. 


CHAPTER   IV. 

ENDOCARDITIS  AND    VALVULAR   DISEASE. 

ACUTE   SIMPLE   ENDOCARDITLS. 

Acute  endocarditis  may  occur  even  in  fcetal  life.  At  this  period  it 
usually  affects  the  right  side  of  the  heart,  and  is  one  of  the  important 
causes  of  congenital  malformations.  In  infancy,  acute  endocarditis  is 
exceedingly  rare,  not  a  single  instance  being  found  in  over  one  thousand 
autopsies  upon  children  under  three  years  of  age  of  which  I  have  records. 
From  the  third  to  the  fifth  year  it  is  )iot  so  rare,  and  after  this  period  it 
is  quite  common.  Of  95  cases  observed  by  Steffen,  15  occurred  before 
the  sixth  year,  and  80  between  the  sixth  and  fourteenth  years. 

Acute  endocarditis  may  be  })rimary,  but  it  is  much  more  frequently  a 
secondary  disease.  The  primary  cases  have  been  the  subject  of  much  dis- 
cussion, but  I  agree  with  those  who  regard  the  great  majority  of  these 
as  rheumatic.  Cheadle  (London)  has  well  said  that  we  are  to  look 
upon  endocarditis  in  children  not  as  a  complication  of  rheumatism,  so 


ACUTE   SIMPLE   ENDOCARDITIS.  575 

ranch  as  a  manifestation — often  the  first — of  that  disease.  Sometimes 
endocarditis  occurs  alone,  and  sometimes  it  is  associated  with  chorea  with- 
out articular  symptoms ;  but  the  latter  almost  invariably  appear  sooner  or 
later.  Endocarditis  is  seen  as  a  frequent  complication  both  of  acute  and 
of  subacute  articular  rheumatism.  The  proportion  of  rheumatic  cases  in 
which  it  occurs  is  much  larger  in  children  than  in  adults.  Compared 
with  rheumatism,  all  other  causes  of  acute  endocarditis  are  very  infre- 
quent. It  is  seen  occasionally  in  the  course  of  nearly  all  the  acute  infec- 
tious diseases,  most  often  with  scarlet  fever,  and  it  sometimes  complicates 
pleurisy  and  pneumonia,  being  usually  associated  with  pericarditis.  In 
infectious  diseases,  and  in  pleurisy  and  pneumonia,  the  endocarditis  is 
probably  excited  by  pathogenic  germs.  Fraenkel  and  Sanger  have  found 
the  staphylococcus  in  cases  of  simple  endocarditis,  and  cultures  by  others 
have  shown  the  presence  of  other  pyogenic  organisms,  including  the 
pneumococcus. 

Lesions. — Acute  inflammation  may  affect  any  part  of  the  endocardium, 
but  in  extra-uterine  life  it  usually  affects  the  valves  of  the  left  side,  involv- 
ing the  mitral  much  more  frequently  than  the  aortic  valve.  Steffen's 
figures  give  only  four  examples  of  aortic  disease  in  ninety-five  cases. 
(Compare  statistics  of  valvular  disease,  page  583.) 

The  pathological  changes  consist  first  in  an  extensive  growth  of  new 
connective-tissue  cells  and  an  infiltration  of  round  cells  beneath  the  endo- 
thelial layer.  This  results  in  the  formation  of  small  masses  of  granulation- 
tissue  upon  the  valves  or  the  endocardium  of  the  heart  wall,  and  upon 
these  there  is  deposited  fibrin  from  the  blood.  In  this  way  the  tiny  wart- 
like excrescences  known  as  vegetations  are  produced.  Bacteria  may  also 
be  caught  in  the  exudate.  As  a  consequence  of  the  inflammation,  the  valve 
is  swollen,  somewhat  shortened,  and  consequently  insufficient.  The  results 
of  the  process  may  be  ulceration  of  this  new-formed  tissue,  which  in  ordi- 
nary cases  is  small  in  amount,  or  organization  and  cicatrization.  Masses 
of  fibrin  may  be  detached  from  the  vegetations  and  swept  into  the  general 
circulation,  lodging  as  emboli  in  the  kidneys,  spleen,  brain,  or  other 
organs.  This  is  not  common  in  acute  endocarditis,  at  least  not  in  the 
first  attacks. 

In  the  milder  forms  of  inflammation  it  is  possible  for  complete  recov- 
ery to  take  place,  with  the  exception  of  a  slight  valvular  thickening,  not 
enough,  however,  to  interfere  in  any  way  with  the  function  of  the  valves. 
But  this  result  is  rare.  In  most  cases  they  remain  slightly  insufficient,  as 
the  least  serious  consequence  of  the  inflammation.  Unfortunately,  it  more 
often  happens  that  an  acute  inflammation  which  may  not  be  at  first  seri- 
ous, proves  the  beginning  of  the  progressive  changes  of  a  chronic  inflam- 
mation, the  full  effects  of  which  are  not  seen  for  years.  Chronic  inflam- 
mation may  follow  the  first  attack  immediately,  or  after  a  considerable 

interval,  or  occur  after  several  acute  attacks. 
u8 


5Y6  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Symptoms. — When  acute  endocarditis  occurs  as  a  primary  disease,  or 
when  it  is  the  only  manifestation  of  rheumatism,  it  usually  begins  abruptly 
with  rather  severe  general  symptoms — high  temperature,  often  102°  to 
105°  F.,  prostration,  exaggerated  heart  action,  restlessness,  and  some- 
times dyspnoea.  There  is  nothing  distinctive  about  these  symptoms,  and 
it  is  not  until  the  heart  is  examined  that  the  disease  is  recognised.  If  the 
heart  is  not  watched,  the  diagnosis  is  not  made,  and  there  may  be  no  sus- 
picion of  the  nature  of  the  attack  until  some  time  afterward,  when  the 
existence  of  valvular  disease  is  discovered.  If  the  heart  is  carefully 
examined  from  day  to  day,  nothing  abnormal  maybe  found  until  the  third 
or  fourth  day,  or  even  later,  when  there  is  heard  the  characteristic  soft, 
blowing,  systolic  murmur  at  the  apex.  The  murmur  is  generally  trans- 
mitted to  the  left.  It  may  be  accompanied  by  a  thrill  and  by  an  accentu- 
ated pulmonic  second  sound,  and  later  there  may  be  evidence  of  slight  dila- 
tation with  the  usual  signs  of  some  degree  of  cardiac  insufficiency.  The 
murmur  gradually  increases  in  intensity  until  the  maximum  is  reached, 
and  then  in  most  cases  somewhat  subsides. 

Acute  endocarditis  sometimes  occurs  in  the  course  of,  or  simultane- 
ously with,  an  attack  of  chorea,  with  symptoms  quite  similar  to  those 
described.  Finlayson  (Grlasgow)  has  called  attention  to  endocarditis  as 
a  frequent  cause  of  obscure  fever  in  choreic  patients,  either  when  occur- 
ring alone  or  with  articular  symptoms.  It  may  develop  at  any  time 
during  the  choreic  attack  or  subsequent  to  it.  When  endocarditis  occurs 
as  a  complication  of  articular  rheumatism,  there  may  be  an  increase  in  the 
temperature  and  in  the  severity  of  the  general  symptoms,  but  rarely  any- 
thing more  definite.  Endocarditis  complicating  other  diseases  is  recog- 
nised only  by  the  physical  signs. 

The  usual  duration  of  acute  endocarditis  is  from  one  to  three  weeks, 
the  febrile  symptoms  frequently  subsiding  in  a  few  days  and  the  cardiac 
symptoms  slowly  diminishing. 

The  attack  may  terminate  fatally  in  the  course  of  a  few  weeks,  owing 
to  the  rapid  development  of  acute  dilatation,  accompanied  by  the  usual 
signs  of  cardiac  insufficiency,  with  drojisy,  cyanosis,  and  often  pulmonary 
complications.  Cerebral  embolism  may  occur,  which  usually  produces 
hemiplegia,  but  rarely  results  fatally.  If  emboli  lodge  in  the  spleen  or 
kidneys,  they  may  lead  to  swelling  of  the  spleen  or  to  hematuria.  The 
patient  may  recover  with  a  murmur  which  lasts  but  a  few  weeks  and 
gradually  disappears — a  rare  result.  Usually  there  is  a  persistent  mur- 
mur, with  the  subsequent  development  of  the  ordinary  signs  of  valvular 
disease.  Lastly,  there  may  be  recurrent  attacks  of  inflammation,  with  the 
ultimate  development  of  chronic  valvular  disease. 

Diagnosis. — The  diagnosis  of  acute  endocarditis  is  very  frequently  not 
made;  not  because  it  is  difficult,  but  because  in  young  children  the  heart 
is  not  examined  as  frequently  and  as  carefully  as  it  should  be.    The  symp- 


ACUTE   SIMPLE   ENDOCARDITIS.  577 

toms  are  few  and  not  diagnostic.  It  is  therefore  of  the  greatest  impor- 
tance that  not  only  in  chorea  and  rheumatism,  but  in  all  acute  febrile 
attacks,  particularly  those  of  obscure  origin,  the  heart  should  be  closely 
watched.  Endocarditis  affecting  the  wall  of  the  heart  can  not  be  diag- 
nosticated. The  murmur  of  valvular  endocarditis  may  be  confounded  with 
pericarditis,  or  with  functional  or  blood  murmurs  occurring  in  the  course  of 
acute  febrile  attacks,  or  with  those  of  ansemic  origin.  From  pericarditis  it 
is  distinguished  by  the  fact  that  the  murmur  is  single,  has  a  soft  blowing 
character,  is  usually  located  at  the  apex,  is  transmitted  beyond  the  bor- 
der of  the  heart,  and  is  diminished  by  a  full  inspiration.  Functional 
murmurs  in  febrile  diseases  are  quite  frequent  in  young  children,  and 
may  at  first  be  difficult  to  distinguish  from  those  of  endocarditis.  Usuallv, 
however,  the  former  are  at  the  base  rather  than  at  the  apex.  They  are 
more  irregular,  both  as  to  time,  transmission,  and  constancy,  than  are  mur- 
murs resulting  from  acute  endocarditis.  The  same  may  be  said  of  anemic 
murmurs,  which,  as  in  adults,  may  be  heard  in  the  carotids,  and  some- 
times over  any  of  the  large  arteries. 

Prognosis. — The  danger  to  life  in  acute  endocarditis  is  not  often  great, 
as  the  disease  seldom  proves  fatal.  However,  death  may  occur  when  it  is 
associated  with  chorea,  but  here  usually  when  an  acute  process  is  ingrafted 
upon  an  old  valvular  disease.  In  other  cases,  death  results  from  compli- 
cations, particularly  pneumonia.  Only  the  progress  of  the  case  enables 
one  to  decide  how  extensive  is  the  damage  which  has  been  done  to  the 
valves.     There  is  always  the  danger  of  recurrent  attacks. 

Treatment. — All  the  so-called  primary  cases,  as  well  as  those  occurring 
with  chorea  and  articular  symptoms,  should  have  the  benefit  of  anti- 
rheumatic remedies,  as  this  is  the  only  plan  wiiich  offers  any  chance  of 
limiting  the  inflammation,  although  the  effect  upon  the  heart  is  rarely 
striking.  Excessive  cardiac  action  is  sometimes  allayed  by  aconite, 
sometimes  best  by  opium.  The  most  important  thing  in  the  management 
of  these  cases,  and  the  one  frequently  overlooked,  is  to  secure  for  the  heart 
as  complete  I'est  as  possible,  not  only  during  the  period  of  acute  inflam- 
mation, but  for  several  succeeding  weeks.  Patients  should  be  kept  in  bed 
for  at  least  a  month,  and  only  the  slightest  exertion  permitted  for  many 
weeks.  It  is  during  this  early  period  of  the  disease  that  changes  take 
place  most  rapidly  in  the  heart  walls,  and  the  gravest  results  sometimes 
follow  the  neglect  of  these  precautions.  Children  are  often  allowed  out  of 
bed  as  soon  as  the  fever  has  subsided,  and  the  heart  disease  is  unnoticed 
until  a  grave  amount  of  dilatation  has  developed,  with  dropsy,  palpitation, 
shortness  of  breath,  slight  cyanosis,  irregular  pulse,  and  cough.  All  chil- 
dren who  have  once  suffered  from  endocarditis  should  be  protected  as 
much  as  possible  against  subsequent  attacks  of  rheumatism. 


578  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

MALIGNANT  ENDOCARDITIS. 

Malignant  or  ulcerative  endocarditis  is  a  rare  disease  in  childhood. 
The  youngest  case  I  have  found  reported  is  that  of  Harris,  which  occurred 
in  a  boy  four  years  old,  and  affected  the  right  side  of  the  heart.  It  was 
secondary  to  a  cardiac  malformation.  Of  the  cases  thus  far  reported  in 
early  life,  about  twenty-five  in  number,  the  great  j^roportion  have  been  in 
children  over  ten  years  of  age,  in  whom  the  disease  does  not  differ  essen- 
tially from  the  adult  type.  For  tlie  most  exhaustive  stady  of  this  subject 
we  are  indebted  to  Osier's  Gulstonian  Lectures. 

Malignant  endocarditis  rarely  occurs  as  a  primary  affection.  Of  the 
acute  diseases,  it  is  most  frequently  secondary  to  pneumonia,  next  to 
rheumatism  and  meningitis.  It  may  be  met  with  in  any  infectious  dis- 
ease or  septic  process.  In  75  per  cent  of  the  cases,  according  to  Osier,  it 
is  ingrafted  upon  a  previous  valvular  disease.  In  my  series  of  collected 
cases  of  congenital  malformations  of  the  heart,  there  were  four  deaths 
from  malignant  endocarditis,  all  but  one,  however,  occurring  in  adult  life. 

The  bacteria  most  frequently  associated  are  the  staphylococcus  and 
streptococcus,  and,  in  the  cases  complicating  pneumonia,  the  pneumococ- 
cus.  These  micro-organisms  are  believed  to  play  an  important  part  in  the 
production  of  the  disease.  Circulating  in  the  blood,  they  lodge  upon  the 
endocardium  of  the  valves,  all  the  more  readily  when  they  are  previously 
diseased. 

Lesions. — Malignant  endocarditis  may  result  in  the  production  of  vege- 
tations which  subsequently  break  down,  or  there  may  be  superficial  ulcera- 
tion affecting  only  the  endocardium,  or  deeper  ulceration  involving  the 
valve,  the  septum,  or  even  the  heart  wall.  In  other  cases  there  is  suppura- 
tion of  the  deeper  tissues  of  the  valve  first  affected,  with  the  production  of 
small  abscesses  at  the  base  of  the  vegetations.  These  conditions  may  lead 
to  large  perforations,  or  even  to  the  destruction  of  the  valve,  to  valvular 
aneurisms,  or  abscesses  of  the  heart  wall.  According  to  Osier,  the  differ- 
ent parts  of  the  heart  are  affected  in  the  following  order :  mitral  valve ; 
aortic,  mitral  and  aortic  combined;  tricuspid  and  pulmonic  valves;  and 
the  cardiac  wall.  The  secondary  lesions  of  malignant  endocarditis  are  due 
to  emboli.  These  are  most  frequent  in  the  spleen  and  kidney,  next  in 
the  brain,  intestines,  and  skin,  and,  if  the  right  side  of  the  heart  is  dis- 
eased, in  the  lungs.  These  emboli  lead  to  the  formation  of  red  or  white 
infarctions,  to  haemorrhages,  or  to  multiple  abscesses  in  the  various  organs 
and  tissues  in  which  they  lodge. 

Symptoms. — Malignant  endocarditis  presents  a  great  variety  of  symp- 
toms, making  the  diagnosis  extremely  difficult  in  perhaps  the  majority  of 
cases.  There  is  generally  a  remittent  type  of  fever,  sometimes  repeated 
rigors,  profuse  sweating,  low  delirium,  stupor  or  coma,  and  extreme  pros- 
tration.    In  many  cases  there  is  a  fine  petechial  eruption  upon  the  skin ; 


CHRONIC  VALVULAR  DISEASE.  579 

diarrhoea  is  also  frequent.  The  cerebral  symptoms  may  be  so  prominent 
as  to  suggest  meningitis.  There  is  usually  a  cardiac  murmur,  the  location 
of  which  depends  upon  the  seat  of  disease.  It  is  most  frequently  the 
murmur  of  mitral  regurgitation.  This  murmur  is  sometimes  faint,  and 
may  be  absent.  The  spleen  is  in  most  cases  enlarged.  From  the  emboli 
there  may  be  hemiplegia,  rapid  swelling  of  the  spleen,  bloody  urine,  cough, 
and  symptoms  of  pneumonia.  The  disease  lasts  from  a  few  days  to  six 
weeks,  death  being  the  almost  invariable  termination.  It  is  due  to  ex- 
haustion or  to  some  embolic  process. 

Diagnosis. — The  most  characteristic  features -of  malignant  endocarditis 
are  the  development  of  pygemic  or  typhoid  symptoms  with  a  petechial 
eruption,  in  a  patient  who  has  previously  had  valvular  disease.  Malignant 
endocarditis  is  differentiated  from  typhoid  fever  by  its  sudden  onset, 
irregular  temperature,  recurring  chills,  profuse  sweats,  petechial  eruption, 
and  dyspnoea.     It  may  be  confounded  with  malarial  fever. 

Treatment. — This  is  entirely  symptomatic ;  no  known  measures  have 
any  influence  upon  the  disease  itself. 

CHRONIC   VALVULAR   DISEASE. 

Chronic  valvular  disease  of  the  heart  in  children  is  usually  the  result 
of  endocarditis ;  in  a  small  number  of  cases  it  depends  upon  congenital 
malformation  ;  but  the  degenerative  lesions  to  which  many  adult  cases  are 
due  have  no  place  in  early  life. 

Lesions. — The  changes  of  chronic  endocarditis  may  be  briefly  described 
as  follows :  The  valvular  segments  are  thickened  by  the  production  of  new 
connective  tissue,  the  contraction  of  which  results  in  retraction,  shorten- 
ing, puckering,  and  imperfect  closure  of  the  valves.  The  valvular  leaflets 
may  adhere  to  each  other,  so  that  the  opening  is  very  much  narrowed. 
This  is  sometimes  reduced  to  a  funnel-shaped  orifice  barely  admitting  the 
tip  of  the  finger,  and  it  may  even  be  much  smaller.  The  leaflets  are  some- 
times adherent  to  the  wall  of  the  heart;  the  chords  tendineas  are  short- 
ened, and  sometimes  entirely  disappear  ;  and,  finally,  the  valves  may  be  the 
seat  of  calcareous  deposits.  These  changes  take  place  very  slowly,  requir- 
ing many  years  for  their  full  development.  From  time  to  time  there  may 
be  attacks  of  acute  inflammation.  The  changes  described  may  bring  about 
(1)  valvular  insufficiency,  owing  to  imperfect  closure,  causing  a  regurgita- 
tion of  blood  through  the  opening  guarded  by  the  valve ;  or  (2)  stenosis, 
with  such  a  narrowing  of  the  opening  that  the  outflow  of  blood  is  ob- 
structed.    In  early  life  it  is  usually  the  mitral  valve  that  is  affected. 

Of  141  cases  in  children  under  fourteen  years  old,  observed  clinically  by 
Dr.  F.  M.  Crandall  and  myself,  the  mitral  valve  was  alone  affected  in  79  per 
cent ;  the  aortic  valve  alone  in  3  per  cent ;  and  both  were  associated  in 
18  per  cent.  Lesions  of  the  aortic  valve  in  early  life  are  therefore  com- 
paratively rare. 


580 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


Following  valvular  lesions,  important  changes  take  place  in  the  wall 
and  cavities  of  the  heart :  these  are  hypertrophy  and  dilatation. 

Hijpertropliy. — This  consists  in  an  increase  in  the  thickness  of  the 
heart  wall,  due  to  an  increase  in  the  size  and  number  of  the  muscular 
fibres.  It  is  principally  of  the  ventricles,  and  is  always  conservative.  It 
may  continue  indefinitely,  or  it  may  be  followed  by  degeneration  and  dila- 
tation. Hypertrophy  occurs  as  a  result  of  any  obstructive  lesion  at  one  of 
the  cardiac  orifices,  in  renal  disease  when  the  obstruction  is  in  the  small 
arteries,  also  when  extra  work  is  thrown  upon  the  ventricles  as  a  result  of 
regurgitation,  and  it  may  follow  primary  dilatation. 

Dilatation. — This  consists  in  an  enlargement  of  the  cavities  of  the 
heart,  usually  with  thinning  of  their  walls.  It  is  generally  most  marked 
in  the  auricles.  Primary  dilatation  is  produced  by  regurgitation  of  blood 
into  any  of  the  cavities  as  a  result  of  valvular  insufficiency.  This  may  to 
a  slight  extent  be  regarded  as  a  conservative  lesion.  Secondary  dilatation, 
or  that  resulting  from  degeneration  of  the  cardiac  muscle,  is  always  in- 
jurious. It  is  usually  caused  by  imperfect  nutrition  of  the  heart  which 
may  be  due  to  local  or  general  causes.  In  most  of  the  cases  both  hyper- 
trophy and  dilatation  continue  for  a  long  time.  So  long  as  hypertrophy 
predominates,  the  circulation  may  be  well  carried  on ;  but  when  dilatation 
comes  to  exceed  hypertrophy,  there  are  signs  of  great  embarrassment  to 
tlie  circulation  and  of  cardiac  insufficiency. 

There  are  other  lesions  accompanying  chronic  valvular  disease,  de- 
pending upon  obstruction  to  the  venous  circulation.  If  this  obstruction 
is  in  the  pulmonary  veins,  it  leads  to  congestion  of  the  lungs,  chronic 
bronchitis,  or  chronic  pneumonia;  if  of  the  systemic  venous  circulation, 
it  leads  to  chronic  congestion  of  the  spleen,  liver,  kidneys,  peritonaeum, 
and  sometimes  to  general  dropsy. 

Etiology. — The  following  table  gives  the  age  and  sex  in  the  cases  ob- 
served bv  Dr.  Crandall  and  mvself  : 


1 

year. 

9 

years. 

3 
yeais. 

4 

yeais. 

5 
years. 

6           7 
years,  years. 

8 
years. 

9 
years. 

10 
years. 

n 

years. 

12 
years. 

13 
years. 

14 
years. 

Males 

Females . . . 

1 
1 

2 
3 

2 
5 

4      6      4 
7      9     10 

9 
3 

8 
11 

6 
12 

5 
14 

7 
4 

6 
2 

1 

3 

=    55, 
=    90, 

or  38^ 
"62^ 

Total... 

2 

5 

7 

11     15     14 

12 

19 

18 

19 

11 

8 

4 

=  145 

The  difference  in  sex  is  very  nearly  the  same  as  was  found  in  my  cases 
of  rheumatism.  Sturges,  in  100  cases,  gives  56  per  cent  females  and  44 
per  cent  males.     Sansom's  figures  alone  give  a  predominance  of  males. 

The  chronic  endocarditis  of  early  life  is,  as  a  rule,  secondary  to  the 
acute  or  subacute  form.  Its  etiological  factors  are  therefore  those  of 
acute  endocarditis.  Of  117  cases  in  my  own  series,  93,  or  80  per  cent, 
gave  a  history  of  previous  rheumatism — T  cases  of  chorea  without  ar- 
ticular symptoms  being  included  as  rheumatic.     Of  the  31  cases  which 


CHRONIC   VALVULAR  DISEASE.  581 

at  the  first  examination  gave  no  history  of  rlicumatism,  8  subsequently 
developed  articular  rheumatism,  and  2  chorea,  so  that  nearly  90  per  cent 
of  this  series  of  cases  presented,  to  my  mind,  conclusive  evidence  of  a 
rheumatic  diathesis.  Thirty  per  cent  had  chorea  previously,  or  developed 
it  wliile  under  observation.  The  more  closely  I  study  cases  of  rheumatism, 
chorea,  and  valvular  disease,  and  the  longer  the  patients  are  kept  under 
observation,  the  deeper  becomes  my  conviction  of  the  very  close  relation- 
ship between  these  three  conditions  in  childhood.  The  percentage  of 
rheumatic  cases  in  this  series  is  considerably  larger  than  that  given  by 
many  writers,  but  it  corresponds  very  closely  with  Cheadle's  careful  obser- 
vations. Valvular  disease  is  occasionally  traced  to  an  attack  of  endo- 
carditis complicating  scarlet  fever,  and  in  rare  cases  to  that  occurring  with 
other  infectious  diseases. 

Symptoms. — The  symptoms  of  chronic  valvular  disease  in  most  cases 
come  on  slowly,  often  insidiously,  and  frequently  there  are  none  until  the 
disease  has  lasted  a  long  time,  the  condition  being  discovered  by  accident. 
The  course  of  valvular  disease  is  usually  divided  into  two  periods,  the  first 
being  that  while  compensation  is  present,  and  the  second  after  compensa- 
tion has  failed.  The  duration  of  the  stage  of  compensation  is  indefinite ; 
it  may  last  a  lifetime.  The  only  subjective  symptom  that  is  of  much  diag- 
nostic value  is  shortness  of  breath  on  exertion.  Occasionally  other  symp- 
toms are  present,  such  as  precordial  pain,  attacks  of  palpitation,  head- 
ache, epistaxis,  antemia,  and  cough.  These  are  rarely  constant,  but  come 
on  when  the  patient's  general  condition  for  any  reason  is  below  normal. 
As  a  rule,  there  is  in  young  subjects  a  tendency  to  an  increase  in  the  dis- 
ease, altliough  this  is  often  slow,  and  may  be  interrupted  by  long  periods 
in  which  the  process  appears  to  be  stationary.  At  such  times  the  patients 
either  have  no  symptoms,  or  suffer  only  from  a  slight  amount  of  incon- 
venience on  marked  exertion. 

Faihire  in  compensation  is  generally  brought  about  by  one  of  the  fol- 
lowing causes  :  There  may  be  an  intercurrent  attack  of  acute  endocarditis, 
which  in  a  short  time  leads  to  a  very  great  increase  in  the  heart's  disability. 
It  may  be  due  to  additional  work  thrown  upon  the  heart  from  excessive 
muscular  exertion,  or  to  the  strain  of  a  prolonged  attack  of  some  acute  ill- 
ness, especially  one  that  is  liable  to  produce  changes  in  the  heart  muscle, 
such  as  typhoid  or  scarlet  fever.  It  is  sometimes  the  increased  work  which 
is  physiologically  thrown  upon  the  heart  at  the  time  of  puberty,  owing  to 
the  rapid  growth  of  the  body.  It  may  result  from  any  cause  which  seri- 
ously affects  the  patient's  general  nutrition,  particularly  when  this  is 
associated  with  marked  anemia. 

The  symptoms  indicating  failure  of  compensation  are  those  depending 
upon  a  weak  heart,  with  imperfect  filling  of  the  arteries  and  overfilling  of 
the  veins.  The  embarrassment  of  the  pulmonary  circulation  leads  to  con- 
stant dyspnoea  or  orthopna?a  and  cough,  sometimes  accompanied  by  profuse 


5S2  DISEASES   OF   THE   CIRCULATORY  SYSTEM. 

expectoration,  whicli  may  be  bloody,  and  in  rare  cases  there  may  be  larger 
pulmonary  lisemorrhages.  The  obstruction  to  the  systemic  venous  circu- 
lation leads  to  dropsy,  which  begins  in  the  feet.  There  may  be  general 
anasarca  and  dropsy  of  the  serous  cavities,  especially  the  peritonaeum  and 
pleura;  also  enlargement  and  functional  disturbances  of  the  liver,  en- 
largement of  the  spleen,  dyspeptic  symptoms,  and  chronic  congestion  of 
the  kidney,  with  scanty  urine  and  albuminuria.  There  may  be  dilatation 
of  the  superficial  veins,  with  clubbing  of  the  fingers,  and  cyanosis ;  and 
there  may  be  cerebral  symptoms,  such  as  headache,  dizziness,  and  faint- 
ing attacks.  The  pulse  is  small  and  soft,  and  the  heart's  action  rapid 
and  irregular. 

It  is  rare  to  see  all  the  symptoms  of  cardiac  failure  in  children 
under  ten  years,  but  about  the  time  of  puberty  they  are  not  uncommon. 
The  symptoms  may  increase  in  severity  until  death  occurs,  or  they  may 
be  severe  for  a  time  and  then  nearly  disappear,  to  return  again  after  a 
longer  or  shorter  interval.*    Death  may  be  due  to  sudden  cardiac  paralysis, 


*  The  course  and  termination  of  these  cases  of  chronic  valvular  disease  is  well 
illustrated  by  the  following  history  of  a  little  girl  who  was  under  observation  for 
nine  years :  When  first  seen  she  was  seven  years  old,  and  gave  a  history  of  cardiac 
symptoms  for  one  year.  There  was  then  present  a  loud  mitral  regurgitant  murmur, 
with  considerable  hypertrophy.  There  was  general  dropsy,  and  all  the  symptoms 
pointed  toward  acute  dilatation.  Under  treatment,  the  dropsy  and  other  symptoms 
disappeared,  and  she  went  on  comfortably  for  over  a  year.  In  her  eighth  and  ninth 
years  there  were  frequent  attacks  of  subacute  rheumatism,  during  which  time  the 
heart  lesion  steadily  increased  in  severity.  At  twelve  years  there  was  an  eruption  of 
subcutaneous  tendinous  nodules,  which  remained  for  over  two  years.  During  this 
year  there  was  heard  for  the  first  time  a  mitral  direct  murmur,  accompanied  by  a  very 
marked  thrill,  mitral  stenosis  having  been  gradually  brought  about  by  the  slowly  pro- 
gressing endocarditis.  This  murmur  gradually  increased  in  intensity  from  that  time, 
while  the  mitral  regurgitant  murmur  became  less  distinct.  The  apex  beat  at  this  time 
was  in  the  sixth  space,  two  and  a  half  inches  to  the  left  of  the  nipple.  From  the 
twelfth  to  the  fifteenth  year  she  grew  very  little  in  height  or  weight,  and  showed  no 
signs  of  maturity,  the  cardiac  symptoms  being  nearly  stationary.  In  the  fifteenth 
year  she  developed  a  marked  enlargement  of  the  liver  and  spleen  with  general  dropsy 
and  all  the  symptoms  of  cardiac  insufficiency,  these  being  the  first  symptoms  of  this 
character  since  she  was  seven  years  old.  There  was  now  heard  for  the  first  time  an 
aortic  regurgitant  murmur  in  addition  to  the  others  formerly  present.  The  symptoms 
disappeared  under  treatment  in  the  course  of  a  few  months,  but  six  months  later  re- 
turned with  greater  severity  and  were  accompanied  by  albuminuria,  the  patient  dying 
from  heart  failure  in  a  few  weeks.  During  the  last  exacerbation  there  was  heard  a 
double  aortic  as  well  as  a  double  mitral  murmur. 

At  autopsy  the  heart  weighed  fifteen  ounces.  There  was  a  very  great  hypertrophy, 
especially  of  the  right  ventricle,  which  was  as  thick  as  the  left.  All  the  cavities  were 
much  dilated.  The  most  important  valvular  lesion  was  mitral  stenosis,  the  orifice  not 
admitting  the  end  of  the  little  finger.  The  valves  were  the  seat  of  calcareous  deposits. 
The  curtains  of  the  aortic  valve  were  thickened  and  adherent ;  there  was  also  thicken- 
ing of  the  pulmonic  and  tricuspid  valves. 


CHRONIC   VALVULAR   DLSEASE.  583 

to  intercurrent  nephritis,  pneumonia,  embolism,  inflammation  of  the  se- 
rous membranes,  or  to  oedema  of  the  lungs. 

Clinical  Varieties. — Of  the  141  cases  of  valvular  disease  in  children 
under  fourteen  years,  previously  referred  to,  the  following  were  the  forms 
and  combinations  recorded.  It  is  to  be  noted  that  these  figures  are  based 
upon  clinical  and  not  pathological  examinations : 

Mitral  insufficiency 131  cases ;  alone  in  99  cases. 

Mitral  stenosis 17      "  "       "4     " 

Aortic  insufficiency 9      "  "       "     0      " 

Aortic  stenosis 28      "  "       "     3      " 

Double  mitral 8     " 

Double  aortic 1  case. 

Double  mitral  and  double  aortic 3  cases. 

Mitral  insufficiency  and  double  aortic 3      " 

Mitral  insufficiency  and  aortic  stenosis 18      " 

Mitral  stenosis  and  aortic  insufficiency 2      " 

Mitral  insufficiency. — This  is  usually  the  result  of  attacks  of  acute 
endocarditis.  It  is  by  far  the  most  frequent  form  of  valvular  disease  in 
early  life,  occurring  in  93  per  cent  of  the  above  cases,  and  alone  in  70  per 
cent.  In  mitral  insufficiency  there  is  regurgitation  of  blood  from  the  left 
ventricle  into  the  left  auricle  during  systole.  This  is  compensated  for  by 
hypertrophy  of  both  ventricles.  It  causes  dilatation  of  the  left  auricle, 
increased  pressure  in  the  pulmonary  veins,  afterward  in  the  pulmonary 
arteries,  hypertrophy  of  the  right  ventricle,  and,  finally,  there  is  dilata- 
tion of  the  right  ventricle,  tricuspid  insufficiency,  dilatation  of  the  right 
auricle,  and  general  systemic  venous  obstruction.  Coincident  with  the 
changes  in  the  right  heart  there  is  hypertrophy  of  the  left  ventricle,  fol- 
lowed by  dilatation. 

In  mitral  insufficiency  there  is  heard  a  systolic  murmur  which  is  syn- 
chronous with  the  apex  impulse  and  with  the  first  sound  of  the  heart,  and 
may  in  part  replace  the  first  sound.  It  is  loudest  at  the  apex,  trans- 
mitted to  the  left,  and  heard  with  almost  equal  distinctness  at  the  inferior 
angle  of  the  left  scapula.  This  is  a  very  diffusible  murmur,  and  may  be 
audible  all  over  the  chest.  It  is  accompanied  by  an  accentuation  of  the 
pulmonic  second  sound  heard  at  the  left  border  of  the  sternum  in  the 
second  space,  and  by  signs  of  hypertrophy  of  the  heart.  When  both  these 
signs  are  wanting,  the  existence  of  mitral  insufficiency  is  somewhat  doubt- 
ful, as  a  similar  murmur  may  be  of  functional  or  accidental  origin.  In 
the  early  stages  of  the  disease  the  signs  of  hypertrophy  predominate  ;  in 
the  later  stages,  those  of  dilatation. 

In  hypertrophy  of  the  left  ventricle  or  of  the  whole  heart,  the  apex 
beat  is  displaced  downward  and  to  the  left.*     It  may  be  in  the  fifth  or 

*  For  normal  position  of  the  apex  in  childhood,  see  page  5dO. 


584  DISEASES   OF   THE   CIRCULATORY  SYSTEM. 

the  sixth  space,  but  rarely  lower,  and  as  far  to  the  left  as  the  axillary  line. 
There  is  often  bulging  of  the  pra?cordia,  so  marked  as  to  cause  a  deformity 
of  the  chest.  The  impulse  is  forcible  and  heaving,  and  over  a  larger  space 
than  normal.  The  area  of  cardiac  dulness  is  increased  in  all  directions, 
but  particularly  downward  and  to  the  left.  In  hypertrophy  involving 
chiefly  the  right  ventricle,  there  may  be  bulging  of  the  lower  part  of  the 
sternum,  and  the  area  of  dulness  is  increased  to  the  right,  in  extreme  cases 
extending  from  one  to  one  and  a  half  inches  beyond  the  right  border  of  the 
sternum.  The  heart  sounds  in  hypertrophy  are  loud  and  distinct,  and 
often  have  a  somewhat  metallic  character.  AYith  hypertrophy  of  the  right 
ventricle  there  may  be  reduplication  or  accentuation  of  the  second  sound. 
The  pulse  is  full  and  strong. 

In  dilatation  the  apex  beat  is  indistinct,  diffuse,  and  undulatory. 
There  is  an  increase  in  the  area  of  cardiac  dulness,  the  outline  being  nearly 
square.  The  cardiac  sounds  are  feeble,  and  murmurs  previously  present 
may  be  lost.  The  heart's  action  is  irregular,  and  the  pulse  small  and 
weak. 

Mitral  stenosis. — This  is  apt  to  occur  from  repeated  attacks  of  subacute 
rheumatism,  with  a  slowly  progressing  endocarditis.  It  is  usually  asso- 
ciated with  mitral  regurgitation,  but  may  occur  alone.  There  is  with  this 
lesion  obstruction  to  the  flow  of  blood  from  the  left  auricle  into  the  left 
ventricle.  It  is  mainly  compensated  for  by  hypertrophy  of  the  right  ven- 
tricle, but  to  a  certain  degree  by  hypertrophy  of  the  left  auricle.  The 
secondary  changes  following  the  lesion  are  hypertrophy  of  the  left  auricle 
followed  by  dilatation,  increased  pressure  in  the  pulmonary  veins,  followed 
by  hypertrophy  and  dilatation  of  the  right  ventricle.  The  left  ventricle 
is  usually  normal  or  small. 

Mitral  stenosis  produces  a  presystolic  murmur  which  is  somewhat 
prolonged,  usually  rough  in  character,  and  terminates  sharply  with  the 
first  sound  of  the  heart.  It  is  loudest  at  or  near  the  apex,  but  is  audible 
over  only  a  small  circumscribed  area.  Quite  as  constant  and  important 
for  diagnosis  is  the  presence  of  a  "purring  thrill,"  which  is  very  distinct 
upon  palpation,  and  terminates  sharply  as  the  apex  strikes  the  chest  wall. 
The  pulse  of  mitral  obstruction  is  usually  small.  The  symptoms  are  few, 
but  those  which  are  present  depend  chiefly  upon  pulmonary  congestion. 

Aortic  stenosis. — This  is  not  very  common  in  early  life,  and  rarely 
occurs  as  the  only  murmur,  being  most  frequently  associated  with  mitral 
insufficiency.  It  is  sometimes  a  congenital  murmur.  Aortic  obstruction 
is  compensated  for  by  hypertrophy  of  the  left  ventricle,  which  may  be 
complete  for  a  long  period,  but  ultimately  it  is  followed  by  dilata- 
tion of  the  left  ventricle,  with  mitral  insufficiency  and  its  consequences. 
In  aortic  obstruction  there  is  an  interference  with  the  outflow  of  blood 
from  the  left  ventricle  into  the  aorta.  It  causes  a  systolic  murmur,  which 
is  usual! V  loudest  at  the  right  border  of  tlie  sternum  in  the  second  space, 


CHRONIC  VALVULAR  DISEASE.  585 

and  is  transmitted  upward,  being  distinct  in  the  carotids.  The  second 
sound  is  generally  weak.  There  are  associated  the  signs  of  marked  hyper- 
trophy of  the  left  ventricle. 

Aortic  obstruction  is  more  frequently  confounded  with  conditions  giv- 
ing accidental  or  functional  murmurs  than  is  any  other  valvular  lesion. 
Without  the  signs  of  hypertrophy  of  the  left  ventricle,  a  positive  diagnosis 
should  not  be  made.  On  account  of  the  almost  jierfect  compensation, 
this  form  of  the  disease  causes  fewer  symptoms  than  any  other  variety, 
possibly  excepting  mitral  obstruction.  The  danger  of  embolism  is  some- 
what greater  than  in  mitral  disease. 

Aortic  insufficiency. — This  is  one  of  the  rarest  valvular  lesions  in  chil- 
dren. In  no  case  on  my  list  did  it  occur  as  the  only  lesion.  It  causes  a 
regurgitation  of  blood  from  the  aorta  into  the  left  ventricle  daring  dias- 
tole. It  is  compensated  for  by  dilatation  and  hypertrophy  of  the  left 
ventricle.  The  order  in  which  the  secondary  changes  take  place  is :  dila- 
tation followed  by  hypertrophy  of  the  left  ventricle,  ultimately  followed 
by  further  dilatation  due  to  degeneration,  this  leading  to  mitral  insuffi- 
ciency with  all  its  remote  consequences.  The  signs  of  aortic  insufficiency 
are  a  prolonged  diastolic  murmur,  with,  or  taking  the  place  of,  the  second 
sound  of  the  heart,  generally  loudest  at  the  left  border  of  the  sternum  in 
the  second  space,  and  transmitted  downward  to  the  apex  of  the  heart  or  the 
ensiform  cartilage.  This  is  invariably  accompanied  by  signs  of  hyper- 
trophy and  dilatation  of  the  left  ventricle,  these  being  usually  marked 
In  the  stage  of  compensation  the  signs  of  hypertrophy  predominate,  and 
when  compensation  has  failed,  the  signs  of  dilatation.  A  characteristic 
symptom  is  the  intense  throbbing  of  the  carotids,  with  the  sudden  disten- 
sion and  complete  collapse  of  their  walls,  and  the  "  ball-pulse  "  of  Corri- 
gan.  Early  in  the  disease  there  may  be  headache,  flashes  of  light  before 
the  eyes,  and  other  evidences  of  cerebral  congestion.  In  the  late  stages 
there  may  be  fainting  attacks.  With  this  lesion  compensation  may  be 
complete  for  a  long  time. 

Tricuspid  insiifficiencij . — This  is  usually  secondary  to  disease  of  the 
left  side  of  the  heart,  occurring  in  its  late  stages.  It  most  frequently  fol- 
lows mitral  insufficiency,  where  it  is  usually  due  to  dilatation  of  the  right 
ventricle  without  changes  in  the  valves.  It  may  be  secondary  to  certain 
diseases  of  the  lungs,  such  as  emphysema,  chronic  interstitial  pneumonia, 
or  chronic  pleurisy,  and  it  may  be  due  to  congenital  malformation.  Tri- 
cuspid insufficiency  gives  a  systolic  murmur,  loudest  over  the  lower  part  of 
the  sternum,  but  heard  usually  over  a  small  area.  It  is  generally  associated 
with  signs  of  dilatation  of  the  right  ventricle.  The  jugular  veins  stand 
out  pi'ominently,  and  often  show  systolic  pulsation,  especially  upon  the 
right  side.  The  symptoms  associated  with  tricuspid  regurgitation  are  due 
to  general  systemic  venous  obstruction,  already  mentioned  in  connection 
with  mitral  insufficiency. 


586  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Tricuspid  stenosis,  pulmonic  stenosis,  and  pulmonic  insufficiency 
are  practically  unknown  in  childhood,  except  in  congenital  cardiac 
disease. 

Prognosis  of  Valvular  Disease. — Complete  recovery  from  valvular  dis- 
ease is  possible  only  when  the  lesions  are  very  slight.  Few  children  die 
from  cardiac  disease  before  reaching  the  age  of  fourteen  years,  sudden 
death  being  extremely  rare.  A  large  proportion  of  the  cases  do  fairly 
well  up  to  about  the  time  of  puberty,  when  they  begin  to  lose  ground, 
often  failing  rapidly.  Others  do  well  until  a  fresh  endocarditis  is  lighted 
up  by  an  intercurrent  attack  of  rheumatism,  after  which  the  disease  may 
make  rapid  progress.  The  proportion  of  children  who  have  serious  cardiac 
lesions  before  the  age  of  eight  years,  and  reach  adult  life  in  good  condition 
is  comparatively  small. 

There  are  several  features  of  cardiac  disease  in  children,  in  consequence 
of  which,  serious  lesions  tend  to  progress  more  rapidly  than  in  adults. 
The  muscular  walls  are  less  resistant,  and  hence  rapid  dilatation  occurs 
much  more  readily  than  in  adult  life.  The  heart  must  provide  not  only 
for  constant  needs,  but  for  the  growth  of  the  body.  If  the  jDatient's  gen- 
eral nutrition  is  poor  during  the  period  of  most  rapid  growth,  this  tells 
quickly  and  seriously  upon  the  heart,  and  dilatation  makes  rapid  progress ; 
but  if  the  general  nutrition  continues  good  the  heart  may  do  more  than 
hold  its  own  throughout  childhood.  The  demands  made  upon  the  heart 
at  puberty  are  especially  severe,  by  reason  of  the  rapid  growth  of  the  body 
and  the  frequency  of  anasmia  and  malnutrition.  There  is  always  present 
the  danger  of  rapid  advances  in  the  disease  from  intercurrent  attacks  of 
rheumatism,  from  which  children  are  more  likely  to  suffer  than  are  older 
subjects.  Extensive  pericardial  adhesions  are  not  infrequent,  and  seriously 
handicap  the  heart,  greatly  increasing  the  tendency  to  dilatation.  The 
effect  upon  the  heart  of  poor  food,  unhygienic  surroundings,  and  general 
malnutrition  is  much  more  marked  than  in  adults. 

These  unfavourable  conditions  are  in  part  offset  by  others  in  which 
the  child  has  an  advantage  over  the  adult.  Disease  of  the  coronary  ar- 
teries is  very  rare,  and  the  valvular  lesions  which  are  most  frequently  met 
with — mitral  insufficiency  and  aortic  obstruction — are  those  which  admit 
of  the  most  complete  compensation. 

In  making  a  prognosis  in  any  given  case,  the  amount  of  hypertrophy 
or  dilatation  which  exists  is  of  much  more  importance  than  the  location 
or  the  special  character  of  the  murmur.  The  condition  of  the  arterial 
and  venous  circulation  must  also  be  taken  into  consideration  ;  also  how 
rapidly  the  disease  is  progressing,  the  condition  of  the  patient's  general 
health,  and  how  well  circumstances  will  admit  of  proper  hygienic  and 
general  management.  The  presence  of  valvular  disease  in  childhood  in- 
creases the  danger  from  every  acute  disease,  especially  pertussis,  diph- 
theria, and  scarlet  fever. 


CHRONIC   VALVULAR  DISEASE.  587 

Diagnosis. — Valvular  disease  is  to  be  particularly  distinguished  from 
conditions  in  which  there  are  heard  functional  or  accidental  mi;rmurs. 
According  to  my  own  experience  the  latter  are  quite  common  even  in 
young  children.  Mistakes  usually  arise  from  attaching  too  much  impor- 
tance to  the  presence  of  murmurs,  and  too  little  to  the  changes  in  the 
walls  and  cavities  of  the  heart,  with  which  valvular  disease  is  almost  in- 
variably associated.  It  is  not  always  possible  to  decide  whether  a  mur- 
mur is  organic  or  functional  until  the  patient  has  been  for  some  time 
under  observation  and  treatment,  particularly  when  antemia  is  present. 
The  diagnostic  points,  so  far  as  the  murmurs  are  concerned,  are  men- 
tioned in  connection  with  aiuemic  murmurs  (page  590). 

Treatment.— A  child  who  is  the  subject  of  chronic  valvular  disease 
should  be  under  constant  medical  supervision.  Irreparable  harm  often 
results  from  wilful,  but  more  frequently  from  ignorant,  disregard  of  the 
simplest  and  most  important  rules  of  life  for  these  patients.  The  facts 
should  be  plainly  stated,  the  course  of  the  disease  and  the  dangers  fully 
explained  to  parents,  and,  when  old  enough,  to  the  child  himself.  At 
the  very  least  the  patient  should  be  carefully  examined  three  or  four 
times  each  year,  in  order  that  the  physician  may  note  the  progress  of  the 
disease,  and  be  able  to  modify  the  child's  occupation,  exercise,  and  sur- 
roundings, in  order  to  meet,  so  far  as  possible,  the  changing  conditions. 
Few  patients  need  more  watchful  oversight  than  children  with  cardiac 
disease.  The  greatest  care  should  be  exercised,  especially  in  all  recent 
cases,  not  to  overtax  the  heart. 

During  the  stage  of  compensation,  treatment  directed  especially  to  the 
heart  is  rarely  necessary.  The  main  purpose  should  be  to  maintain  the 
patient's  general  nutrition  at  the  highest  possible  point  during  the  period 
of  active  growth.  To  this  end,  diet,  sleep,  study,  and  exercise  should  re- 
ceive the  most  careful  attention.  If  malnutrition  and  ana?mia  are  allowed 
to  go  on  unchecked  until  they  have  become  severe,  the  cardiac  disease 
may  make  rapid  strides,  and  as  much  harm  be  done  in  a  few  months  as 
otherwise  might  not  occur  in  years.  The  special  symptoms  of  malnutri- 
tion and  anemia  should  be  met  as  they  arise,  by  the  same  means  as  when 
they  occur  under  other  conditions.  The  question  of  exercise  and  recrea- 
tion is  always  a  difficult  one  to  settle.  Often  too  little  latitude  is  given, 
and  the  heart,  like  the  voluntary  muscles,  loses  its  tone.  Every  form  of 
exercise  requiring  a  prolonged  severe  strain  should  be  forbidden,  particu- 
larly swimming  and  competitive  games,  like  ball  and  tennis,  and  others 
requiring  much  running ;  but  skating,  rowing,  mountain-climbing,  horse- 
back exercise,  gymnastics,  and  even  cycling  on  the  level — all  in  modera- 
tion— may  be  allowed  not  only  without  harm,  but  with  tlie  greatest  bene- 
fit; but  any  of  these,  used  immoderately,  may  be  productive  of  great 
injury.  All  exercise  should  be  taken  with  regularity  and  system,  the 
amount  being  carefully  measured  by  the  child's  condition.     If  the  patient 


588  DISEASES  OF  THE   CIRCULATORY  SYSTEM. 

is  a  boy  who  must  earn  his  own  living,  the  physician  should  see  to  it  that 
the  occupation  chosen  is  not  one  liable  to  make  special  demands  upon  the 
heart. 

Special  watchfulness  is  required  at  the  time  of  puberty  to  prevent  over- 
pressure in  schools,  and  the  development  of  anremia  or  chlorosis.  The 
first  symptoms  of  these  conditions  should  be  treated  energetically,  and  if 
the  heart  seems  to  be  overtaxed  the  child  should  be  put  to  bed.  Patients 
should  be  so  far  as  possible  removed  from  conditions  liable  to  induce 
fresh  attacks  of  rheumatism.  To  this  end,  if  possible,  they  should  spend 
the  winter  and  spring  months  in  a  warm,  dry  climate. 

In  the  stage  of  failing  compensation,  the  same  general  conditions  are 
present  as  in  adults,  and  they  are  to  be  managed  in  pretty  much  the  same 
way.  When  such  symptoms  are  first  seen,  prolonged  rest  in  bed  should 
be  insisted  upon  as  the  thing  most  likely  to  restore  the  normal  conditions. 
Cardiac  dropsy  with  low  arterial  tension  and  weak  pulse,  calls  for  digitalis. 
An  overloaded  venous  circulation  may  be  relieved  by  diuretics,  or,  better, 
by  saline  purgatives.  Iron  and  tonics  generally  are  indicated,  particularly 
strychnine  and  cod-liver  oil.  In  cases  of  sudden  heart  failure,  nitroglycer- 
in, ether,  and  ammonia  are  as  valuable  as  in  adults;  but  better,  probably, 
than  any  of  these  is  the  use  of  strychnine  hypodermically. 

MYOCARDITIS. 

Disease  of  the  muscular  wall  of  the  heart  is  rare  in  children,  and  of 
comparatively  little  importance,  except  in  connection  with  the  acute  in- 
fectious diseases.  Myocarditis  may,  however,  occur  at  any  age,  even  in 
foetal  life.  As  seen  in  children,  it  is  almost  invariably  a  secondary  lesion, 
usually  the  result  of  some  infectious  process.  The  two  diseases  which 
furnish  most  of  the  cases  are  scarlet  fever  and  diphtheria.  The  most 
important  local  cause  is  pericarditis  with  adhesions. 

Lesions. — In  extra-uterine  life,  myocarditis,  as  a  rule,  affects  the  wall 
of  the  left  ventricle,  the  papillary  muscles,  or  the  septum.  The  heart  is 
pale  or  of  a  yellowish-white  colour,  very  soft  and  flabby,  and  there  is  fre- 
quently dilatation  of  the  cavities.  Small  ecchymoses  may  be  seen  beneath 
the  pericardium. 

Two  varieties  of  myocarditis  are  described :  In  the  parenchymatous 
form  there  is  a  degeneration  of  the  muscle  fibre  which,  according  to 
Komberg,  is  most  frequently  albuminous,  next  fatty,  and  least  frequently 
hyaline.  There  is  a  loss  of  the  transverse  striations,  and  there  may  be 
complete  disintegration  of  the  fibres.  This  process  may  be  circumscribed, 
but  it  is  usually  diffuse.  In  the  interstitial  form  the  lesion  usually  occurs 
in  small,  circumscribed  areas.  There  is  an  infiltration  of  round  cells  be- 
tween the  muscular  fibres  of  the  heart.  The  process,  when  acute,  may  re- 
sult in  absorption  or  in  the  production  of  small  abscesses.  There  may  also 
be  congestion  and  minute  blood  extravasations.     In  chronic  cases  it  may 


ANEMIC   MURMURS.  589 

lead  to  the  formation  of  larger  or  smaller  areas  of  dense  connective  tissue 
resembling  cicatrices,  in  the  heart  wall.  Either  the  interstitial  or  the  pa- 
renchymatous form  may  occur  alone,  but  in  most  of  the  acute  cases  they 
are  combined.  In  addition,  there  is  usually  some  degree  of  mural  endo- 
carditis and  inflammation  of  the  pericardium  next  to  the  heart  wall. 
Dilatation  frequently  follows  ;  rarely  abscesses  may  form,  which  may  open 
into  the  heart  or  into  the  pericardium.  Cardiac  aneurism,  and  even  rup- 
ture, have  been  known  to  occur  in  a  child  of  six  years  (Hadden's  case). 

Symptoms. — These  are  very  rarely  sufficiently  marked  to  enable  one 
to  make  a  positive  diagnosis.  In  many  cases  in  which  advanced  lesions 
have  been  found  at  autopsy  there  have  been  no  symptoms  during  life, 
and  in  others  none  until  the  occurrence  of  sudden  death.  This  is  usu- 
ally from  cardiac  paralysis,  rarely  from  rupture.  In  eight  cases  studied 
by  Eomberg,  which  occurred  in  the  course  of  diphtheria,  not  one  had 
cardiac  symptoms  during  life  and  two  died  suddenly.  When  symptoms 
are  j^resent,  they  are  generally  those  of  feeble  heart  action — a  faint  apex 
impulse,  a  slow,  weak  pulse  of  irregular  rhythm,  pallor,  dyspnoea,  and 
attacks  of  syncope.  In  the  late  stages  there  may  be  the  physical  signs  of 
dilatation,  with  dropsy  of  the  feet  or  the  serous  cavities,  and  scanty  urine, 
sometimes  containing  albumin. 

Diagnosis. — A  positive  diagnosis  of  myocarditis  is  impossible.  It  may 
be  suspected  in  the  course  of  diphtheria,  scarlet  or  typhoid  fever,  when 
cardiac  symptoms  like  those  mentioned  occur,  and  when  pericarditis  and 
endocarditis  can  be  excluded  by  the  physical  examination. 

Treatment. — This  is  mainly  symptomatic.  After  severe  attacks  of 
those  infectious  diseases  in  which  myocarditis  is  liable  to  occur,  and  at 
any  time  when  it  is  suspected,  patients  should  be  kept  recumbent  for 
several  weeks,  and  special  care  exercised  to  prevent  any  sudden  exertion, 
as  death  has  occurred  from  so  slight  a  thing  as  suddenly  sitting  up  in 
bed.  Iron,  alcohol,  and  tonics  should  be  given,  the  best  of  all  of  these 
being  strychnine.  Digitalis  should  be  used  with  caution,  and  never  in 
large  doses.  In  some  cases  with  symptoms  indicating  imminent  heart 
failure,  more  striking  benefit  follows  the  use  of  morphine  hypodermically 
than  any  other  plan  of  treatment. 

AX.EMIC   MURMURS. 

As  already  stated,  these  are  not  uncommon  even  in  infancy.  They 
may  be  confounded  with  organic  murmurs,  either  from  congenital  mal- 
formations or  acquired  disease.  I  have  several  times  found  the  heart 
normal  at  autopsy  in  cases  where  a  diagnosis  of  congenital  disease  had 
been  unhesitatingly  made  during  life,  the  murmur  having  been  of  anfemic 
origin.  In  any  anaemic  infant,  as  well  as  older  child,  one  should  hesitate 
to  make  a  diagnosis  either  of  congenital  or  acquired  organic  disease,  from 
the  mere  presence  of  a  murmur. 


590  DISEASES  OF   THE   CIRCULATORY  SYSTEM. 

An  auremic  murmur  is  usually  systolic,  heard  at  the  base  of  the  heart, 
also  in  the  carotids,  often  in  the  subclavian  arteries,  and  occasionally  over 
any  of  the  large  trunks  of  the  body.  The  murmur  varies  from  day  to  day, 
and  sometimes  it  is  altered  by  changing  the  position  of  the  patient.  It 
may  be  loud  enough  to  be  heard  over  a  great  part  of  the  chest  in  front, 
and  even  behind.  There  is  frequently  present  a  venous  hum  in  the  neck. 
There  are  no  signs  of  hypertrophy,  nor  is  there  the  accentuated  second 
sound  so  characteristic  of  mitral  disease.  The  pulse  is  not  usually  strong. 
Ansemic  murmurs  diminish  in  intensity  and  ultimately  disappear  with 
improvement  in  the  general  condition  of  the  patient.  In  some  cases  one 
must  wait  for  the  effects  of  treatment  before  giving  a  positive  opinion. 

FUNCTIONAL  DISORDERS  OP   THE   HEART. 

Disturbances  in  the  heart's  action  unconnected  with  organic  disease, 
are  rare  in  infants  and  young  children;  but  after  the  seventh  year  they 
are  not  uncommon,  becoming  in  fact  quite  frequent  as  puberty  approaches. 
One  of  the  most  important  causes  is  indigestion  ;  another  is  overpressure 
in  schools,  or  anything  else  leading  to  nervous  exhaustion.  In  these  cir- 
cumstances it  is  usually  associated  with  other  mental  or  psychical  dis- 
turbances. An  important  predisposing  cause  is  the  demand  made  upon 
the  heart  by  the  rapid  growth  of  the  body  about  the  time  of  puberty, 
particularly  when  this  is  associated  with  anasmia.  In  some  of  the  cases 
there  is  a  definite  exciting  cause,  such  as  fright  or  great  excitement,  and 
it  may  be  due  to  the  excessive  use  of  tea,  coffee,  or  tobacco,  especially  in 
the  form  of  cigarette-smoking.  In  a  few  instances  it  has  been  traced  to 
masturbation.  It  may  follow  any  acute  disease,  such  as  typhoid  fever, 
malaria,  or  one  of  the  exanthemata,  and  occasionally  it  occurs  in  the 
course  of  these  diseases,  or  with  bronchitis  or  pneumonia. 

Symptoms. — The  usual  manifestations  are  attacks  of  palpitation ;  less 
frequently  there  is  tachycardia  (rapid  heart)  or  bradycardia  (slow  heart). 
The  majority  of  children  complain  more  with  functional  disturbances 
than  with  organic  disease,  certainly  while  the  latter  is  accompanied  by 
compensation.  Attacks  of  palpitation  occur  in  paroxysms.  In  the  severe 
form  there  is  usually  a  sense  of  oppression  in  the  region  of  the  heart, 
with  some  dyspnoea,  or  even  orthopncBa.  The  pulse  is  usually  rapid,  from 
130  to  130,  and  is  irregular  both  as  to  force  and  rhythm.  The  carotids 
pulsate  strongly.  The  apex  impulse  is  felt  over  an  increased  area,  the 
heart  sounds  are  usually  strong  but  irregular,  and  sometimes  a  slight  mur- 
mur is  heard.  The  face  is  pale  or  flushed.  There  may  be  headache,  ver- 
tigo, spots  before  the  eyes,  and  noises  in  the  ears.  Sometimes  there  is 
slight  cyanosis  with  cold  hands  and  feet,  and  general  perspiration.  The 
frequency  of  these  attacks  depends  upon  the  nature  of  the  exciting  cause. 
Their  duration  is  from  a  few  minutes  to  several  hours. 


•DISEASES   OP  THE   BLOOD-VESSELS.  591 

Diagnosis. — Functional  disorders  are  differentiated,  from  organic  car- 
diac disease  only  by  careful  and  repeated  examinations  of  the  heart.  In 
the  diagnosis  of  functional  disturbance  especial  importance  is  to  be  at- 
tached to  a  neurotic  or  neurasthenic  condition  of  the  patient,  to  the 
presence  of  some  adequate  exciting  cause,  the  absence  of  evidence  of 
enlargement  of  the  heart,  and  the  fact  that  the  pulmonic  second  sound  is 
not  increased. 

Prognosis. — This  in  most  cases  is  favourable,  for  with  improvement 
in  the  patient's  general  condition,  with  the  growth  of  the  body,  and  in 
girls  with  the  establishment  of  menstruation,  the  attacks  usually  disappear. 

Treatment. — During  the  attacks,  digitalis  in  moderate  doses  should  be 
given,  also  bromides  or  valerian.  The  curative  treatment  is  to  be  directed 
toward  the  cause.  Where  no  special  cause  can  be  discovered  a  general 
tonic  plan  of  treatment  should  be  adopted,  with  careful  regulation  of 
the  patient's  diet,  exercise,  and  mode  of  life.  All  stimulating  food,  tea, 
coffee,  and  tobacco  should  be  prohibited.  Anaemia  should  receive  its  ap- 
propriate remedies.  The  hours  of  sleep  and  study,  and  the  amount  and 
character  of  exercise  allowed,  should  be  carefully  regulated.  During  the 
intervals  no  treatment  of  the  heart  is  necessary. 

DISEASES  OF  THE   BLOOD-VESSELS. 

Abnormally  Small  Arteries  {Arterial  hypoplasia). — This  condition  is 
not  a  very  common  one,  but  it  has  attracted  a  good  deal  of  attention, 
having  been  studied  especially  by  Virchow.  The  only  thing  which  is  ab- 
normal in  the  circulatory  system  may  be  that  the  aorta,  and  sometimes  all 
the  large  vessels  are  only  two  thirds  or  three  fourths  their  usual  calibre, 
or  even  less.  This  may  interfere  seriously  with  the  growth  and  develop- 
ment of  the  body,  especially  of  the  genital  organs,  although  this  result  is 
not  a  constant  one.  The  condition  is  found  occasionally  in  cases  of  chlo- 
rosis, and  in  the  congenital  cases  it  may  be  the  chief  cause.  There  is 
usually  associated  a  certain  amount  of  hypertrophy  of  the  heart.  The 
other  symptoms  are  angemia,  and  sometimes  an  imperfect  development  of 
the  body.     A  positive  diagnosis  during  life  is  impossible. 

Aneurism  and  Atheroma. — In  early  life  chronic  disease  of  the  blood- 
vessels is  exceedingly  rare,  yet  a  sufficient  number  of  observations  have 
been  recorded  to  show  that  even  young  children  are  not  exempt  from  this 
form  of  disease.  There  had  been  reported  up  to  1890  twenty-eight  cases 
of  aneurism  in  patients  under  twenty  years  of  age  (Jacobi).*  Of  these, 
however,  only  twelve  were  under  fourteen  years.  Sanne  f  records  the 
youngest  case,  which  occurred  in  a  foetus  born  at  about  the  eighth  month, 

*  A.  Jacobi,  Archives  of  Paediatrics,  vol.  vii,  p.  16L 

f  Sanne,  Revue  Mensuelle  des  Maladies  des  I'Enfance,  vol.  v,  p.  56.     In  these  arti- 
cles will  be  found  references  to  most  of  the  reported  cases. 
39 


592  DISEASES  OF  THE   CIRCULATORY   SYSTEM. 

in  whose  body  there  was  found  a  large  aneurism  of  the  abdominal  aorta 
just  below  the  origin  of  the  renal  arteries.  Of  the  eleven  remaining  cases 
occurring  in  children  under  fourteen  years,  in  over  one  half  the  number 
the  arch  of  the  aorta  was  the  part  affected.  In  one  case  the  seat  was  the 
femoral  artery,  in  another  the  external  iliac,  and  in  still  another  the 
abdominal  aorta. 

Probably  the  most  important  etiological  factor,  as  in  adult  life,  is 
syphilis,  but  in  only  a  few  of  the  cases  reported  was  the  evidence  of  syphi- 
lis conclusive.  In  two  cases  there  was  general  tuberculosis.  In  addition 
to  these  general  causes,  aneurism  may  be  due  to  some  local  condition, 
such  as  an  erosion  from  bone,  an  abscess  in  the  neighbourhood,  or  to  em- 
bolism. The  symptoms  and  course  of  aneurism  in  young  children  do  not 
differ  essentially  from  those  of  the  disease  as  seen  in  adults. 

In  addition  to  the  cases  of  aneurism  referred  to  above,  I  have  found 
reports  of  seven  cases  of  atheroma  in  very  young  subjects.  In  Sanne's 
case  the  patient  was  but  two  years  old,  and  laatches  of  atheromatous  de- 
generation were  found  in  several  places  in  the  aorta.  In  HaR'kins's  case, 
eleven  years  old,  there  was  found  extensive  atheromatous  disease  of  the 
aorta,  subclavian  and  carotid  arteries.  In  Filatoff's  case,  atheromatous 
degeneration  aft'ected  the  arteries  at  the  base  of  the  brain,  causing  death 
from  cerebral  haemorrhage.  It  is  interesting  to  note  that  in  this  patient, 
who  was  only  eleven  years  old,  there  was  also  present  chronic  diffuse 
nephritis  with  contracted  kidneys.  A  similar  condition  of  the  kidneys 
and  arteries  was  observed  by  Dickinson  in  a  girl  of  six  years. 

Embolism  and  Thrombosis. — Embolism  has  already  been  referred  to  in 
connection  with  acute  endocarditis.  It  may  be  seen  at  any  age,  even  in 
infancy,  but  generally  occurs  in  patients  over  five  years  old.  The  emboli 
are  usually  swept  into  the  circulation  from  vegetations  upon  the  valves 
of  the  heart.  The  symptoms  which  they  produce  will  depend  upon  the 
nature  of  the  emboli  and  the  vessels  occluded  by  them.  If  they  lodge  in 
the  brain  they  may  cause  paralysis  or  convulsions ;  if  in  the  spleen,  pain 
and  swelling  of  this  organ ;  if  in  the  kidneys,  pain,  tenderness,  and  some- 
times hoBmaturia ;  if  in  the  lungs,  cough,  sometimes  accompanied  by 
hsemoptysis  and  occasionally  by  a  sharp  thoracic  pain.  If  the  emboli  are 
infectious,  they  may  give  rise  to  abscesses.  The  pathological  results  fol- 
lowing embolism  are  similar  to  those  which  are  seen  in  adults. 

The  most  frequent  form  of  thrombosis,  that  occurring  in  the  sinuses  of 
the  brain,  is  discussed  in  connection  with  Diseases  of  the  Nervous  System. 
Cardiac  thrombi,  especially  of  the  right  side  of  the  heart,  are  not  infre- 
quently found  in  patients  dying  from  heart  disease,  pneumonia,  and  occa- 
sionally also  from  other  acute  inflammatory  processes  and  acute  infectious 
diseases,  particularly  diphtheria.  These  thrombi  are  in  most  cases  pro- 
duced during  the  last  few  hours  of  life,  or  just  at  the  time  of  death,  and  are 
of  no  clinical  importance.     They  frequently  extend  from  the  heart  into  the 


DISEASES  OF  THE   BLOOD-VESSELS.  593 

large  blood-vessels,  particularly  the  pulmonary  artery.  Thrombosis  occa- 
sionally occurs  in  all  the  large  vascular  trunks  in  childhood  as  well  as  in 
adult  life. 

Thrombosis  of  the  internal  jugular  vein. — Pasteur*  reports  a  case  in  a 
child  two  and  a  half  years  old,  in  which  the  middle  of  the  vein  was  filled 
with  an  organized  thrombus,  and  the  lower  piortion  obliterated  and  re- 
duced to  a  fibrous  cord.  The  symptoms  were  swelling,  oedema,  and  cya- 
nosis of  the  face,  and  dilatation  of  the  facial  vein.,  but  not  of  the  external 
jugular.  There  were  clubbing  of  the  fingers  and  oedema  of  the  feet,  but 
not  of  the  arm.  The  heart  was  found  to  be  dilated  and  hypertrophied, 
but  was  not  the  seat  of  valvular  disease.  The  symptoms  had  existed  since 
an  attack  of  pneumonia,  eighteen  months  before  death. 

Thrombosis  of  the  vena  cava. — Quite  a  number  of  cases  are  on  record 
where  this  has  occurred  as  the  result  of  pressure  from  large  abdominal 
tumours ;  it  has  followed  new  growths  of  the  kidney  and  large  masses  of 
tuberculous  lymph  nodes.  Xeurutter  and  Salmon  have  recorded  a  case  of 
thrombosis,  a^Dparently  of  marantic  origin,  in  a  child  seven  years  old. 
The  thrombus  filled  the  vena  cava,  and  extended  to  the  origin  of  the 
hepatic  veins  and  into  both  femorals.  Death  occurred  from  tuberculosis. 
In  Scudder's  case  (seventeen  years  old)  there  was  apparently  obliteration 
(probably  congenital)  of  the  inferior  vena  cava ;  there  was  an  extensive 
varicose  condition  of  all  the  abdominal  veins.  The  symptoms  of  throm- 
bosis of  the  vena  cava  are  swelling  and  cedema  of  the  feet — sometimes  of 
the  abdominal  walls  and  the  groin — and  very  great  dilatation  of  the  super- 
ficial abdominal  veins. 

Thrombosis  of  the  aorta. — A  case  has  been  reported  by  Leopold  in  a 
newly-born  child  which  was  delivered  by  version.  The  thrombus  was  of 
recent  origin,  and  filled  the  lower  aorta,  extending  into  the  femoral  artery. 
A  case  of  thrombosis  of  the  aorta  occurring  in  a  girl  of  thirteen  years  has 
been  reported  by  Wallis.  The  aorta  was  very  narrow,  and  probably  the 
seat  of  syphilitic  disease.  The  thrombus  extended  from  the  origin  of  the 
renal  arteries  to  the  coeliac  axis. 

Thrombosis  in  infectious  diseases.  —  There  is  occasionally  seen  in 
typhoid  fever,  but  more  frequently  in  diphtheria,  thrombosis  of  some  of 
the  large  venous  trunks,  usually  of  one  of  the  lower  extremities.  The 
symptoms  are  pain,  localized  swelling,  and  partial  paralysis.  If  the  artery 
is  affected,  there  may  be  gangrene. 

*  Lancet,  February  11,  1888. 


SECTION  YI. 
DISEASES  OF  THE  URO-GENITAL  SYSTEM. 

CHAPTER   I. 
THE   URINE  IN  INFANCY  AND   CHILDHOOD. 

While  a  study  of  the  urine  is  of  much  less  importance  in  early  life 
than  of  the  symptoms  referable  either  to  the  digestive  or  respiratory  sys- 
tem, it  is  deserving  of  much  more  attention  than  it  has  generally  received. 
In  infancy  especially  it  is  attended  with  difficulty,  owing  to  the  fact  that 
it  is  by  no  means  an  easy  matter  to  secure  a  specimen  for  examination. 

Methods  of  Collecting  TJrine. — In  male  infants  this  may  be  done  by 
placing  the  penis  in  the  neck  of  a  small  bottle  which  lies  between  the 
thighs  and  is  secured  in  position  by  pieces  of  tape  passing  over  the  hips 
and  beneath  the  perinseum.  A  still  better  plan  is  to  use  a  condom  in  the 
place  of  a  bottle.  The  urine  of  female  infants  can  sometimes  be  collected 
in  a  similar  way  by  placing  a  small  cup  over  the  vulva  and  holding  it  in 
place  by  the  napkin.  In  either  sex,  if  the  infant  is  placed  upon  a  chamber 
regularly  every  ten  or  twenty  minutes  for  a  few  hours,  it  is  rarely  difficult 
to  secure  the  urine,  especially  if  at  the  same  time  a  cold  hand  or  a  cold 
compress  be  placed  over  the  bladder;  sometimes  hot  applications  will 
answer  the  purpose  better.  A  small  amount,  sufficient  to  test  for  albu- 
min, may  often  be  obtained  by  placing  absorbent  cotton  over  the  vulva  or 
penis.  The  most  certain  of  all  means,  however,  is  catheterization;  in 
females  sometimes  nothing  else  will  answer  the  purpose.  A  soft  rubber 
catheter,  size  G  or  7,  American  scale  (9  or  11  French),  should  be  used  for 
infants. 

Daily  Quantity. — This  is  relatively  much  larger  in  infants  than  in 
older  children  and  in  adults,  on  account  of  the  more  active  metabolism  of 
the  young  child  and  the  large  amount  of  water  taken  with  the  food.  The 
quantity  fluctuates  widely  from  day  to  day  according  to  the  amount  of 
fluid  food  taken  and  the  activity  of  the  skin  and  bowels.  The  following 
figures  are  the  averages  obtained  by  combining  the  results  of  the  investi- 
gations of  Schabanowa,  Cruse,  Camerer,  Pollak,  Martin-Ruge,  Berti, 
Schiff,  and  Herter : 

594 


•THE   URINE  IN  INFANCY  AND   CHILDHOOD. 


591 


Average  Daily  Qvuntity  of  Urine  in  Health. 


First  twenty-four  hours  . . 
Second  twenty-four  hours. 

Three  to  six  days 

Seven  days  to  two  months 

Two  to  six  months 

Six  months  to  two  years.  . 

Two  to  five  years 

Fi  ve  to  eight  years 

Eight  to  fourteen  years.. . 


Grammes. 

Ounces. 

0  to       60 

Oto    2 

10  "        90 

i  "     3 

90  "      250 

3  "    8 

150  •'      400 

5  "  13 

210  "      500 

7  "  16 

250  "      600 

8  "  20 

500  "      800 

16  «  26 

600  "  1,200 

20  "  40 

1,000  "  1,500 

32  "  48 

Frequency  of  Micturition. — This  is  greatest  in  young  infants,  and 
diminishes  steadily  as  age  advances.  In  the  first  two  years,  during  the 
waking  hours,  the  urine  is  generally  passed  as  often  as  twice  an  hour,  while 
during  sleep  it  is  retained  from  two  to  six  hours.  By  the  third  year  the 
urine  may  be  held  during  sleep  for  eight  or  nine  hours,  and  at  other  times 
for  two  or  three  hours.  Such  control  of  the  sphincter  of  the  bladder  is 
often  obtained  at  two  years,  and  sometimes  even  at  an  earlier  period. 
From  slight  nervous  disturbances  or  minor  ailments  of  any  kind,  this  con- 
trol is  impaired,  and  the  water  may  be  passed  by  children  of  four  or  five 
years  with  the  frequency  seen  in  infants. 

Physical  Characters. — The  urine  of  the  newly  born  is  usually  highly 
coloured.  During  later  infancy  it  is  pale  and  frequently  turbid,  even 
when  practically  normal,  owing  to  the  presence  of  mucus ;  this  turbidity 
often  no  amount  of  filtration  will  entirely  remove.  Less  frequently  tur- 
bidity depends  upon  urates.  The  urine  of  the  first  few  days  of  life  often 
shows  a  deposit  of  urates  or  uric  acid  in  the  form  of  a  reddish-yellow 
stain  upon  the  napkin.  The  reaction  of  the  urine  at  this  time  is  usu- 
ally strongly  acid,  but  throughout  the  rest  of  infancy  it  is  faintly  acid  or 
neutral. 

The  specific  gravity  is  higher  during  the  first  two  days  than  at  any 
time  in  infancy  on  account  of  the  scanty  supply  of  fluid  taken ;  it  is 
usually  lowest  from  the  third  to  the  sixth  day,  but  from  this  time  it  rises 
steadily  until  puberty  is  reached.  The  specific  gravity  will  of  course  vary 
with  the  quantity.  From  the  writers  already  referred  to  the  following 
figures  are  taken : 

Specific  gravity. 

First  to  third  day 1  -010  to  1  •  012 

Fourth  to  tenth  "day 1-004  '•  1-008 

Tenth  day  to  sixth  month 1-004  "  1-010 

Six  months  to  two  years 1-006  "  1-012 

Two  to  eight  years 1-008  '■  1-016 

Eight  to  fourteen  years 1-012  "  1  -020 

Microscopically,  the  urine  of  the  newly  born  shows  the  presence  of 
many  squamous  epithelial  cells,  mucus,  granular  matter,  and  crystals  of 


596  DISEASES  OF   THE   URO-GENITAL  SYSTEM.  . 

uric  acid  and  amorphous  or  crystalline  urates.  It  is  not  uncommon  to 
find  hyaline  and  even  granular  casts.  Martin-Ruge  found  hyaline  casts 
in  the  urine  of  fourteen  out  of  twenty-four  healthy  nursing  infants  ex- 
amined during  the  first  week.  Granular  casts  were  much  less  frequent. 
The  microscopical  appearances  of  the  normal  urine  of  later  infancy  and 
childhood  present  no  peculiarities. 

Composition. —  Urea. — The  following  figures  show  the  average  daily 
quantity  of  urea  eliminated  at  the  different  ages  : 

Age.  Daily  quantity  of  urea. 

First  day 0-076  to    0-114  gramme. 

Second  to  seventh  day 0- 140  "     0'660 

One  to  two  months 0-90    "     1-40 

Three  to  five  years 13-09    "14-01    grammes. 

Five  to  thh-teen  years 16*05     "21-03 

Uric  acid. — Few  observations  have  been  made  upon  the  elimination 
of  uric  acid,  but  all  authorities  agree  that  it  is  much  higher  in  the  newly 
born  than  at  any  subsequent  period  of  life.  The  quantity  is  better  ap- 
preciated by  giving  the  ratio  between  the  uric  acid  and  urea  than  by  the 
absolute  quantity  of  the  former.  The  figures  here  given  for  the  newly 
born  are  taken  from  Martin-Riige ;  the  others  are  from  Herter. 

Hatio  of  Uric  Acid  to  Urea. 

In  the  newly  born.. 1  to  14 

Under  one  year 1  '"  60-80 

From  two  to  five  years 1  "  50-70 

From  five  to  fifteen  years 1  "  45-60 

The  inorganic  salts  j^phosphates,  chlorides,  sulphates)  are  all  present 
in  the  urine  of  the  newly  born,  but  in  relatively  small  quantity,  increasing 
as  age  advances.     The  colouring  matters  are  also  less  abundant. 

Albumin  is  often  present  in  the  urine  during  the  first  days,  but  usu- 
ally in  small  amount.  Cruse  found  it  twenty-eight  times  in  ninety  obser- 
vations upon  healthy  infants ;  usually  the  quantity  was  small,  amounting 
to  traces  only,  but  in  two  cases  it  was  quite  large  upon  the  second  day. 
These  observations  are  confirmed  by  the  investigations  of  Martin-Ruge, 
and  also  of  Pollak. 

Sugar  is  frequently  found  in  the  urine  of  healthy  infants  during  the 
first  two  months.  This  subject  is  referred  to  later  under  the  head  of 
Glycosuria. 

FUNCTIONAL   OR  CYCLIC   ALBUMINURIA. 

Etiology. — This  condition,  although  a  rare  one  in  young  children,  is 
quite  common  between  the  ages  of  ten  and  sixteen  years.  I  shall  not  in 
this  connection  include  cases  sometimes  classed  as  febrile  albuminuria,  in 
which  there  is  usually  present  the  condition  described  as  acute  degenera- 
tion of  the  kidneys. 


FUNCTIONAL  OR  CYCLIC  ALBUMINURIA.  597 

The  causes  of  functional  or  physiological  albuminuria,  and  the  cir- 
cumstances in  which  it  has  been  observed,  are  many  and  "varied.  It  is 
much  more  common  in  males  than  in  females.  In  many  patients  it  is 
regularly  cyclic  in  character,  albumin  being  absent  in  the  urine  passed 
during  the  night  or  early  morning,  but  present  during  the  day,  diminish- 
ing in  the  evening  and  absent  at  bed-time.  In  a  case  reported  by  Tiemann, 
the  morning  urine  showed  no  trace  of  albumin  in  seventy-eight  of  eighty- 
four  examinations.  At  noon  albumin  was  present  in  ninety-eight  of 
one  hundred  and  thirteen  examinations.  In  certain  cases  albuminuria  is 
distinctly  traceable  to  cold  bathing ;  in  others,  to  fatigue  following  ex- 
cessive muscular  exercise  ;  in  still  others,  to  dysj^eptic  conditions.  It  may 
be  associated  with  a  diet  rich  in  nitrogenous  food.  In  other  cases  none 
of  these  conditions  exist,  and  there  is  simply  the  occasional  presence  of 
albumin  in  the  urine. 

Many  theories  have  been  advanced  in  explanation  of  cyclic  albuminuria. 
Sometimes  it  appears  to  be  clearly  traceable  to  irritation  of  the  kidney  by 
uric  acid,  urates,  or  oxalates.  Kinnicutt  believes  this  to  be  one  of  the 
prominent  causes,  and  that  albuminuria  is  due  to  vaso-motor  disturbances 
in  the  kidney.  Delafield  compares  the  exudation  of  serum  from  the  ves- 
sels of  the  kidney  to  the  dropsy  of  the  feet  seen  in  anaemia.  Da  Costa 
believes  that  it  always  depends  upon  slight  changes  of  an  evanescent  char- 
acter in  the  kidney. 

Symptoms. — Many  of  the  patients  exhibiting  cyclic  or  periodical  al- 
buminuria are  well  nourished,  and  have  no  other  signs  of  disease ;  others 
show  dyspeptic  symptoms,  and  are  ansemic  and  poorly  nourished,  suffering 
from  headaches  and  other  neuroses.  In  the  cases  distinctly  periodical  the 
amount  of  albumin  is  commonly  small.  It  is  not  infrequently  associated 
with  temporary  glycosuria.  As  a  rule,  casts  are  absent,  although  it  is  not 
uncommon  to  find  a  few  hyaline  casts,  and  occasionally  granular  casts  are 
also  present.  A  gouty  family  history  exists  in  a  certain  proportion  of  the 
cases,  and  some  of  the  patients  themselves  present  other  evidences  of  this 
diathesis. 

Diagnosis. — Pavy  mentions  the  following  points  as  characteristic  of 
physiological  or  functional  albuminuria :  (1)  The  time  of  its  occurrence. 
The  absence  of  albumin  early  in  the  morning,  its  presence  in  the  fore- 
noon, and  diminution  toward  evening.  When  this  is  repeated  day  after 
day  the  diagnosis  is,  he  believes,  quite  positive.  (2)  The  absence  of  seri- 
ous impairment  of  the  general  health  and  of  the  characteristic  symptoms 
of  nephritis,  such  as  dropsy,  cardiac  hypertrophy,  a  pulse  of  high  tension, 
retinal  changes,  etc.  (3)  The  fact  that  casts  are,  as  a  rule,  absent.  (4) 
That  crystals  of  oxalate  of  lime  are  present,  and  the  urine  is  of  high 
specific  gravity. 

Too  much  stress  is  certainly  laid  by  Pavy  and  many  other  writers 
upon  the  fact  that  the  albumin  is  found  in  the  urine  only  at  certain 


598  DISEASES  OP  THE  URO-GENITAL  SYSTEM. 

times  in  the  clay.  This  is  not  characteristic  of  functional  albuminuria,  as 
the  same  thing  occurs  in  many  cases  of  chronic  nephritis,  especially  in 
the  early  stages  when  the  amount  of  albumin  present  is  small.  All  these 
cases  must  be  carefully  watched  for  a  long  time  and  many  observations 
made,  befoi'e  nephritis  can  positively  be  excluded. 

Prognosis. — The  prognosis  in  cases  of  purely  functional  albuminuria  is 
good.  It  is  to  be  remembered  that  patients  who  for  a  considerable  time 
have  been  regarded  as  having  only  functional  albuminuria  have  ultimately 
developed  nephritis ;  hence  an  absolutely  favourable  prognosis  is  possible 
only  after  a  long  period  of  observation.  If  albumin  is  constantly  present 
it  is  probably  pathological,  and  the  longer  it  continues  the  more  serious  is 
the  outlook. 

Treatment. — This  is  to  be  directed  toward  the  patient's  general  condi- 
tion rather  than  to  the  kidneys  and  the  urine.  The  dyspeptic  symptoms 
must  be  relieved,  the  patient's  mode  of  life  regulated,  only  moderate  exer- 
cise allowed,  and  a  simple  diet  given  which  does  not  consist  too  largely  of 
nitrogenous  fgod.  If  the  urine  is  of  high  specific  gravity,  and  contains 
oxalate-of-lime  crystals,  alkalies  and  mineral  waters  should  be  given  in 
addition.     Iron  is  indicated  if  there  is  ana3mia  present. 

HEMATURIA. 

Hsematuria  is  characterized  by  the  presence  of  red  blood-cells  in  the 
urine,  and  is  to  be  distinguished  from  hsemoglobinuria  where  only  blood 
pigment  is  present. 

Hasmaturia  may  result  from  local  or  general  causes.  In  infancy  it 
may  be  due  to  new  growths  of  the  kidney.  In  such  cases  the  haemor- 
rhages are  often  abundant,  and  may  be  the  first  symptom  of  the  condition. 
Hsematuria  may  occur  also  as  a  symptom  of  acute  nephritis,  especially 
that  complicating  scarlet  fever,  or  it  may  result  from  the  irritation  of  a 
calculus  in  the  kidney,  the  ureter,  or  the  bladder.  In  rare  instances  its 
cause  is  a  new  growth  of  the  bladder,  and  it  may  be  due  to  traumatism. 
Among  the  general  causes  the  most  important  are :  the  hsemorrhagic  dis- 
ease of  the  newly  born ;  the  blood  dyscrasias,  such  as  scurvy,  purpura,  and 
hsemophilia  ;  and  infectious  diseases,  particularly  malaria,  typhoid,  variola, 
scarlet  fever,  and  influenza.  In  most  of  these  cases  the  amount  of  blood 
passed  is  small.  When  it  is  large  it  may  appear  in  the  urine  as  clear 
blood,  or  as  clots,  or  it  may  impart  simply  a  reddish  or  smoky  colour  to 
the  urine.  The  colour,  however,  is  not  a  reliable  guide ;  the  best  of  all  is 
the  microscopical  examination.  For  a  simple  chemical  test  guaiacum  may 
be  used. 

To  discover  the  source  of  the  blood  may  be  quite  difficult.  Large 
haemorrhages  are  much  more  likely  to  come  from  the  kidneys  than  from 
the  bladder.    The  presence  of  blood  casts  from  the  renal  tubules,  or  larger 


GLYCOSURIA.  599 

ones  from  the  ureter,  are  conclusive  evidence  of  the  renal  origin  of  the 
haBmorrhage. 

In  children,  renal  haemorrhage  in  itself  rarely  requires  treatment; 
vv^hen  it  does,  the  same  remedies  are  indicated  as  in  the  adult,  viz.,  ergot, 
gallic  acid,  and  rest  in  bed.  Some  obstinate  cases  have  been  cured  by 
drinking  water  from  alum  springs. 

H^EMOGLOBINURIA. 

In  this  condition  blood  pigment  appears  in  the  urine  in  large  quantity, 
but  red  blood-cells  are  very  few  in  number,  or  are  absent  altogether.  In 
severe  cases  the  urine  may  be  almost  black.  There  is  commonly  a  small 
amount  of  albumin.  This  condition  may  be  recognised  by  the  ap2:)earance 
of  granules  of  pigment  under  the  microscope,  or  by  Heller's  test;  the 
most  conclusive  means  of  diagnosis,  however,  is  the  spectroscope. 

Epidemic  hsemoglobinuria  (Winckel's  disease)  has  already  been  de- 
scribed in  the  chapter  on  Diseases  of  the  Newly  Born.  Hsemoglobiuuria 
may  be  due  to  certain  poisons,  as  carbolic  acid  or  chlorate  of  potash,  or  to 
certain  infectious  diseases,  as  scarlet  fever,  typhoid  fever,  malaria,  syphilis, 
and  erysipelas. 

Paroxysmal  hemoglobinuria  occurs  in  childhood,  although  it  is  an 
exceedingly  rare  condition.  A  typical  case  in  a  child  of  four  and  a  half 
years  has  been  reported  by  Mackenzie.  This  was  a  delicate  child  of  syphi- 
litic parents ;  the  haemoglobinuria  was  preceded  by  fever  and  chills,  with- 
out any  other  evidence  of  the  presence  of  malaria. 

The  exact  pathology  of  hemoglobinuria  is  at  present  unknown,  and 
its  treatment  is  very  unsatisfactory. 

GLYCOSURIA. 

By  this  term  is  understood  the  occasional  or  transient  appearance  of 
sugar  in  the  urine.  This  is  not  very  infrequent  in  children,  and  may  be 
met  with  even  during  the  first  month  of  life.  Grosz  has  published  some 
careful  investigations  upon  the  glycosuria  of  early  infancy.*  He  made 
many  observations  upon  fifty  infants  during  the  first  month  of  life,  from 
which  the  following  conclusions  were  drawn  :  Glycosuria  is  not  uncommon 
in  nursing  infants;  but  it  is  not  seen  in  nursing  infants  who  are  per- 
fectly healthy.  It  occurs  particularly  with  certain  disturbances  of  diges- 
tion, whether  functional  or  inflammatory.  The  sugar  found  in  the  urine 
under  these  conditions  reacts  strongly  to  the  reduction  test  (Fehling's), 
but  not  to  the  fermentation  test ;  sometimes  the  polariscope  shows  that  it 
has  the  power  of  dextro-rotation.  This  is  believed  to  be  milk  sugar,  or  one 
of  its  derivatives.     It  is  not  of  constant  or  regular  occurrence.     It  may  be 

*  Jahrbuch  fiir  Kinderheilkuude,  Bd.  xxxiv,  p.  83. 


eOO  DISEASES  OF   THE  URO-GENITAL   SYSTEM. 

produced  artificially  by  increasing  the  amount  of  milk  sugar  above  that 
which  can  be  normally  absorbed.  This  quantity  Grosz  places  at  3-3 
grammes  for  each  kilogramme  of  the  body  weight.  If  more  than  this  is 
given,  or  if  there  is  diminished  capacity  for  the  absorption  of  sugar,  gly- 
cosuria occurs. 

Koplik  has  made  some  observations  upon  the  urine  of  patients 
fed  chiefly  npon  infant  foods  composed  largely  of  sugar.  He  found 
sugar  in  five  out  of  ten  cases  examined ;  in  three,  the  sugar  responded 
both  to  Fehling's  and  the  fermentation  test ;  in  two  cases  to  Fehling's 
test  only. 

There  seems  to  be  no  doubt  regarding  the  existence  of  dietetic  glyco- 
suria in  infants  and  in  older  children.  Repeated  examinations  of  the 
lU'ine  are,  however,  necessary  in  order  to  exclude  more  serious  disease. 

PYURIA. 

Pus  in  the  urine  may  exist  as  an  acute  or  a  chronic  condition.  In 
either  case,  in  a  child,  it  is  much  more  likely  to  come  from  the  pelvis  of  the 
kidney  than  from  any  other  source.  It  may,  however,  come  from  any  part 
of  the  genito-urinary  tract — the  kidney  or  its  pelvis,  the  ureters,  the  blad- 
der, the  urethra,  or  the  vagina.  Sometimes  it  comes  from  an  outside 
source,  as  when  an  abscess  from  perinephritis,  appendicitis,  or  caries  of 
the  spine  opens  into  the  urinary  tract. 

Coming  from  the  pelvis  of  the  kidney,  pus  may  indicate,  if  the 
condition  is  an  acute  one,  pyelitis,  pyelo-nephritis,  or  pyonephrosis ;  if  it 
is  chronic,  it  points  to  renal  tuberculosis  or  calculus.  The  amount  of  pus 
in  any  of  these  conditions  may  be  quite  large.  The  urine  is  turbid  and 
usually  acid  in  reaction.  It  contains  many  epithelial  cells  of  the  transi- 
tional forms  described  in  the  article  on  Pyelitis.  The  urine  when  con- 
taining much  pus  is  always  albuminous.  A  turbidity  due  to  pus  may  be 
mistaken  for  an  excessive  deposit  of  urates,  but  a  microscopical  examina- 
tion quickly  reveals  its  true  nature.  It  is  rare  that  pus  comes  from  the 
ureters  except  in  connection  with  congenital  malformations  or  the  im- 
paction of  calculi.  Pus  from  the  bladder  is  usually  in  small  quantity, 
especially  in  young  children,  and  it  is  mixed  with  mucus.  The  urine  may 
be  alkaline  or  acid  in  reaction ;  there  are  associated  the  symptoms  of  vesi- 
cal irritation  or  of  cystitis.  Pus  from  the  lower  genital  tract  is  rare  in 
children,  but  its  causes  are  usually  easily  recognised  by  a  local  examina- 
tion. When  the  cause  of  pyuria  is  the  opening  of  an  abscess  into  the 
urinary  tract  there  is  generally  a  sudden  appearance  of  pus  in  large 
amount.  It  is  in  most  cases  of  short  duration,  possibly  only  a  few  days, 
and  it  may  disappear  quite  rapidly. 

The  treatment  of  pyuria  depends  altogether  upon  its  cause.  Improve- 
ment in  the  symptoms  sometimes  follows  the  use  of  benzoic  acid  or  ben- 


LITHURIA.  gOl 

zoate  of  ammonia  in  doses  of  from  two  to  five  grains  every  three  hours  to 
a  child  of  five  years.  It  is  especially  indicated  where  the  urine  is  stron^^lv 
alkaline. 

LITHURIA. 

Lithuria  is  a  condition  in  which  there  is  an  excessive  elimination  in 
the  urine  of  uric  acid  or  of  urates.  The  amount  of  nitrogen  compounds 
eliminated  by  the  kidneys  as  uric  acid  and  urea,  varies  much  from  day  to 
day  with  the  nature  of  the  food  and  other  conditions.  Hence  in  estima- 
ting an  excess  of  uric  acid,  the  absolute  quantity  eliminated  in  twenty- 
four  hours  is  much  less  significant  than  the  ratio  of  the  uric  acid  to  the 
urea  (page  59G).  Whenever  this  ratio  is  continuously  disturbed,  the  excre- 
tion of  uric  acid  may  be  considered  abnormal,  except,  of  course,  in  grave 
pathological  conditions  of  the  kidney,  where  there  is  an  insufficient  elimi- 
nation of  urea.  Eegarding  the  source  of  uric  acid,  the  theory  of  Horbac- 
zewski  is  that  most  widely  accei^ted,  viz.,  that  it  results  from  the  destruc- 
tion of  the  nuclein  of  the  cells  of  the  body,  particularly  of  the  white 
blood-cells. 

For  accui'ate  knowledge  as  to  the  amount  of  uric  acid  eliminated, 
nothing  short  of  a  quantitative  cheiiiical  analysis  can  be  dej^ended  upon. 
But  if  amorphous  urates  are  deposited  in  large  amount,  uric  acid  may  be 
considered  excessive  if  the  specific  gravity  is  not  high  (above  1.025).  If 
the  specific  gravity  is  high,  the  precipitation  may  be  explained  simply  by 
the  concentration  of  the  urine.  The  deposition  of  the  crystals  of  uric 
acid,  forming  the  familiar  brick-dust  deposit,  is  not  evidence  of  excessive 
elimination.  For  a  quantitative  clinical  test,  that  of  Haycrof  t  is  probably 
the  best.* 

Lithuria  is  not  a  specific  condition,  but  rather  a  very  general  symptom 
associated  with  many  kinds  of  disturbances  of  nutrition.  It  may  be  found 
in  anaemia,  malnutrition,  chorea,  rheumatism,  chronic  dvspepsia,  and  in  a 
great  variety  of  other  disorders.  Regarding  the  significance  of  lithuria, 
thus  much  may  be  positively  asserted :  The  excessive  elimination  of  uric 
acid  when  continuous  is  always  evidence  of  a  serious  disturbance  of  nutri- 
tion. The  gravity  of  the  condition  will  depend  upon  the  degree  of  this 
excess  and  upon  its  duration. 

The  treatment  of  lithuria  is  the  treatment  of  the  condition  upon  which 
it  depends.  The  essential  pathological  condition  is  not  so  much  excessive 
elimination  as  excessive  production. 

Urine  containing  Crystals  of  TJric  Acid  in  the  Form  of  Brick-Dust 
Deposit. — This  condition  is  not  to  be  confounded  Avith  the  one  just 
described.  As  already  stated,  such  precipitation  is  not  to  be  taken  as  evi- 
dence of  an  excess  of  uric  acid,  and,  in  fact,  in  most  of  these  cases  there 

*  See  Haii?  on  Uric  Acid  in  Ilealth  and  Disease. 


002  DISEASES  OF  THE   URO-GENITAL  SYSTEM. 

is  no  excess.  The  condition  is  rather  one  in  which  the  solvent  jDower  of 
the  urine  for  uric  acid  is  much  reduced.  Such  urine,  as  a  rule,  is  high- 
coloured,  strongly  acid,  and  may  have  a  high  specific  gravity. 

This  condition  also  is  dependent  upon  a  disturbance  of  nutrition,  and 
one  which  is  most  frequently  associated  with  a  gouty  diathesis.  It  is  not 
very  common  in  children  except  in  those  of  gouty  antecedents.  In  such 
patients  it  is  only  occasionally  present,  and  is  usually  associated  with  some 
other  disturbance  of  nutrition,  often  of  digestion.  It  is  frequently  the 
cause  of  local  irritation  of  the  urinary  passages,  which  is  usually  slight,  but 
which  may  be  severe. 

In  my  experience  these  cases  are  most  improved  by  cutting  off  sugar 
from  the  diet  almost  entirely,  by  greatly  reducing  the  amount  of  starchy 
food  and  substituting  a  diet  rich  in  nitrogen  and  fat,  viz.,  meat,  milk, 
and  cream,  together  with  plenty  of  outdoor  exercise.  The  continued  use 
of  alkaline  waters  is  also  of  decided  advantage  in  most  cases. 

INDICANURIA. 

ludicanuria  is  a  condition  characterized  by  the  presence  of  indican  in 
the  urine.  To  Herter  is  due  the  credit  of  bringing  this  subject  promi- 
nently to  the  minds  of  the  profession  in  this  country.  Indican  (indoxyl- 
potassium  sulphate)  is  derived  from  indol,  which  is  formed  in  the  intes- 
tine by  the  agency  of  bacteria  from  the  excessive  putrefaction  of  the 
proteids.  It  may  also  be  produced  in  other  parts  of  the  body  where  putre- 
factive processes  are  going  on,  as  in  extensive  suppuration  without  drain- 
age, in  joulmonary  cavities,  empyema,  etc.  Indican  is  only  one  of  the 
ethereal  sulphates  produced  in  the  manner  above  indicated,  and  when 
other  conditions  like  those  mentioned  are  excluded  it  may  be  taken  as  an 
index  of  the  amount  of  putrefaction  going  on  in  the  intestine. 

The  presence  of  indican  in  the  urine  is  demonstrated  by  adding  certain 
oxidizing  agents,  which  produce  an  indigo-blue  colour.*     The  existence 

*  The  commonly  employed  test  for  indican  is  that  known  as  Jaffe's  test.  It  is 
described  by  Herter  as  follows :  Pour  into  a  test-tube  equal  quantities  of  urine  and 
strong  hydrochloric  acid  so  as  to  fill  the  tube  to  within  half  an  inch  of  the  top,  and 
shake.  If  there  is  much  indican,  a  dark  blue  or  purple  colour  will  be  produced.  Then 
add  sufficient  chloroform  to  completely  fill  the  tube  and  shake  thoroughly.  It  is 
important  that  thp  chloroform  should  completely  fill  the  tube  so  that  no  air  bubbles 
get  in  by  the  agitation.  If,  after  standing,  the  chloroform  assumes  a  deep-blue  or  vio- 
let colour,  there  is  certainly  an  excess  of  indican.  The  reaction  may  not  appear  at 
first,  but  may  come  out  after  standing  several  hours,  or  if  slight  at  first  it  may  in- 
crease in  intensity.  Sometimes,  when  no  reaction  is  obtained,  it  may  be  produced  by 
adding  one  drop  of  a  saturated  solution  of  chloride  of  lime  or  of  peroxide  of  hydro- 
gen. No  more  than  one  drop  should  be  added  at  a  time,  or  the  blue  colour  may  be 
bleached.  In  alkaline  urine  the  indican  is  usually  destroyed,  so  that  the  test  may  be 
negative. 


ACETONURIA— DIACETONURIA.  603 

of  indicanuria  in  children  was  formerly  believed  to  be  pathognomonic  of 
tuberculosis.  Later  investigations  have  shown  that  this  is  not  the  case  ;  for 
in  cases  of  tuberculosis  indican  is  almost  as  frequenth-  absent  as  present. 

Herter  gives  the  following  as  the  conditions  under  which  indicanuria 
is  likely  to  be  present :  It  is  found  in  chronic  intestinal  indigestion ;  in 
very  many  cases  of  chronic  constipation;  in  many  cases  of  epilepsy,  just 
about  the  time  of  the  seizures ;  in  some  cases  of  masturbation ;  frequently 
in  children  who  are  the  subjects  of  night  terrors,  and  in  whom  there 
are  usually  disturbances  of  digestion.  According  to  other  observers, 
it  is  found  with  great  constancy  in  acute  putrefactive  diarrhoeas.  With 
the  exceptions  above  noted,  the  source  of  the  indican  is  always  the 
same,  viz.,  the  excessive  putrefaction  of  the  proteid  substances  in  the 
intestine. 

Indicanuria  is  most  frequently  a  symptom  either  of  acute  or  chronic 
intestinal  disease.  It  is  important  as  being  a  guide  by  which  we  may  esti- 
mate the  other  symptoms  in  these  conditions,  and  the  effects  of  treatment. 
While  a  trace  of  indican  is  frequently  present  in  health,  a  strong  indican 
reaction  is  always  to  be  considered  abnormal  in  a  child.  The  indications 
for  treatment  are  to  diminish  intestinal  putrefaction.  This  is  mainly 
dietetic,  and  is  to  be  accomplished  by  means  referred  to  in  the  treatment 
of  chronic  intestinal  indigestion  (page  368). 

ACETON  URIA— DIACETONURIA. 

Acetone  exists  in  small  quantities  in  the  urine  of  healthy  children. 
According  to  Baginsky  and  Schrach,  it  is  found  in  large  quantities  in 
many  febrile  diseases.  It  increases  with  the  height  of  the  fever  and 
subsides  with  it.  Acetone  is  probably  formed  from  the  destruction  of 
the  nitrogenous  material  of  the  body,  as  it  is  increased  by  a  nitrogenous 
diet,  and  may  disappear  by  a  diet  of  carbohydrates.  Baginsky  found  it 
also  in  children  with  epilepsy,  sometimes  during  the  attacks.  It  is  not, 
however,  believed  to  be  the  cause  of  the  convulsive  seizures,  as  it  is  absent 
in  convulsions  occurring  under  other  conditions.  It  has  no  relation  to 
rickets.  According  to  Schrach,  there  is  no  connection  between  acetonuria 
and  the  nervous  symptoms  accompanying  fever.  Von  Jaksch  found  ace- 
tone in  a  case  of  diabetic  coma. 

Binet  found  diacetic  acid  in  sixty-nine  out  of  one  hundred  and  fifty 
examinations  in  febrile  diseases,  chiefly  in  scarlet  fever,  measles,  and  pneu- 
monia. In  diabetes  this  condition  often  precedes  the  development  of 
coma,  otherwise  it  is  of  no  prognostic  significance.  Schrach  found  diace- 
tonuria  exceedingly  common  in  all  cases  of  continuous  high  fever.  It  is 
more  frequently  present  than  acetonuria,  and  ceases  with  the  fever.* 

*  For  literature,  see  Baginsky,  Archiv  fiir  Kinderheill^unde,  Bd.  xi,  p.  1. 


604:  DISEASES   OP  THE    URO-GENITAL   SYSTEM. 


ANURIA. 

By  tins  term  is  meant  an  arrest  of  the  urinary  secretion.  To  that  form 
which  occurs  in  the  course  of  renal  disease  the  term  "  suppression  "  is  gen- 
erally applied.  Anuria  is  to  be  carefully  distinguished  from  retention, 
from  the  scanty  secretion  which  occurs  whenever  food  is  refused  or  with- 
held on  account  of  illness,  and  also  from  that  which  accompanies  acute 
diarrhoea  with  large,  watery  discharges.  Anuria  is  sometimes  seen  in  the 
newly  born,  where  it  depends  upon  some  malformation  of  the  genital 
tract;  or  it  may  depend  upon  uric-acid  infarctions  in  the  kidneys.  The 
first  urine  passed  after  such  an  attack  is  very  often  highly  acid,  and 
may  contain  an  abundance  of  uric-acid  crystals  and  larger  masses  visible 
to  the  naked  eye.  Other  cases  admit  of  no  such  explanation,  and  the 
condition  must  be  regarded  as  of  nervous  origin.  For  the  time,  the 
secretion  appears  to  be  completely  arrested,  as  the  bladder,  both  by  pal- 
pation and  catheterization,  is  found  to  be  empty.  This  condition  is  not  a 
very  uncommon  one  in  infancy,  and  it  may  continue  for  from  twelve  to 
thirty-six  hours.  So  long  as  infants  appear  to  be  perfectly  normal  in 
every  other  res2:)ect,  the  suspension  of  the  urinary  secretion  even  for 
twenty-four  hours  need  excite  no  anxiety. 

The  treatment  is  very  simple  and  effectual,  and  consists  in  the  admin- 
istration of  sweet  spirits  of  nitre,  either  alone  or  in  combination  with  the 
acetate  or  citrate  of  potash,  and  plenty  of  water.  To  an  infant  of  three 
months  one  minim  of  the  nitre  and  one  grain  of  the  citrate  of  potash  may 
be  given  every  hour  in  half  an  ounce  of  water  until  the  urinary  secretion 
is  established,  which  will  usually  be  in  six  or  eight  hours.  If  the  urine  is 
very  highly  acid,  and  stains  the  napkins,  the  potash  should  be  continued 
for  several  days.  Hot  fomentations  over  the  kidneys  may  be  used  with 
advantage. 

DIABETES   INSIPIDUS   (POLYURIA). 

This  is  a  chronic  disease  characterized  by  the  excretion  of  a  very  large 
amount  of  pale  urine  of  low  specific  gravity.  It  is  invariably  accompanied 
by  polydipsia.     The  disease  is  an  exceedingly  rare  one  in  children. 

The  exact  pathology  of  diabetes  insipidus  is  not  known  ;  but  from  the 
conditions  under  which  it  occurs  it  is  believed  to  be  a  neurosis.  The 
irritation  which  gives  rise  to  it  may  be  in  or  near  the  floor  of  the  fourth 
ventricle,  or  it  may  affect  the  renal  nerves. 

Etiology. — Of  eighty-five  cases  collected  by  Strauss,  twenty-one  were 
under  ten  years  of  age  and  nine  under  five  years.  In  Eoberts'  collection 
of  seventy  cases,  the  disease  began  in  twenty-two  before  ten  years,  and 
in  seven  during  infancy.  In  some  cases  it  begins  soon  after  birth.  Males 
are  more  frequently  affected  than  females,  and  in  certain  cases  heredity  is 
an  important  factor.     Weil  has  published  a  remarkable  example  of  the 


disease  existing  iii  many 
the  head,  concussion  of 
occipital  region,  tubercui 
drocephalus,  all  have  been 
sometimes  has  followed  the  i 
no  cause  whatever  can  be  founa. 

Symptoms. — The  quantity  of  urme  .o  ^„.        a.,  .     .,.1^  „u 

that  in  diabetes  meilitus.  From  five  to  twenty  pints  daily  may  oe  passed. 
The  urine  is  pale,  the  specific  gravity  from  1-001  to  l-OOO,  and  it  contains 
neither  albumin  nor  grape  sugar.  In  a  few  cases  the  j)resence  of  inosite 
(muscle  sugar)  has  been  found.  Restricting  the  amount  of  fluid  taken 
causes  a  very  marked  diminution  in  the  amount  of  urine.  The  intense 
thirst  leads  patients  to  drink  enormously  of  water  and  other  fluids.  Vari- 
ous contradictory  statements  are  made  by  different  writers  regarding  the 
quantity  of  uric  acid  and  urea  eliminated  in  these  cases.  The  following 
are  the  results  obtained  in  a  case  recently  under  observation,  in  the  Babies' 
Hospital.*  The  child  was  three  years  old,  quite  anaemic,  and  losing  in 
weight.  On  January  20th  the  fluids  were  unrestricted,  on  the  other  days 
they  were  restricted : 


Date. 

DaUy  quantity  of 
urine. 

Specific 
gravity. 

Total 
urea. 

Total 
uric  acid. 

Indican 
reaction. 

Inosite. 

January  20  

Grammes. 

3,300 

750 

775 

1,320 

Ounces. 

lOU 

25" 

25i- 
49" 

1-006 
1-010 
1-010 

Grammes. 

22-276 

9-049 

6-478 

Grammes. 
0-173 
0-072 

6-ii6 

None. 
Strong. 

Xone. 

None. 

«        25 

None. 

"        26 

None. 

February  8 

1-007    :  12-113 

None. 

The  elimination  of  urea  in  this  case  is  excessive,  but  the  uric  acid  is 
not  far  from  the  normal. 

Xervous  symptoms  are  usually  present.  There  may  be  disturbed  sleep 
from  the  frequent  micturition,  paljjitation,  flushing  of  the  face  and  other 
vaso-motor  disturbances,  headache,  restlessness,  and  neuralgia.  There 
may  be  incontinence  of  urine.  The  skin  is  pale  and  dry,  and  perspiration 
is  scanty.  The  general  health  may  not  be  disturbed.  In  most  cases,  how- 
ever, it  is  somewhat  affected,  and  there  may  be  the  usual  symptoms  of 
malnutrition,  and  even  neurasthenia.  If  it  affects  young  children,  their 
growth  may  be  considerably  retarded.  The  appetite  usually  remains  quite 
good.  The  temperature  is  at  times  slightly  subnormal.  The  course  of 
the  disease  is  indefinite.  It  is  very  chronic,  and  may  last  for  many  years, 
death  taking  place  only  fi'om  intercurrent  affections. 

Prognosis. — A  few  of  the  cases  recover  spontaneously.  Those  of  short 
duration  are  often  cured  by  treatment.     Of  the  chronic  cases  in  which 


*  The  analyses  were  made  by  Dr.  C.  A.  Herter. 


SYSTEM. 

tiled.     The  prognosis  is 
ligestive  tract  or  organic 

wo  marked  symptoms,  ex- 

t,es  mellitus  it  is  easily  distin- 

the  absence  of  sugar  from  the 

v..  ji"  ui.xiUrea,   .iixv/iiic  nephritis  with  contracted  kidney  may 

be  confounded  with  it. 

Treatment. — Fluids  should  be  moderately  restricted.  It  is  a  serious 
mistake  to  reduce  the  quantity  of  fluids  too  much,  since  the  drinking  is 
not  the  cause  of  the  diuresis.  The  diet  should  be  simple  and  nutritious, 
consisting  largely  of  meat,  with  a  moderate  amount  of  carbohydrates.  The 
general  treatment  should  be  directed  to  the  condition  of  malnutrition. 
The  clothing  should  be  warm,  and  a  moderate  amount  of  exercise  should 
be  allowed.  Drugs  are  of  little  use ;  those  which  have  sometimes  been 
beneficial  are  arsenic,  belladonna,  ergotine,  the  bromides,  and  antipyrine. 
Treatment  must  be  continued  for  many  months  to  be  of  any  value. 


CHAPTER  II. 

DISEASES  OF  THE  KIDNEYS. 

MALFORMATIONS   AND   MALPOSITIONS. 

Malformations  of  the  kidney  are  not  infrequent.  In  seven  hun- 
dred and  twenty-six  consecutive  autopsies  at  the  New  York  Infant  Asy- 
lum malformations  of  the  kidney  or  ureters  were  met  with  in  seventeen 
cases.  This  does  not  represent  the  actual  frequency  with  which  they 
occur,  for  in  about  half  the  number  of  autopsies  in  two  other  institutions 
only  a  single  example  was  seen.  Adding  to  the  cases  mentioned  two 
others  seen  elsewhere,  there  are  twenty  cases  of  renal  malformation  of 
which  I  have  notes,  classed  as  follows : 

Fusion  of  the  kidneys,  or  horseshoe  kidney 4  cases. 

Supernumerary  ureters 4     " 

Hydronephrosis  (alone) 8     " 

Cystic  degeneration  of  the  kidney  (alone) 2     " 

Hydronephrosis  and  cystic  kidney 1  case. 

Single  kidney 1      " 

In  all  malformations  the  left  kidney  is  much  more  frequently  affected 
than  the  right,  the  proportion  being  nearly  two  to  one.  Malformations 
are  more  often  seen  in  males  than  in  females. 


MALFORMATIONS  AND   MALPOSITIONS   OF   THE   KIDNEY.       607 

Fusion  of  the  Kidneys. — In  one  case,  in  a  child  who  died  of  pneumonia 
at  the  age  of  three  years,  the  kidneys  were  fused  into  one  irregular  ovoid 
mass,  lying  upon  the  lumbar  vertebrae ;  in  another  case  the  mass  lay  upon 
the  promontory  of  the  sacrum  ;  in  both  there  were  two  renal  arteries  and 
two  ureters.  In  the  two  other  cases  the  organs  were  united  at  their  lower  ex- 
tremities, and  in  both  of  these  there  were  two  ureters  passing  in  front  of  the 
kidney.  In  one  there  was  also  hydronephrosis  and  chronic  diffuse  nephritis. 
The  children  died  at  the  ages  of  four  and  five  months  respectively. 

Cystic  Degeneration  of  the  Kidneys. — In  two  of  these  three  cases  the 
right  kidney  was  affected,  and  in  one  the  left.  The  ages  at  which  the  chil- 
dren died  were  from  seven  to  ten  months.  Xo  renal  symptoms  were  pres- 
ent. In  all  the  cases  the  cystic  kidney  was  very  small,  about  an  inch  and 
a  half  in  length  and  one  inch  in  width.  The  organ  was  entirely  made  up 
of  smaller  and  larger  cysts  containing  a  clear  fluid,  held  together  by  loose 
connective  tissue.  The  ureter  was  small  and  rarely  pervious  throughout. 
In  one  case  there  was  hydronephrosis  of  the  opposite  side ;  in  the  others 
the  opi^osite  kidney  was  considerably  enlarged,  being  about  one  half  larger 
than  normal.  In  addition  to  these  small  cystic  kidneys  there  has  been 
described  a  cystic  degeneration  in  which  very  large  cysts  have  formed  even 
in  utero,  sometimes  filling  the  abdominal  cavity  of  the  child  and  seriously 
interfering  with  delivery. 

Single  Kidney,  the  other  being  rudimentary  or  absent. — Of  this  I  have 
seen  but  one  example,  which  was  found  in  a  young  man  twenty-two  years 
of  age,  who  died  of  typhus  fever  in  Bellevue  Hospital.  The  right  kidney 
weighed  seven  and  a  half  ounces ;  the  left  was  represented  by  a  nodular 
mass  about  the  size  of  an  ovary,  showing  no  trace  of  renal  tissue.  The 
ureter  was  pervious  to  within  four  inches  of  the  kidney ;  the  suprarenal 
capsule  was  normal.  Macdonald  has  reported  a  case  in  which  there  was 
no  trace  whatever  of  the  right  kidney  ;  the  left  was  greatly  enlarged,  and 
weighed  nine  ounces.  There  were  two  suprarenal  capsules  but  only  one 
ureter.  Schaeffer  has  reported  absence  of  both  kidneys  in  a  seven-months' 
foetus,  associated  with  many  other  malformations. 

Hydronephrosis. — Of  the  ten  cases  of  which  I  have  notes,  this  existed 
as  the  principal  deformity  in  eight.  In  two  cases  it  was  associated  respec- 
tively with  cystic  degeneration  of  the  opposite  kidney  and  horseshoe  kid- 
ney. In  seven  cases  only  the  left  side  was  affected ;  in  three  there  was 
double  hydronephrosis.  Seven  patients  were  males  and  three  females. 
Six  died  before  they  were  six  months  old,  and  only  two  lived  to  be  two 
years  old.  This  condition  is  undoubtedly  the  result  of  some  obstruction 
to  the  outflow  of  urine  in  the  ureter,  bladder,  urethra,  or  prepuce,  but  in 
only  three  of  my  cases  could  there  be  found  an  obstruction  sufficient  to 
explain  the  deformity.  In  two  there  was  marked  hypertrophy  of  the 
bladder.  In  no  case  was  a  calculus  found  as  the  cause  of  the  obstruction. 
In  most  of  the  cases  the  ureter  was  dilated  to  a  diameter  of  from  one 
40 


g08  DISEASES   OF   THE   URO-GENITAL   SYSTEM. 

fourth  to  one  half  of  an  inch,  and  in  two  it  was  so  large  as  to  be  easily 
mistaken  for  the  small  intestine.  Usually  the  ureters  appeared  much  elon- 
gated and  sacculated ;  the  pelvis  of  the  kidney  was  dilated  to  the  capacity 
of  half  an  ounce  or  more,  the  calices  forming  pockets  about  half  an  inch  in 
diameter.  Less  frequently  the  greater  part  of  the  kidney  was  destroyed, 
leaving  only  a  series  of  communicating  pockets  surrounded  by  a  thin  cortex 
of  renal  tissue  from  one  fourth  to  one  eighth  of  an  inch  in  thickness.  In 
five  cases  there  was  chronic  diifuse  nephritis  of  the  affected  side,  and 
sometimes  both  kidneys  were  involved,  even  though  the  hydronephrosis 
was  unilateral.  The  nephritis  was  usually  of  a  very  advanced  type.  In 
two  cases,  typical  examples  of  the  atrophic  form  (contracted  kidney)  were 
seen,  one  of  these  children  dying  at  the  age  of  one  month.*  The  organs 
are  shown  in  Fig.  105.  In  two  of  the  cases  the  bladder  was  the  seat  of 
very  marked  hypertrophy. 

Urinary  symptoms  were  noted  in  but  one  case,  and  in  that  they  were 
due  to  pyelo-nephritis  dependent  upon  the  presence  of  calculi  in  the  kidney 
not  the  seat  of  hydronephrosis.  In  no  other  case  was  the  malformation  sus- 
pected during  life.  Four  patients  died  of  marasmus,  two  of  acute  broncho- 
pneumonia, and  one  of  ileo-colitis.  In  only  one  was  there  any  malforma- 
tion outside  the  urinary  tract,  this  being  a  case  of  congenital  heart  disease. 

Double  hydronephrosis  is  generally  associated  with,  or  results  in,  such 
changes  in  the  kidneys  that  the  patients  die  during  infancy,  commonly 
in  the  first  year.  At  this  age  it  rarely  gives  rise  to  a  tumour,  and  is  rec- 
ognised only  by  the  changes  in  the  urine  or  by  the  other  symptoms  of 
nephritis.  There  may  be  the  general  and  local  symptoms  of  chronic  dif- 
fuse nephritis,  or,  when  infection  of  the  genital  tract  occurs,  there  are 
added  the  symptoms  of  pyelitis.  In  the  great  majority  of  cases  the  con- 
dition is  unrecognised,  the  patient  dying  of  some  disease  not  perha})s  in 
itself  fatal,  but  rendered  so  by  the  condition  of  the  kidneys. 

If  hydronephrosis  is  unilateral  there  may  be  no  symjitoms  until  the 

*  This  was  in  every  way  a  remarkable  case.  The  child  died  apparently  of  maras- 
mus. There  was  double  hydronephrosis,  the  ureters  being  three  fourths  of  an  inch  in 
diameter.  The  right  kidney  was  nodular  upon  the  surface,  and  had  a  very  adherent 
capsule.  Just  beneath  the  capsule  there  wei'e  small  cysts  containing  pus.  The  left 
kidney  was  the  seat  of  hydronephrosis,  only  its  cortex  remaining,  this  being  about  one 
sixth  of  an  inch  in  thickness.  Microscopical  examination  showed  great  thickening  of 
the  capsule  of  the  right  kidney,  and  several  small  abscesses  situated  in  the  cortex 
just  beneath  the  capsule.  The  rest  of  the  kidney  was  converted  into  a  mass  of  dense 
fibrous  tissue  in  which  were  scattered  many  uriniferous  tubules,  the  epithelium  of 
which  was  clear,  nucleated,  and  of  the  embryonic  type.  The  left  kidney  was  the  seat 
of  chronic  diffuse  nephritis  of  the  atrophic  variety,  with  well-marked  changes  in  the 
medullary  portions.  The  cortex  showed  much  exudation  and  less  atrophy,  being  nearly 
normal  in  thickness.  The  small  size  of  the  organ  was  due  chiefly  to  atrophy  of  the 
pyramids.  The  walls  of  the  bladder  were  greatly  hypertrophied,  being  in  places  one 
fourth  of  an  inch  thick.     The  urethra  and  prepuce  were  normal. 


MALFORMATIONS   AND   MALPOSITIONS   OF   THE  KIDNEY.       609 

dilatation  of  the  pelvis  of  the  kidney  has  reached  a  sufficient  size  to  form 
an  abdominal  tumour.  In  most  of  the  cases  in  children  this  condition 
has  been  noted  between  the  third  and  the  eleventh  years.  This  tumour 
may  be  situated  in  the  lumbar  region,  or  it  may  fill  the  abdomen.  It  is 
cystic,  and  may  be  confounded  with  a  dermoid  cyst  of  the  ovarv.     On 


Fig.  105. — Congenital  hydronephrosis,  dilated  ureters,  and  hyperlrophied  bladder.    (From  a  child 

one  month  old.y 


aspiration  a  fluid  is  withdrawn  which  may  be  clear,  or  of  a  brownish 
colour,  and  recognised  as  urine  by  the  fact  that  it  contains  urates  and 
urea.  After  aspiration  the  urine  passed  per  uretliram  may  be  bloody. 
Aspiration  affords  only  temporary  relief,  as  the  tumour  quickly  refills.  If 
an  incision  is  made  and  the  kidney  drained,  a  cure  may  result  with  the 
formation  of  a  fistula.  This  may  continue  indefinitely,  or  infection  of 
the  fistulous  tract  may  occur  and  suppurative  nephritis  be  set  up,  which 


610  DISEASES  OF  THE   URO-GENITAL   SYSTEM. 

speedily  carries  off  the  patient.  A  better  operation  is  nephrectomy,  which 
may  result  in  a  permanent  cure  if  the  opposite  kidney  is  healthy,  which 
is  usually  the  case  if  the  child  is  over  three  years  of  age  for  the  reason 
above  stated,  viz.,  that  a  child  with  malformation  of  both  kidneys  usually 
dies  in  infancy.  Whether  the  other  kidney  is  the  seat  of  serious  disease 
or  not,  will  depend  much  upon  how  far  advanced  the  changes  are  upon 
the  side  of  the  hydronephrosis.  In  most  cases  the  sooner  this  condition 
is  removed  the  better  will  be  the  outlook  for  the  patient ;  hence  the  ques- 
tion of  operation  should  always  be  carefully  considered. 

Supernumerary  TJreters. — These  were  noted  in  four  cases,  more  fre- 
quently on  the  left  side.  The  usual  deformity  was  for  two  ureters  to  be 
given  off,  one  from  the  upper  and  one  from  the  lower  part  of  the  kidney, 
each  ureter  having  a  separate  pelvis.  The  ureters  either  joined  just  above 
the  bladder,  or  entered  this  organ  by  separate  openings.  This  condition 
is  of  no  practical  importance,  and  was  not  found  associated  with  other 
renal  changes. 

Malposition  of  the  Kidney. — This  was  noted  in  my  series  of  autopsies 
only  once,  in  a  case  of  fusion  of  the  kidneys  already  mentioned.  Of 
twenty-one  cases  collected  by  Eoberts,  the  displacement  was  always  of  one 
kidney  only  ;  the  left  being  displaced  fifteen  times,  the  right  six  times. 
Northrup  has  reported  two  cases,  both  displacements  of  the  left  kidney  ; 
in  one,  the  organ  lay  in  the  hollow  of  the  sacrum  ;  in  the  other,  in  the 
median  line,  partly  above  and  partly  below  the  promontory  of  the  sacrum. 
Malpositions  of  the  kidney  are  compatible  with  perfect  health  and  de- 
velopment.    In  most  of  the  cases  there  is  no  other  deformity  present. 

Movable  or  Floating  Kidney. — This  is  one  of  the  rarest  of  the  abnor- 
mal conditions  seen  in  this  organ  in  early  life.  Cases  have,  however,  been 
reported  by  Phillips,  Korsakow,  and  others,  with  symptoms  similar  to 
those  seen  in  adult  life. 

URIC-ACID   INFARCTIONS. 

These  consist  in  a  deposit  in  the  straight  tubes  of  the  kidneys  of  uric 
acid  or  of  amorphous  or  crystalline  urates  ;  usually  both  kidneys  are  af- 
fected, and  all  the  pyramids  of  each  kidney.  The  infarctions  appear  to 
the  naked  eye  as  fine,  brownish,  fan-shaped  strige.  Associated  with  them 
there  may  be  granular  deposits  of  uric-acid  salts  in  the  pelvis  of  the  kidney, 
and  sometimes  evidences  of  catarrhal  inflammation  of  the  pelvis,  including 
even  the  presence  of  blood.  This  condition  probably  occurs,  to  some  de- 
gree at  least,  in  nearly  all  infants  during  the  first  ten  days  of  life.  It  was 
formerly  supposed  that  the  discovery  of  these  appearances  was  proof  that 
an  infant  had  breathed,  and  a  certain  medico-legal  importance  was  there- 
fore attached  to  them.  This  is  now  known  not  to  be  the  case,  as  they  are 
sometimes  found  in  still-born  infants. 

The  cause  of  this  condition  is  the  excretion  of  uric  acid  before  there  is 


CHRONIC   CONGESTIOX   OF   THE   KIDNEY.  611 

sufficient  water  to  dissolve  it,  so  that  the  crystals  are  deposited  in  the 
tubes.  Uric-acid  infarctions  are  found  chiefly  in  children  dying  before 
the  end  of  the  second  week,  although  it  is  not  uncommon  to  see  them  as 
late  as  the  third  or  fourth  or  even  the  sixth  month.  In  most  of  the 
cases,  as  the  urinary  secretion  becomes  more  abundant,  the  deposits  are 
washed  out  in  the  urine  and  appear  as  brownish-red  stains  upon  the  nap- 
kins. Infarctions  may  give  rise  to  a  slight  inflammation  of  the  renal 
tubules,  but  very  rarely  to  any  serious  lesion  ;  sometimes  they  remain  as 
deposits  in  the  calices  or  the  pelvis  of  the  kidney  or  in  the  bladder,  form- 
ing the  nucleus  of  a  calculus.  The  symptoms  to  which  they  give  rise  are 
mainly  scanty  urination  during  the  first  week  of  life,  and  occasionally 
anuria  for  the  first  day  or  two.  Sometimes  there  is  evidence  of  pain  on 
micturition,  and  there  is  the  stain  upon  the  napkin  already  referred  to. 
The  treatment  is  to  give  water  freely  and  some  alkaline  diuretic  such  as 
citrate  of  potash.  One  grain  should  be  given  every  two  hours  until  the 
secretion  is  fully  established  ;  this  in  most  cases  will  be  within  twenty- 
four  hours. 

ACUTE   CONGESTION   OF   THE   KIDNEY. 

In  acute  congestion  of  the  kidney  all  its  blood-vessels  contain  much 
more  blood  than  normal,  and  from  them  there  may  be  an  escape  of  serum 
and  even  of  the  red  blood-cells  by  diapedesis.  This  congestion  mav 
result  from  traumatism,  the  ingestion  of  certain  poisons,  from  any  of  the 
infectious  diseases,  or  from  cold. 

The  urine  is  usually  scanty,  of  high  specific  gravity,  and  contains 
albumin  and  red  blood-cells,  sometimes  blood  casts.  This  may  be  only  a 
temporary  condition  passing  off  in  a  few  days  without  further  symptoms, 
or  it  may  exist  as  the  first  stage  of  acute  nephritis.  It  is  most  serious  when 
it  occurs  in  kidneys  already  the  seat  of  serious  disease.  There  are  some- 
times no  symptoms  except  those  of  the  urine ;  or  there  may  be  headache, 
pain  in  the  back,  and  some  general  indisposition. 

The  treatment  consists  in  free  catharsis,  the  use  of  hot  vapour 
baths,  and  counter-irritation  over  the  kidneys  by  means  of  hot  poultices  or 
dry  cups. 

CHRONIC   CONGESTION   OF   THE    KIDNEY. 

This  results  from  interference  with  the  return  cii'culation  of  the  kid- 
ney, and  may  be  caused  by  congenital  malformation  or  valvular  disease  of 
the  heart,  chronic  broncho-pneumonia  or  chronic  pleurisy;  also  by  the 
pressure  of  any  abdominal  tumour  upon  the  inferior  vena  cava  or  the 
renal  veins. 

The  kidneys  are  generally  enlarged,  firmer  than  normal,  and  dark- 
coloured.  All  the  capillary  vessels  are  swollen  and  distended  with  blood, 
and  their  walls  are  thickened.     In  addition  to  the  symptoms  of  the  pri- 


612  DISEASES  OF   THE   URO-GENITAL   SYSTEM. 

mary  disease,  the  amount  of  urine  passed  is  usually  scanty  and  of  high 
speciiic  gravity.  Albumin  and  casts  are  generally  present,  but  are  not 
constant.  The  treatment  should  be  directed  toward  the  primary  con- 
dition, and,  in  addition,  an  effort  should  be  made  to  increase  the  urine  by 
alkaline  diuretics,  caffein,  digitalis,  and  the  sweet  spirits  of  nitre. 


ACUTE   DEGENERATION   OF  THE   KIDNEYS. 

In  the  succeeding  pages  devoted  to  diseases  of  the  kidney  I  shall  fol- 
low the  classification  of  Delafield,  which  seems  to  me  the  simplest  and 
most  exact  that  has  yet  been  proposed.  For  the  description  of  the  lesions 
I  am  indebted  largely  to  his  Lectures. 

In  acute  degeneration  of  the  kidney  the  principal  or  only  change  is  in 
the  epithelium  of  the  tubules.  It  is  exceedingly  common  both  in  infancy 
and  in  childhood,  being  found  to  a  greater  or  less  degree  in  all  autopsies 
upon  patients  dying  of  acute  infectious  diseases,  but  it  is  most  marked  in 
cases  of  scarlet  fever,  diphtheria,  and  acute  pleuro-pneumonia.  It  may 
be  found  in  any  disease  characterized  by  prolonged  high  temperature  ;  and 
it  is  the  explanation  of  the  cases  of  so-called  febrile  albuminuria.  The 
cause  is  in  all  probability  direct  irritation  of  the  epithelium  of  the  tubules 
by  the  toxines  eliminated  by  the  kidneys.  It  may  also  be  induced  by 
irritating  drugs,  such  as  cantharides  or  turpentine.  By  some  writers  these 
cases  have  been  classed  as  examples  of  acute  nephritis ;  hence  the  great 
discrepancy  which  exists  in  statements  made  as  to  the  frequency  of 
nephritis  in  the  different  infectious  diseases. 

The  kidneys  are  usually  slightly  enlarged,  and  paler  than  normal.  On 
section  the  cortex  may  be  somewhat  thickened,  and  the  straight  tubules 
marked  by  yellowish-gray  lines.  It  ia  the  appearance  commonly  spoken 
of  as  "  cloudy  swelling."  The  organs  are  seldom  much  congested.  The 
microscope  shows  a  granular  degeneration  and  death  of  the  epithelium 
of  the  tubules,  and  when  severe  this  may  be  accompanied  by  congestion 
and  the  exudation  of  serum. 

Acute  degeneration  of  the  kidneys  gives  rise  to  no  symptoms  in  addi- 
tion to  those  of  the  original  disease,  except  the  appearance  of  a  moderate 
amount  of  albumin  in  the  urine,  and  sometimes  a  few  hyaline  or  granular 
casts.  It  can  not  be  said  that  such  a  condition  adds  much  to  the  danger 
of  the  original  disease.  In  cases  that  recover,  the  condition  of  the  kidney 
entirely  clears  up.  The  development  of  the  symptoms  of  degeneration  of 
the  kidneys  in  infectious  diseases  calls  for  no  special  treatment  beyond  a 
continuance  of  the  fluid  diet. 


ACUTE   EXUDATIVE   NEPHRITIS.  613 


ACUTE   EXUDATIVE   NEPHRITIS. 

Synonyms :  Acute  parenchymatous  nephritis,  acute  desquamative  nephritis,  acute 
septic  interstitial  nephritis. 

Etiology. — This  variety  of  nephritis  occtirs  apparently  as  a  primary  dis- 
ease both  in  infants  and  in  older  children.  Most  such  cases  are  undoubt- 
edly of  infectious  origin,  although  the  point  of  entrance  of  the  infection 
it  may  be  difficult  or  impossible  to  determine.  This  form  of  inflammation 
is  much  more  frequently  secondary  to  the  acute  infectious  diseases,  espe- 
cially to  scarlet  fever  and  diphtheria.  It  occasionally  follows  measles, 
varicella,  empyema,  typhoid  fever,  acute  diarrhoeal  diseases,  pneumonia, 
meningitis,  influenza,  and,  in  rare  instances,  eczema.  This  is  the  char- 
acteristic variety  of  secondary  nephritis  occurring  in  septic  conditions. 
The  exciting  cause  of  the  inflammation  is  in  some  cases  the  irritation 
from  toxines ;  in  others  there  is  in  addition  the  entrance  of  p3'ogeuic 
germs,  carried  by  the  circulation. 

Lesions. — This  inflammation  is  characterized  by  congestion  and  exuda- 
tion of  the  blood  plasma  with  leucocytes  and  red  blood-cells,  also  by 
changes  in  the  renal  epithelium  and  the  glomeruli.  In  infants  and  young 
children  the  predominant  feature  of  the  lesion  is  usually  the  exudation  of 
leucocytes.  In  severe  cases  the  kidneys  are  enlarged,  and  usually  soft  and 
(edematous.  The  cortex,  which  is  the  seat  of  the  most  marked  changes,  is 
thickened  and  of  a  uniform  yellowish-white  colour,  or  it  may  be  mottled 
with  red,  owing  to  small  haemorrhages.  Sometimes  there  is  congestion  of 
the  entire  organ.  At  other  times,  both  on  the  surface  and  on  section,  the 
kidney  presents  a  mottled  yellow  appearance,  these  yellow  spots  being 
aggregations  of  pus  cells ;  they  are  scattered  through  the  organ,  and  vary 
in  size  from  a  pin's  head  to  a  pea.  Minute  abscesses  may  even  be  found. 
The  microscope  .shows  the  renal  epithelitim  of  the  tubules  to  be  swollen, 
loosened,  and  degenerated.  The  tubules  may  be  dilated,  and  contain  red 
and  white  blood-cells  and  degenerated  epithelium.  The  glomerular  changes 
are  often  marked.  There  are  swelling  and  proliferation  of  the  cells  cover- 
ing the  capillary  tufts,  and  similar  changes  in  the  capillaries  themselves. 
There  may  be  red  or  white  blood-cells  in  the  cavities  of  the  capsules,  and 
cocci  may  be  found  in  the  small  blood-vessels.  There  are  accumulations 
of  leucocytes  in  the  tubes,  in  the  stroma,  and  in  the  venous  capillaries. 
These  cells  are  usually  in  irregular  patches.  The  excessive  emigration 
of  leucocytes  may  not  be  accompanied  by  blood  serum,  and  hence  there 
may  be  no  albumin  in  the  urine. 

I  have  made  autopsies  upon  six  cases  of  nephritis  of  this  variety  in 
young  infants,  which  were  apparently  primary.  In  all  these  cases  the 
excessive  exudation  of  leucocytes  was  the  striking  feature  of  the  disease. 


614  DISEASES  OF  THE   URO-GENITAL  SYSTEM. 

Under  the  microscope  they  were  in  places  so  dense  as  to  obscure  all  the 
renal  elements. 

Symptoms. — 1.  Primary  form  in  infants. — These  cases  are  not  com- 
mon, and  the  symptoms  are  so  obscure  that  they  are  usually  overlooked. 
In  1887  ^  1  published  five  cases  of  my  own,  and  collected  from  literature 
fourteen  others  of  primary  nephritis  under  two  years  of  age.  Since  that 
time  four  additional  cases  have  come  under  my  observation. 

A  study  of  these  cases  yields  the  following  facts  :  The  onset  in  nearly 
every  instance  was  abrupt,  usually  with  high  fever  and  vomiting,  the 
temperature  being  in  several  cases  over  104°  F.  Dropsy  was  very  excep- 
tional, being  noted  in  but  six  cases  ;  in  most  of  these  it  was  slight,  and 
seen  only  toward  the  close  of  the  disease.  Fever  was  present  in  all  cases. 
In  those  observed  by  myself  it  was  high  and  irregular  in  type,  ranging 
from  101°  to  105°  F,  The  duration  of  the  disease  was  from  eight  days 
to  four  weeks,  the  average  being  about  two  and  a  half  weeks.  Vomiting 
and  diarrhoea  were  noted  in  half  the  cases,  but  were  rarely  prominent, 
and  marked  either  the  onset  of  the  attack,  or  were  traceable  to  indigestion 
accompanying  the  fever ;  very  rarely  did  they  exist  as  symptoms  of  urae- 
mia. Ansmia  was  a  prominent  symptom  in  nearly  every  case,  and  it  was 
this  which  enabled  me  in  several  instances  to  make  a  correct  diagnosis. 
Nervous  symptoms  were  usually  prominent.  In  several  patients  there 
was  dyspnoea  without  pulmonary  disease,  partly  due,  no  doubt,  to  the 
anaemia.  In  nearly  all  cases  there  was  marked  restlessness  or  muscular 
twitchings,  and  in  three  there  were  convulsions.  Dulness  and  apathy 
were  present  in  the  majority  of  the  fatal  cases,  but  deep  coma  was  never 
seen.  Several  patients  presented  the  typical  symptoms  of  the  typhoid 
condition.  The  urine  was  rarely  scanty  until  near  the  close  of  the 
disease,  and  sometimes  not  even  then.  Suppression  of  urine  occurred 
in  but  a  few  cases.  Albumin  was  frequently  absent  early  in  the  attack, 
but  was  invariably  present  at  a  late  period,  although  rarely  in  large 
amount.  Casts  were  found  in  all  cases  that  were  carefully  examined 
microscopically.  They  were  not  usually  numerous,  and  were  chiefly  of 
the  hyaline,  granular,  and  epithelial  varieties.  No  blood  casts  were  seen. 
There  were  usually  many  pus  cells  and  renal  epithelial  cells,  together  with 
red  blood-cells  in  moderate  numbers. 

Of  the  twenty-three  cases,  fifteen  died  and  eight  recovered.  Of  my 
own  nine  cases,  eight  were  fatal,  the  diagnosis  being  confirmed  by  autopsy 
in  every  case  but  one.  Whether  these  figures  represent  the  actual  mor- 
tality of  the  disease  it  is  difficult  to  say.  No  doubt  there  are  many  mild 
cases  which  escape  notice  altogether.  The  severe  ones,  however,  are  quite 
uniformly  fatal,  chiefly  on  account  of  the  tender  age  of  the  patients. 

2.  Primary  form  in  older  cliildren. — This  also  is  a  rare  form  of  renal 

*  Archives  of  Paediatrics,  vol.  iv,  pp.  1,  103  ;  and  ix,  p.  263. 


ACUTE   DIFFUSE  NEPHRITIS.  615 

disease.  As  compared  with  the  same  condition  in  infants,  the  onset  is 
usually  less  abrupt,  the  febrile  symptoms  are  less  marked,  and  the  termina- 
tion is  less  frequently  fatal.  There  is  little  dropsy,  often  none  at  all.  The 
urine  is  only  slightly  diminished  in  quantity  ;  the  amount  of  albumin  is 
small ;  casts  are  not  numerous,  and  usually  hyaline,  epithelial,  or  granu- 
lar ;  very  rarely  is  there  much  blood  present.  Uraemia  is  very  infrequent, 
and  the  prognosis  is  much  more  favourable  than  in  infancy. 

3.  Secondary  foi'm. — This  is  the  most  common  variety  of  secondary 
nephritis  of  infectious  diseases.  It  usually  occurs  at  the  height  of  the 
febrile  process,  and  its  severity  is  generally  proportionate  to  the  intensity 
of  the  infection.  The  constitutional  symptoms  are  often  not  marked,  and 
dropsy  is  rare.  Unless  the  urine  is  examined  the  condition  may  be  over- 
looked. The  urinary  changes  are  essentially  the  same  as  those  already 
mentioned  in  the  primary  cases.  While  the  involvement  of  the  kidneys 
adds  to  the  danger  of  the  primary  disease,  it  is  rare  that  the  nephritis  is 
itself  the  cause  of  death.  Suppression  of  urine  and  the  development  of 
the  symptoms  of  acute  uraemia  are  infrequent. 

ACUTE   DIFFUSE   NEPHRITIS. 
Synonyms  :  Acute  Bright's  disease,  glomerulo-nephritis. 

This  is  a  more  severe  form  of  inflammation  than  is  exudative  nephritis, 
and  is  much  more  likely  to  be  followed  by  permanent  damage  to  the 
kidney. 

Etiology. — Acute  diffuse  nephritis  occasionally  occurs  in  children  ap- 
parently as  a  primary  disease,  its  origin  being  then  obscure.  It  is  usually 
attributed  to  cold  and  exposure,  and  certainly  this  is  sometimes  the  case. 
It  is  the  secondary  form  which  is  especially  important  in  early  life,  and  in 
the  great  majority  of  cases  this  follows  scarlet  fever.  It  is  the  characteris- 
tic post-scarlatinal  nephritis.  Occasionally,  however,  it  follows  diphtheria, 
and  may  indeed  occur  after  any  severe  form  of  infectious  disease.  The 
cause  in  the  scarlet-fever  cases  is  now  generally  admitted  to  be  the  poison 
of  the  primary  disease — probably  the  result  of  direct  irritation  from  tox- 
ines.  While  it  may  sometimes  follow  a  definite  exposure,  as  when  patients 
have  been  allowed  to  get  up  or  go  out  too  soon,  it  occurs  also  in  those 
who  have  been  kept  in  bed  throughout  the  attack  ;  sometimes  even  in  mild 
cases.  But  there  is  little  doubt  that  exposure  may  jirecipitate  an  attack 
in  a  patient  who  might  otherwise  have  escaped.  An  important  etiological 
factor  is  the  too  early  use  of  solid  food.  The  frequency  of  nephritis  as  a 
sequel  of  scarlet  fever  varies  much  in  different  epidemics ;  in  some  it  is 
rarely  seen,  while  in  otliers  it  may  occur  in  nearly  half  the  cases ;  the 
average  is  probably  from  six  to  ten  per  cent.  While  it  most  frequently 
follows  a  severe  form  of  scarlet  fever,  it  may  occur  after  an  attack 
which   has   been   so   mild  as  to  escape  notice  until  the  appearance  of 


(316  DISEASES  OF   THE   URO-GEXITAL   SYSTEM. 

desquamation.  Season  appears  to  have  but  little  influence  upon  its 
frequency. 

Lesions.—  In  this  form  of  inflammation  most  of  the  changes  of  acute 
exudative  nephritis  are  present,  but  in  addition  there  are  marked  altera- 
tions in  the  stroma  of  the  kidney  and  the  Malpighian  bodies.  The  kid- 
neys are  enlarged,  often  considerably  so,  and  appear  rather  soft  and  flabby. 
In  the  early  stage  they  are  sometimes  much  congested  ;  later,  they  are  of 
a  yellowish-white  colour  with  a  fine  red  mottling.  The  cortex  usually 
appears  much  thickened  and  yellow,  while  the  pyramids  are  red.  The 
characteristic  lesions  of  this  form  of  nephritis  are  a  production  of  con- 
nective-tissue cells  in  the  stroma,  and  proliferation  of  the  cells  forming 
the  capsules  of  the  ^lalpighian  bodies.  These  changes  usually  occur  in 
patches.  In  recent  cases  there  are  found  only  the  new  connective-tissue 
cells  ;  in  older  ones  the  connective  tissue  is  more  dense  and  even  fibrous 
in  character.  The  changes  in  the  glomeruli  may  be  permanent,  the  tufts 
being  compressed  by  the  growth  of  the  endothelial  cells  lining  the  cap- 
sules, which  may  ultimately  form  new  fibrous  tissue. 

Symptoms. — When  the  disease  is  primary,  it  may  begin  abruptly  with 
febrile  symptoms,  dropsy,  headache,  lumbar  pains,  scanty  urine,  and  often 
with  vomiting ;  or  it  may  come  on  somewhat  insidiously  with  few  consti- 
tutional symptoms,  but  with  dropsy  and  changes  in  the  urine.  When  it 
follows  scarlet  fever  it  most  frequently  develops  during  the  third  or  fourth 
week  of  the  disease.  The  onset  is  usually  gradual,  with  dropsy,  scantv 
urine,  and  moderate  fever.  The  subsequent  course  may  be  the  same  in 
both  the  primary  and  secondary  cases,  whatever  the  mode  of  onset. 

There  is  in  most  cases  some  fever ;  usually  the  temperature  ranges 
from  100°  to  101-5°  F.,  but  in  very  severe  attacks  it  may  be  104°  or  105° 
F.  Dropsy  is  almost  invariably  present,  and  is  generally  marked.  It  is 
first  seen  in  the  face,  next  in  the  feet,  legs,  and  scrotum,  and  there  may 
be  general  anasarca,  with  dropsy  of  the  serous  cavities  of  the  body ;  this 
is  usually  of  the  pleura  or  the  peritoneum,  rarely  of  the  pericardium. 
As  the  disease  progresses  there  is  always  a  very  marked  degree  of 
anaemia. 

The  urine  is,  as  a  rule,  greatly  diminished  in  quantity,  and  may  be 
suppressed.  Albumin  is  invariably  present,  and  usually  in  large  amount, 
often  enough  to  render  the  urine  solid  upon  boiling.  The  urine  is  of  a 
dark,  reddish-brown  or  smoky  colour,  owing  to  the  presence  of  red  blood- 
globules  or  haemoglobin.  The  amount  of  urea  eliminated  is  far  below  the 
normal.  The  specific  gravity  may  be  low,  even  though  the  quantity  is 
very  small.  Casts  are  present  in  great  numbers — chiefly  hyaline,  gran- 
ular, and  epithelial  casts  from  the  straight  tubes ;  not  infrequently  there 
are  blood  casts.  Occasionally  twisted  or  cork-screw  casts  are  seen.  These 
come  from  the  convoluted  tubes,  and  are  regarded  by  Ripley  (New  York) 
as    of   grave    significance,  indicating    that    all   parts   of  the  kidney  are 


ACUTE   DIFFUSE  NEPHRITIS.  617 

involved.  Red  blood-cells  are  present  in  great  numbers ;  also  many 
leucocytes,  and  always  a  large  amount  of  renal  epithelium. 

The  duration  of  the  active  symptoms  in  cases  terminating  in  recovery 
is  from  one  to  three  weeks.  The  temperature  and  dropsy  gradually  sub- 
side. Improvement  in  the  urine  is  shown  by  an  increase  in  quantity,  by 
increased  elimination  of  urea,  and  by  a  diminution  in  the  amount  of 
blood,  albumin,  and  the  number  of  casts.  A  few  casts  may  persist  for 
several  weeks,  and  a  small  amount  of  albumin  for  two  or  three  months. 

In  the  graver  cases,  where  the  onset  is  accompanied  by  high  temper- 
ature, pain  in  the  back  and  loins,  and  a  rapid,  full  pulse  of  high  tension, 
the  urine  is  very  scanty  and  is  often  suppressed.  Then  follow  the  symp- 
toms of  uraemia.  In  children  this  is  usually  manifested  by  vomiting, 
great  restlessness  or  apathy,  and  often  by  diarrhoea.  Less  frequently 
there  are  headache,  dimness  of  vision,  stupor  developing  into  coma,  or  con- 
vulsions. If  the  secretion  of  urine  is  re-established,  the  nervous  symptoms 
abate  and  the  patient  may  recover.  This  has  been  known  to  occur  after 
complete  suppression  has  lasted  thirty-six  hours.  Care  should  be  taken 
not  to  mistake  retention  for  suppression.  If  doubt  exists,  percussion  of 
the  bladder  and  the  use  of  the  catheter  will  quickly  settle  the  question. 

There  are  several  complications  for  which  the  physician  must  con- 
stantly be  on  the  lookout  during  attacks  of  acute  nephritis;  the  most 
frequent  are  pneumonia,  pleurisy,  pericarditis,  and  endocarditis;  more 
rarely  there  may  be  meningitis  and  oedema  of  the  glottis.  It  is  from  com- 
l^licatious  or  acute  uraemia  that  death  usually  occurs. 

Prognosis. — This  is  to  be  considered  from  two  points  of  view :  first, 
the  danger  to  life  during  the  acute  stage  of  the  disease,  and,  secondly,  the 
danger  of  the  development  of  chronic  nephritis.  The  great  majority  of 
patients  survive  the  acute  stage,  and  not  infrequently  even  those  recover 
who  have  presented  grave  symptoms  of  uraemic  poisoning.  The  quantity 
and  specific  gravity  of  the  urine,  and  the  number  and  variety  of  the  casts, 
are  a  much  better  guide  in  prognosis  than  the  amount  of  albumin.  The 
existence  of  severe  nervous  symptoms,  such  as  stupor,  intense  headache, 
dimness  of  vision,  and  persistent  vomiting,  add  much  to  the  gravity  of 
the  case,  as  does  also  the  presence  of  any  serious  complication.  In  gen- 
eral it  may  be  said  that  if  there  is  no  suppression  of  urine,  or  if  there  are 
no  symptoms  of  ura?mia  and  no  complications,  recovery  is  almost  certain 
if  the  child  is  over  three  years  old ;  in  younger  children  the  outlook  is  less 
favourable.  The  general  opinion  prevails  that  acute  diffuse  nephritis  in 
childhood,  whether  it  is  primary  or  occurs  as  a  complication  of  scarlet 
fever,  is  rarely  followed  by  the  chronic  form  of  the  disease;  and  such  was 
the  view  I  formerly  held.  Larger  experience,  however,  has  convinced  me 
that  this  sequel  is  not  very  uncommon.  The  interval  of  apparent  health 
may  sometimes  cover  a  period  of  several  years,  and  the  later  nephritis 
may  be  attributed  to  other  causes ;  but  all  cases  of  severe  scarlatinal  ne- 


618  DISEASES  OF  THE  URO-GENITAL  SYSTEM. 

phritis  slionld  be  curefully  watched  for  a  long  time,  and  after  a  severe 
attack  a  guarded  prognosis  should  always  be  given  as  regards  the  ultimate 
result.* 

Treatment  of  Acute  Nephritis. — Prophylaxis  is  important,  and  relates 
principally  to  the  secondary  form  which  occurs  in  the  course  of  infectious 
diseases,  especially  post-scarlatinal  nephritis ;  f  but  the  measures  here  out- 
lined apply  equally  to  all  varieties.  The  inflammation  of  the  kidney  being 
in  most  of  these  cases  the  result  of  direct  irritation  by  the  toxines  which 
are  eliminated  by  them,  it  follows  that  elimination  through  the  skin  and 
intestines  should  be  increased,  and  that  the  urine  should  be  rendered  as 
little  irritating  as  possible  by  largely  increasing  its  quantity.  The  first 
indication  is  met  by  frequent  sponging,  warm  baths,  and  keeping  the 
bowels  freely  opened  by  saline  cathartics,  sufficient  being  given  to  produce 
one  or  two  loose  movements  daily.  To  meet  the  second  indication,  the 
patient  should  be  kept  upon  a  fluid  diet,  preferably  milk,  at  least  for 
the  three  weeks  of  the  disease,  and,  if  possible,  for  a  full  month.  At  the 
same  time  he  should  drink  very  freely  of  alkaline  mineral  waters,  or  of 
plain  water  to  which  a  small  dose  (two  or  three  grains)  of  some  alkaline 
diuretic  like  the  citrate  of  potassium  has  been  added.  If  milk  is  not  well 
borne,  kumyss,  whey,  buttermilk,  or  junket  may  be  used,  or  thin  gruels 
mixed  with  milk.  When  the  first  trace  of  albumin  appears  in  the  urine 
this  plan  of  treatment  should  invariably  be  followed.  In  addition  to  these 
measures,  after  an  attack  of  scarlet  fever  the  patient  should  be  kept  in  bed 
for  at  least  a  week  after  the  temperature  has  become  normal. 

The  mild  cases  of  acute  nephritis  tend  to  spontaneous  recovery  under 
the  hygienic  and  dietetic  treatment  mentioned — i.  e.,  rest  in  bed,  fluid  diet, 
the  drinking  of  large  quantities  of  water,  and  attention  to  the  action  of 
the  skin  and  bowels.  These  measures  should  be  continued  so  long  as 
the  urine  contains  any  considerable  amount  of  albumin,  or  so  long  as  the 
patient's  general  condition  will  jiermit.  Should  he  become  very  ansmic, 
or  lose  much  in  weight,  it  may  be  necessary  to  enlarge  the  diet  by  the 
addition  of  solid  food.  This  should  at  first  be  of  the  carbohydrates  only, 
usually  in  the  form  of  some  farinaceous  food.  An  increase  in  the  diet 
and  exercise  should  be  made  very  gradually,  and  the  effect  upon  the 
urine  carefully  watched. 

*  The  following  case  may  be  cited  as  an  illustration  of  this  point :  A  girl  at  the  age 
of  seven  years  had  scarlet  fever,  followed  by  nephritis ;  the  dropsy  having  lasted,  it 
was  reported,  for  three  months.  She  was  believed  to  have  recovered  perfectly,  and 
remained  in  apparent  health  until  she  was  sixteen,  when,  as  a  supposed  result  of  a 
severe  chilling,  she  developed  dropsy  and  all  the  symptoms  of  acute  nephritis.  From 
that  time,  although  she  lived  for  three  years,  and  was  often  for  months  at  a  time 
seemingly  in  the  best  of  health,  her  urine  was  never  free  from  casts  and  albumin,  and 
she  finally  died  in  uriemic  convulsions. 

t  See  'w.  H.  Flint,  New  York  Medical  Journal,  January  6,  1894. 


CHRONIC   NEPHRITIS.  019 

The  severe  cases,  with  scanty  urine,  fever,  and  marked  dropsy,  require 
more  active  treatment.  Free  diaphoresis  should  be  maintained  by  the 
hot  pack  or  vapour  bath  (page  54),  and  in  bad  cases  even  pilocarpine  may 
be  used  hypodermically,  a  dose  of  gr.  ^l  being  given  to  a  child  of  three 
or  four  years.  To  counteract  the  depressing  effects  of  this  drug,  stimu- 
lants should  be  given  at  the  same  time.  Active  counter-irritation  should 
be  maintained  over  the  kidneys  by  dry  cups  followed  by  poultices,  or 
the  mustard  paste.  Two  or  three  loose  movements  from  the  bowels  should 
be  secured  by  the  administration  of  calomel,  or,  better,  by  Rochelle,  or  Ep- 
som salts.  Harm  is  sometimes  done  by  carrying  this  depletion  too  far,  and 
its  effect  upon  the  patient's  general  condition  must  be  closely  watched.    If 

stippression  of  urine  occurs  with  the  development  of  uraemic  symptoms 

delirium,  high  temperature,  flushed  face,  vomiting,  and  a  pulse  of  high 
tension — nitroglycerin  may  be  given ;  a  child  of  five  years  may  take  gr. 
ji^  every  hour  for  three  or  four  doses,  or  until  an  effect  is  produced. 
Uremic  convulsions  may  often  be  averted  by  the  use  of  morphine  hypo- 
dermically ;  but  if  the  symptoms  are  very  urgent,  nothing  is  so  rapid  or 
so  certain  to  give  relief  as  venesection.  This  has  lately  been  revived  in 
the  practice  of  Xew  York  physicians,  and  has  now  the  endorsement  of  the 
best  practitioners  in  the  city.  From  a  child  of  five  years  from  two  to  six 
ounces  of  blood  may  be  taken,  according  to  the  general  condition  and  the 
urgency  of  the  symptoms.  Even  though  the  improvement  which  follows 
bleeding  under  the  conditions  mentioned  is  very  certain,  it  is  often  only 
temporary ;  but  it  gives  time  for  the  use  of  other  measures,  such  as  ca- 
tharsis and  diaphoresis.  The  depressing  effects  may  be  largely  overcome 
by  following  the  venesection  by  an  intravenous  injection  of  a  saline  solu- 
tion (gr.  iv  to  water  3  j).  The  amount  introduced  should  be  nearly  twice 
that  of  the  blood  taken. 

One  should  always  be  on  the  lookout  for  complications,  especially 
dropsy  of  the  serous  cavities,  pericarditis  or  endocarditis,  and  oedema  of  the 
lungs.  Convalescence  is  nearly  always  slow,  and  a  patient  who  has  suf- 
fered from  nephritis  needs  careful  attention  for  a  long  time.  Anaemia  is 
always  present,  and  iron  is  required.  The  diet  must  consist  largely  of 
fluids  for  several  months.  If  the  disease  tends  to  pass  into  a  subacute 
form,  the  child  should,  if  possible,  be  sent  to  a  warm  climate,  and  kept 
there  during  the  succeeding  winter,  and  every  means  taken  to  build  up; 
the  general  nutrition.  Flannels  should  be  worn  next  to  the  skin,  and 
every  precaution  taken  against  any  exposure  which  might  cause  an  exacer- 
bation of  the  disease. 

CHROXIC    NEPHRITIS. 

Chronic  inflammation  of  the  kidney  is  an  infrequent  condition  in 
childhood.  In  infancy  it  is  almost  unknown,  except  in  connection  with 
congenital  hydronephrosis  or  other  malformations  of  the  kidney.     Two 


Q20  DISEASES  OF   THE   URO-GENITAL   SYSTEM. 

pathological  varieties  are  met  with:  (1)  Chronic  diffuse  nephritis  with 
exudation,  known  also  as  the  large  white  kidney,  chronic  parenchyma- 
tous nephritis,  and  waxy  kidney.  {2)  Chronic  diffuse  nephritis  without 
exudation,  known  also  as  interstitial  nephritis,  granular  kidney,  and  con- 
tracted kidney. 

Etiology. — Chronic  nephritis  is  most  frequently  seen  as  a  sequel  of  the 
acute  nephritis  of  scarlet  fever.  It  also  occurs  with  the  prolonged 
suppuration  of  chronic  bone  or  joint  disease,  where  it  may  be  chronic 
from  the  beginning.  The  only  other  important  causes  in  early  life  are 
hereditary  syphilis,  alcoholism,  chronic  tuberculosis,  and  valvular  disease 
of  the  heart.  Nearly  all  the  cases  occur  in  children  over  seven  years 
of  age. 

Lesions.— The  lesions  of  chronic  nephritis  in  childhood  do  not  differ 
essentially  from  those  seen  in  later  life.  In  chronic  diffuse  nephritis 
with  exudation,  the  kidneys  are  usually  enlarged,  the  surface  is  smooth 
or  slightly  nodular,  and  yellowish- white  on  section.  The  microscope 
shows  that  the  renal  epithelium  is  swollen,  granular,  fatty,  and  degen- 
erated. The  tubes  contain  cast-matter  and  the  detritus  of  broken-down 
epithelial  cells.  In  some  places  they  are  dilated,  in  others  atrophied.  In 
the  glomeruli  there  is  a  growth  of  capsule  cells,  compression  and  atrophy 
of  the  tufts,  with  the  formation  of  new  connective  tissue.  When  there  is 
waxy  degeneration,  the  kidneys  are  usually  considerably  enlarged,  and  of 
a  glistening  gray  colour.  Amyloid  degeneration  is  seen  especially  in  the 
small  arteries  of  the  kidney  and  the  capillary  vessels  of  the  tufts.  With 
iodine  the  mahogany-brown  reaction  is  obtained.  Amyloid  changes  in 
the  kidney  are  nearly  always  associated  with  similar  lesions  in  the  liver 
and  spleen,  and  sometimes  also  in  the  intestinal  villi. 

In  the  chronic  diffuse  nephritis  toithout  exudation  (granular  kidney) 
the  organs  are  smaller  than  normal,  with  a  nodular  surface  and  adherent 
capsule.  The  cortex  is  thinned,  and  the  colour  is  gray  or  red.  In  addi- 
tion to  the  lesions  found  in  the  preceding  variety,  there  is  an  extensive 
production  of  new  connective  tissue,  which  is  irregularly  distributed 
throughout  the  kidneys.  The  tubules  in  some  places  are  dilated  to  form 
cysts  of  considerable  size,  while  in  others  they  have  completely  disap- 
peared. The  glomeruli  may  be  atrophied  to  little  fibrous  balls,  but  if 
chronic  congestion  has  preceded  the  inflammation,  they  may  be  large  and 
the  capillaries  dilated. 

Symptoms. — 1.  Chronic  nephritis  loith  exudation. — This  form  of  dis- 
ease is  not  usually  chronic  from  the  outset,  but  follows  an  acute  attack 
from  which  the  patient  is  often  supposed  to  have  recovered  completely. 
The  symptoms  sometimes  immediately  follow  the  acute  attack ;  at  others 
there  is  an  interval  of  apparent  recovery,  extending  over  a  few  months  or 
even  years.  Very  rarely  no  such  history  of  an  antecedent  acute  attack  can 
be  obtained,  and  the  symptoms  come  on  gradually  and  insidiously.     Such 


CHRONIC  NEPHRITIS.  621 

cases  occur  chiefly  in  older  children,  and  their  clinical  features  do  not 
differ  essentially  from  those  of  adult  life. 

As  a  rule  dropsy  is  present,  although  it  is  variable  in  amount,  and  fluc- 
tuates considerably  from  time  to  time.  There  may  be  not  only  oedema  of 
the  cellular  tissue,  but  effusion  into  the  pleura,  peritonaeum,  and  even  the 
pericardium.  As  the  case  progresses,  anaemia  is  always  a  marked  symp- 
tom. There  are  various  disturbances  of  digestion — loss  of  appetite,  occa- 
sional vomiting,  and  attacks  of  diarrhoea.  From  time  to  time  nervous 
symptoms  may  be  quite  prominent,  such  as  headaches,  sleeplessness,  neu- 
ralgia, fatigue  upon  slight  exertion,  and  dyspnoea.  Attacks  of  epistaxis 
are  not  infrequent. 

The  urine  contains  albumin  and  casts  nearly  all  the  time.  They  vary 
much  in  amount  at  different  periods  in  the  disease,  according  to  the 
rapidity  of  its  progress.  During  periods  of  exacerbation,  both  albumin 
and  casts  are  very  abundant,  while  in  the  intervals  the  amount  of  albumin 
is  small  and  the  casts  few.  The  casts  are  hyaline,  granular,  epithelial,  and 
fatty.  The  daily  quantity  of  urine  is  much  reduced  during  the  periods  of 
exacerbation,  while  at  other  times  it  may  be  nearly  normal.  The  specific 
gravity  is  usually  low. 

If  waxy  degeneration  is  present,  there  are  generally  associated  with  the 
renal  symptoms,  others  dependent  upon  waxy  changes  in  other  organs. 
The  spleen  and  liver  are  enlarged ;  there  may  be  ascites  and  diarrhoea,  and 
there  is  usually  present  the  peculiar  "  alabaster  cachexia." 

The  duration  of  this  form  of  chronic  nephritis  depends  much  upon  the 
surroundings  of  the  patient  and  the  treatment.  It  is  rarely  shorter  than 
two  years,  and  it  may  last  for  many  years.  The  progress  is  always  irregu- 
lar, and  marked  by  periods  of  exacerbation  and  remission.  The  patients 
die  from  acute  uraemia,  or  from  complicating  pneumonia,  pleurisy,  peri- 
carditis, endocarditis,  or  from  pulmonary  oedema. 

2.  Chronic  nephritis  without  exudation. — This  is  a  very  rare  disease 
in  early  life,  being  much  less  frequent  even  than  the  preceding  variety  of 
nephritis.  In  some  cases  there  is  a  history  of  hereditary  syphilis;  in 
others,  of  chronic  alcoholism.  The  early  symptoms  are  few,  and  the  dis- 
ease usually  develops  insidiously.  The  urine  is  pale,  excessive  in  amount, 
and  of  low  specific  gravity — 1-001  to  1*008.  Albumin  is  more  often 
absent  than  present,  and,  when  found,  the  quantity  is  small.  Dropsy 
likewise  is  rare,  and  never  marked.  Nervous  symptoms  are  often  prom- 
inent, such  as  headaches,  attacks  of  spasmodic  dyspnoea  resembling 
asthma,  neuralgias,  and  disturbances  of  vision.  High  arterial  tension 
and  hypertrophy  of  the  left  ventricle  are  regular  symptoms;  and  even 
atheromatous  degeneration  of  the  arteries  may  be  present.  Dickinson 
reports  an  instance  of  this  in  a  patient  only  six  years  of  age.  Late  in 
the  disease,  haemorrhages  may  occur,  and  these  may  be  the  cause  of 
death.     Filatoff  has  reported  a  cerebral  haemorrhage  in  a  child  of  eleven. 


022  DISEASES  OF   THE   URO-GENITAL  SYSTEM. 

Acute  uraemia  is,  however,  the  usual  termination  of  this  form  of  nephritis. 
The  course  is  slow,  aud  the  disease  may  be  overlooked  until  the  final 
uremic  symptoms  occur. 

Prognosis. — The  prognosis  of  chronic  nephritis  as  to  complete  recovery, 
is  always  unfavourable ;  and  although  cases  are  seen  in  which  symptoms 
are  absent  for  several  years,  they  almost  invariably  return.  Cases  have 
been  reported  of  recovery  from  waxy  degeneration  of  the  kidney  after 
removal  of  the  bone  disease  upon  which  the  condition  depended.  Al- 
though symptoms  may  be  absent  for  a  long  time,  complete  recovery  is  very 
doubtful.  An  extended  period  of  observation  is  necessary  before  the  pa- 
tient can  be  pronounced  cured.  As  to  the  duration  of  the  disease,  no  exact 
prognosis  can  be  given  because,  from  the  symptoms,  it  is  difficult  or  im- 
possible to  determine  exactly  the  extent  of  the  disease  in  the  kidney  and 
the  rapidity  of  its  progress.  According  to  Delafield,  the  continued  pas- 
sage of  a  large  amount  of  urine  of  low  specific  gravity  is  invariably  to 
be  interpreted  as  evidence  of  fibroid  changes  in  the  Malpighian  tufts, 
and  is  a  bad  symptom.  A  large  amount  of  dropsy,  the  coexistence  of 
valvular  disease  of  the  heart,  and  marked  renal  insufficiency,  as  shown 
by  a  quantitative  examination  of  the  urine,  are  all  very  unfavourable 
symptoms. 

Diagnosis. — Chronic  nephritis  like  the  acute  forms  is  likely  to  be  over- 
looked because  of  the  failure  to  examine  the  urine  in  children.  Kegular 
and  frequent  examinations  should  be  made  in  all  cases  of  convulsions,  of 
persistent  or  frequent  headaches,  severe  anaemia,  hypertrophy  of  the  heart, 
high  arterial  tension  and  of  general  malnutrition,  as  well  as  when  the 
more  obvious  symptoms  of  renal  disease,  such  as  dropsy  and  scanty  urine, 
are  present.  Nor  should  one  be  too  ready  to  make  the  diagnosis  of  func- 
tional albuminuria  because  he  finds  albumin  only  occasionally  and  in 
small  quantity.  All  such  cases  demand  most  careful  observation  and  the 
closest  attention  for  a  long  period  before  excluding  organic  renal  disease. 

Treatment. — Children  with  chronic  nephritis  are  to  be  treated  on  the 
same  general  plan  as  adults.  The  purpose  of  treatment  is  to  retard  as 
much  as  possible  the  progress  of  the  disease  and  to  relieve  the  symptoms 
as  they  arise.  It  is  of  the  greatest  importance  to  remove  the  j^atient  from 
conditions  in  which  exacerbations  are  liable  to  occur.  If  it  is  possible, 
he  should  be  sent  to  a  warm,  dry  climate  in  winter,  and  all  exposure 
to  cold  avoided ;  an  out-door  life  is  desirable.  Most  patients  require  a 
general  tonic  treatment  with  very  modei'ate  but  regular  exercise,  never 
carried  to  the  point  of  fatigue,  as  much  rest  as  possible  in  a  recumbent 
position,  a  fluid  diet,  consisting  largely  of  milk  as  long  as  this  can  be 
borne,  and  the  administration  of  iron,  particularly  the  tincture  of  the 
chloride.  Excessive  dropsy  calls  for  diuretics,  saline  cathartics,  and  heart 
stimulants.  If  uraemia  develops,  with  high  arterial  tension  and  stupor, 
headache,  and  convulsions,  venesection  should  be  resorted  to,  or  nitro- 


MALIGNANT   TUMOURS  OF   THE   KIDNEY.  623 

glycerin  used.     Morphine  may  be  given  hypodermically  if  the  pupils  are 
dilated  and  nervous  symptoms  are  very  marked. 

TUBERCULOSIS   OF   THE   KIDNEY. 

In  general  tuberculosis,  miliary  tubercles  are  frequently  seen  both  upon 
the  surface  of  the  kidney  and  in  its  substance.  These  give  rise  to  no 
symptoms  and  are  of  no  clinical  importance.  Larger  tuberculous  deposits 
are  extremely  rare  in  early  life.  They  usually  occur  in  patients  who  are 
the  subjects  of  general  tuberculosis,  and  are  associated  with  tuberculosis 
of  other  parts  of  the  genito-urinary  tract ;  or  they  may  exist  as  the  pri- 
mary, and  even  the  only,  tuberculous  lesion  in  the  body.  At  least  two 
such  cases  are  on  record  in  children,  one  reported  by  West  and  the  other 
by  Rilliet  and  Barthez.  Infection  of  the  kidney  generally  takes  place 
through  the  circulation,  and  not  from  the  bladder.  Aldibert's  figures 
show  that  in  children  the  bladder  usually  escapes  even  when  the  kidneys 
a.re  tuberculous,  for  of  thirteen  cases  of  renal  tuberculosis  the  bladder 
was  involved  in  but  two.  The  ages  of  twelve  of  these  patients  were  as  fol- 
lows :  from  two  to  four  years,  four  cases  ;  from  seven  to  eleven,  five  cases ; 
from  eleven  to  fourteen,  three  cases.  The  disease  probably  begins  in  the 
mucous  membrane  of  the  pelvis  and  the  calices  of  the  kidney,  and  extends 
to  the  pyramids,  finally  involving  the  cortex.  As  a  rule,  but  one  kidney 
is  affected.  The  process  may  be  confined  to  the  pyramids,  where  are 
found  cheesy  nodules  which  may  be  single  or  multiple.  These  ultimately 
break  down  and  form  abscesses.  The  process  may  result  in  almost  com- 
plete destruction  of  the  pyramids,  and  even  of  portions  of  the  cortex,  so 
that  the  kidney  may  consist  of  a  mere  shell  of  renal  tissue.  Suppuration 
in  the  neighbourhood  of  the  kidney  (perinephritic  abscess)  often  coexists. 

The  symptoms  are  quite  indefinite.  There  may  be  localized  pain  and 
tenderness  in  the  region  of  the  kidney,  and  a  tumour  if  there  is  perine- 
phritis. The  symptoms  of  irritability  of  the  bladder  may  be  almost  as 
severe  as  in  cases  of  calculus.  Pus  appears  in  the  urine  usually  as  a 
constant  symptom  ;  but  the  only  thing  that  is  diagnostic  is  the  discovery 
of  tubercle  bacilli  in  the  urine. 

The  treatment  of  renal  tuberculosis  is  purely  surgical.  Of  the  thirteen 
cases  collected  by  Aldibert  in  which  nephrectomy  was  done  for  this  con- 
dition, there  were  nine  recoveries  and  four  deaths ;  two  of  the  deaths, 
however,  not  being  traceable  to  the  operation  or  to  the  original  disease. 
No  recurrence  had  taken  place  in  one  case  at  the  end  of  eight  years,  and 
none  in  another  after  three  years. 

MALIGNANT   TUMOURS  OF   THE   KIDNEY. 

In  the  great  majority  of  cases  tumours  of  the  kidney  are  malignant. 
Of  fifty-one  cases  collected  by  Aldibert  which  were  operated  upon,  forty- 
eight  were  malignant  and  three  benign. 
41 


624  DISEASES  OP  THE  URO-GENITAL  SYSTEM. 

Malignant  growths  are  almost  invariably  primary.  In  children  under 
five  years,  although  not  common,  they  are  yet  more  frequent  than  any  other 
variety  of  malignant  tumour  of  the  abdomen.  The  earlier  cases  reported 
were  classed  as  carcinoma.  It  is  now  well  established  that  carcinoma  is 
very  infrequent,  and  that  nearly  all  the  cases  are  varieties  of  sarcoma. 
Fischer  reports  nineteen  of  sarcoma  and  two  of  carcinoma  ;  Aldibert, 
thirty-eight  of  sarcoma  and  five  of  carcinoma.  The  sarcoma  may  be 
round-  or  spindle-celled,  or  myo-sarcoma.  In  some  of  the  cases  there  are 
both  sarcomatous  and  carcinomatous  features,  so  that  they  might  be 
classed  as  sarcomatous  carcinoma.  The  tumour  grows  from  the  cortex 
of  the  kidney,  or  from  the  pelvis,  sometimes  from  the  adrenals.  It  may 
infiltrate  the  whole  kidney,  so  that  there  is  no  trace  of  renal  structure  re- 
maining, or  it  may  form  an  immense  tumour  on  one  side  of  the  kidney,, 
which  is  only  partially  invaded.  These  tumours  are  very  rarely  cystic, 
but  they  are  quite  soft,  and  haemorrhages  often  occur  into  their  sub- 
stance. Secondary  growths  may  occur  in  the  liver,  the  lungs,  the  retro- 
peritoneal glands,  in  the  opposite  kidney,  in  the  intestines,  or  in  the 
pancreas.  Pressure  of  the  tumour  upon  the  ureter  may  lead  to  hydrone- 
phrosis ;  and  upon  the  inferior  vena  cava,  to  thrombosis  of  that  vessel. 
As  it  grows,  the  tumour  sometimes  becomes  adherent  to  nearly  all  the 
abdominal  organs  by  localized  peritonitis.  It  may  lead  to  ascites,  but 
it  very  rarely  causes  general  peritonitis.  The  growth  may  reach  a  great 
size,  usually  from  five  to  fifteen  pounds,  but  in  one  case  reported  by 
Jacobi  it  weighed  thirty- six  pounds.  In  Seibert's  collection  of  48  cases 
the  right  kidney  was  involved  in  24,  the  left  in  22,  and  both  kidneys  in 
2  cases. 

Etiology. — These  tumours  of  the  kidney  may  be  congenital.  This 
was  true  of  5  cases  in  a  series  of  55  collected  by  Jacobi.  The  major- 
ity occur  in  early  childhood.  In  the  collection  of  130  cases  by  Long- 
street  Taylor  in  which  the  ages  are  given,  106  were  in  the  first  five 
years,  and  57  of  these  in  the  first  two  years  of  life.  The  sexes  were 
about  equally  affected.  In  a  small  number  of  cases  the  history  of  a  fall 
was  given. 

Symptoms. — The  principal  symptoms  are  tumour,  haematuria,  and 
cachexia.  The  tumour  is  usually  first  noticed.  It  is  in  most  cases  dis- 
covered in  the  loin,  but  grows  forward  toward  the  median  line.  Its 
surface  may  be  lobulated  and  irregular  or  quite  smooth  ;  and  although 
solid,  it  is  sometimes  so  soft  as  to  give  an  obscui*e  sensation  of  fiuctua- 
tion.  It  may  grow  to  an  enormous  size,  causing  displacement  of  the 
liver,  spleen,  intestines,  and  lungs.  The  progress  of  the  growth  is  usu- 
ally rapid,  so  that  from  the  size  of  a  fist,  the  tumour  may  grow  in  the 
course  of  three  or  four  months  so  as  to  fill  the  abdomen.  By  careful 
palpation  it  will  be  found — certainly  when  the  tumour  is  small — that 
although  it  may  be  quite  freely  movable,  its  attachment  is  near  the  lum- 


MALIGNANT  TUMOURS  OF   THE   KIDNEY.  625 

bar  spine.  Aspiration  may  show  blood,  but  more  frequently  the  result 
is  negative. 

Haematuria  was  observed  before  the  tumour  in  19  of  50  cases  (Seibert), 
it  being  then  the  first  symptom  noticed.  The  amount  of  blood  passed 
is  sometimes  quite  large,  but  is  usually  small,  and  may  be  discovered 
only  by  the  microscope.  Pain  is  rare,  and  is  due  to  localized  peritonitis. 
Constitutional  symptoms  are  absent  until  the  tumour  has  attained  a  large 
size,  when  a  cachexia  develops  and  the  patient  wastes  steadily  while  the 
tumour  continues  to  grow.  The  pressure  effects  are  dyspnoea,  from  com- 
pression of  the  lungs;  oedema  of  the  lower  extremities,  from  pressure 
upon  or  thrombosis  of  the  vena  cava ;  vomiting  and  indigestion,  from 
pressure  upon  the  stomach  and  intestines.  Secondary  deposits  very  rarely 
cause  any  symptoms  except  in  the  lungs,  where  they  may  give  rise  to 
cough,  and  even  to  haemoptysis. 

The  course  of  the  disease  is  steadily  from  bad  to  worse.  The  usual 
duration  of  life  in  patients  not  operated  upon,  is  from  three  to  ten  months 
after  the  tumour  is  discovered ;  very  rarely  do  they  live  a  year,  death 
usually  occurring  from  exhaustion. 

Diagnosis. — The  diagnosis  of  sarcoma  of  the  kidney  is  usually  quite 
easily  made  from  the  position  and  attachment  of  the  tumour,  its  rapid 
growth  and  solid  character,  the  existence  of  hgematuria,  and  the  age  of 
the  patient  (under  five  years).  It  may  be  confounded  with  hydronephro- 
sis, dermoid  cyst  of  the  ovary,  enlargement  of  the  spleen,  retro-peritoneal 
sarcoma,  tumours  of  the  liver,  or  even  of  the  abdominal  wall. 

Treatment. — Nothing  is  to  be  said  regarding  the  medical  treatment  of 
these  cases.  Unless  operated  upon,  I  believe  they  invariably  terminate 
fatally.  The  results  of  operation  during  recent  years  have  been  so  en- 
couraging that  no  case  should  be  abandoned,  no  matter  how  young  the 
patient.  Aldibert  has  collected  the  results  of  forty-five  cases  operated 
upon  :  twenty  deaths  occurred  soon  after  the  operation,  two  thirds  of 
them  from  shock  ;  in  eleven  cases  recurrence  of  the  growth  occurred 
within  nine  months,  and  caused  death.  This  raises  the  total  mortality  to 
78  per  cent.  Recently,  in  the  Babies'  Hospital,  two  cases  have  been 
successfully  operated  upon  by  my  colleague.  Dr.  Robert  Abbe ;  one,  a 
nursing  child,  thirteen  months  old,  where  the  tumour  weighed  seven 
pounds,  and  the  child  after  the  operation  only  fifteen  pounds.  This  case 
made  an  uninterrupted  recovery,  and  three  years  after  the  operation  was 
in  perfect  health.  The  accompanying  illustrations  (Figs.  106  and  107) 
are  from  photographs  of  this  patient.  The  second  case  was  in  a  child 
two  years  old,  and  the  tumour  weighed  two  and  a  quarter  pounds.  The 
child  made  an  excellent  recovery,  and  was  in  perfect  health  three  years 
and  nine  months  after  the  operation.  These  results  certainly  are  en- 
couraging, and  show  conclusively  that  infancy  is  no  contraindication  to 
the  operation. 


626 


PYELITIS.  627 

For  a  discussion  of  the  surgical  aspects  of  this  question,  and  details 
of  the  operation,  see  the  papers  of  Abbe*  and  Aldibert.f 

Benign  Tumours. — These  are  distinguished  by  their  slow  growth,  and 
by  the  fact  that  the  constitutional  symptoms  are  mild  or  wanting.  Of 
the  three  cases  collected  by  Aldibert,  one  was  adenoma,  one  fibroma,  and 
one  was  fibro-cystic.  Two  cases  recovered,  and  one  died  of  septic  peri- 
tonitis.    The  duration  of  the  disease  was  from  twenty  months  to  six  years. 

PYELITIS. 

Pyelitis  is  an  inflammation  of  the  mucous  membrane  lining  the  pelvis 
of  the  kidney.  It  may  exist  alone,  or  with  an  inflammation  of  a  portion 
of  the  ureter,  or  of  the  kidney  itself  (pyelo-nephritis) ;  and  it  may  be  acute 
or  chronic.  It  may  result  in  an  accumulation  of  pus  in  considerable 
quaiitity  in  the  pelvis  of  the  kidney  (pyonephrosis). 

Etiology. — Of  local  causes,  the  most  frequent  is  irritation  from  renal 
calculi.  It  is  also  associated  with  congenital  malformations  of  the  kid- 
neys or  ureters,  with  renal  tuberculosis  and  renal  tumours.  It  may 
result  from  an  extension  of  inflammation  from  the  tissues  surrounding 
the  kidney  (perinephritis),  or  from  an  abscess  ojDening  into  the  pelvis  of 
the  kidney.  The  secondary  pyelitis,  which  so  often  follows  cystitis  in 
adults,  is  an  extremely  rare  occurrence  in  childhood.  In  addition  to  the 
forms  mentioned,  there  is  seen  an  infectious  form  of  acute  pyelitis,  which 
usually  occurs  as  a  complication  of  scarlet  or  typhoid  fever,  diphtheria, 
malaria,  or  pyaemia ;  but  it  is  also  seen  apart  from  these  diseases,  when  it 
occurs  apparently  as  a  primary  affection.  I  have  seen  in  infants  three 
cases  of  this  description.  In  this  group  of  cases  the  infection  is  probably 
through  the  circulation,  but  in  the  cases  which  occur  independently  of 
the  acute  infectious  diseases  it  may  be  impossible  to  determine  the  point 
of  entrance  of  the  infection.  In  most,  if  not  all  these  cases  there  is 
also  present  a  certain  amount  of  nephritis. 

Lesions. — When  pyelitis  develops  from  a  local  cause  it  is  usually  uni- 
lateral. In  the  infectious  form  both  kidneys  are  involved.  In  the  acute 
cases  there  are  the  usual  appearances  of  an  acute  catarrhal  inflammation 
of  the  mucous  membrane,  with  congestion,  swelling,  and  sometimes 
minute  haemorrhages.  In  chronic  cases  there  is  thickening  and  some- 
times a  granular  condition  of  the  lining  membrane.  There  may  be  an 
accumulation  of  pus  of  considerable  size,  distending  the  pelvis  and  calices 
(pyonephrosis).  If  the  condition  is  one  depending  upon  a  calculus  or  con- 
genital deformity,  and  in  all  protracted  and  severe  cases,  the  kidney  itself 
is  involved  to  a  greater  or  less  degree ;  the  extent  of  the  nephritis  will  de- 
pend upon  the  nature  of  the  exciting  cause  and  the  duration  of  the  process. 

*  Annals  of  Surgery,  January,  1894. 

f  Revue  Mensuelle  des  Maladies  de  I'Enfance,  November,  1893. 


628  DISEASES  OF   THE   URO-GENITAL  SYSTEM. 

Symptoms. — The  history  of  the  following  ease  illustrates  the  main 
clinical  features  of  acute  infectious  pyelitis,  in  this  instance  occurring 
apparently  as  a  primary  disease  : 

A  previously  healthy  female  infant  of  eight  months  was  taken  sud- 
denly with  a  chill,  followed  by  a  very  high  fever.  The  child  was  ill  for 
ten  days  before  the  nature  of  the  disease  was  suspected.  During  this 
time  the  temperature  ranged  between  101°  and  106°  F.,  touching  105° 
nearly  every  day ;  but  the  chill  was  not  repeated.  The  other  constitu- 
tional symptoms  were  not  severe.  At  the  first  examination  of  the  urine 
there  was  found  a  large  amount  of  jdus,  which  on  standing  was  equal  to 
one  twelfth  of  the  volume  of  the  urine  passed  ;  the  reaction  was  strongly 
acid.  There  were  no  signs  of  vaginitis  or  vulvitis,  no  ardor  uriyim,  no 
evidence  of  local  pain  either  in  the  bladder  or  kidney,  no  abnormal  fre- 
quency of  micturition,  no  localized  tenderness,  and  no  vomiting.  At 
later  examinations  there  were  found  in  moderate  numbers  epithelial  cells 
from  the  bladder,  and  the  tubules  and  pelvis  of  the  kidney,  also  a  few 
hyaline  casts,  but  not  more  albumin  than  would  be  explained  by  the 
amount  of  pus.  Under  no  treatment  except  alkaline  diuretics,  the  tem- 
perature gradually  fell  to  normal  and  the  pus  steadily  diminished  in 
quantity,  and  at  the  end  of  five  weeks  had  practically  disappeared  from 
the  urine.  A  report  sixteen  months  later  stated  that  the  child  had  re- 
mained well  and  entirely  free  from  urinary  symptoms. 

In  some  cases  there  are  recurring  chills,  Avith  wide  fluctuations  in 
temperature;  in  others  there  may  be  only  pyuria,  with  moderate  fever 
and  few  other  constitutional  symptoms.  If  the  disease  complicates  one  of 
the  acute  infectious  diseases,  pyuria  may  be  the  only  symptom.  The 
urine  in  acute  pyelitis  is  turbid  from  the  presence  of  pus,  the  amount 
of  which  may  be  from  one  to  fifty  per  cent  of  the  volume  of  the  urine. 
The  quantity  of  urine  is  generally  somewhat  diminished,  and  it  may  be 
quite  scanty.  The  reaction  is  usually  acid,  even  though  the  amount  of 
pus  is  large.  Albumin  is  present  in  proportion  to  the  amount  of  pus  or 
the  degree  of  nephritis.  Red  blood-cells  are  found  under  the  microscope 
in  most  of  the  very  acute  cases,  and  may  be  in  sufficient  numbers  to 
colour  the  urine.  The  pus  cells  in  recent  cases  are  usually  well  preserved, 
but  in  old  cases  they  may  be  degenerated.  There  are  many  epithelial 
cells — conical,  fusiform,  and  irregular  cells  with  long  tails.  There  may 
be  renal  epithelium  and  hyaline,  granular  or  epithelial  casts,  varying  in 
number  with  the  severity  of  the  nephritis.  Bacteria  also  are  found  in 
great  numbers. 

In  chronic  pyelitis  only  pyuria  may  be  present,  or  there  may  be  a 
tumour  owing  to  the  pyonephrosis.  From  time  to  time  in  the  chronic 
form  there  may  be  intermittent  attacks  of  acute  pyelitis  resembling  those 
above  described.  In  pyelitis  depending  upon  congenital  malformations, 
pyuria  is  usually  the  only  symptom,  unless  pyonephrosis  is  present.    With 


PYELITIS.  629 

calculi  we  may  have  acute  or  chronic  pyelitis ;  there  may  be  localized 
pain,  tenderness,  sometimes  a  tumour,  occasionally  hasmaturia,  and  per- 
haps a  history  of  renal  colic  or  the  passage  of  gravel,  ^yith  tuberculosis 
we  have  chronic  pyuria  and  the  presence  of  tubercle  bacilli  in  the  urine. 
There  are  commonly  associated  the  symptoms  of  general  tuberculosis. 
If  associated  with  perinephritis,  the  inflammation  is  usually  acute,  and 
there  are  present  the  local  symptoms  of  the  original  disease.  If  an  ab- 
scess opens  into  the  pelvis  of  the  kidney  we  may  have  a  sudden  dis- 
charge of  pus  in  large  quantity  with  a  subsidence  of  previous  local  svmp- 
toras,  including  the  tumour.  With  neoplasms  we  have  congestion  and 
hsemorrliage  more  frequently  than  pus,  but  both  may  be  present. 

Diagnosis. — The  characteristic  symptoms  of  acute  jjyelitis  are  a  chill, 
which  may  be  repeated,  high  and  fluctuating  temperature,  scanty  urine, 
frequently  pain  and  tenderness  over  the  kidneys,  and  pyuria.  The  diao^- 
nosis  of  pyelitis  is  made  only  by  an  examination  of  the  urine,  which 
should  never  be  omitted  in  cases  of  obscure  high  temperature,  even  in 
infancy,  particularly  if  chills  are  associated.  Given  the  existence  of  a 
large  amount  of  pus  in  the  urine,  it  may  be  difficult  to  decide  whether 
this  comes  from  the  bladder  or  the  kidney.  Pus  from  the  bladder  is  ex- 
ceedingly rare  in  children  even  when  a  vesical  calculus  is  present.  If  the 
pus  comes  from  the  opening  of  an  abscess  into  the  bladder,  ureter,  or  pelvis 
of  the  kidney,  the  local  signs  of  such  abscess  will  usually  be  present.  The 
existence  in  an  acid  urine  of  a  large  amount  of  pus,  many  epithelial  cells 
like  those  described,  with  high  fever  and  chills,  are  generally  sufficient 
to  establish  the  diagnosis  of  pyelitis. 

Prognosis. — In  cases  apparently  primary,  and  in  those  complicating 
infectious  diseases,  the  prognosis  is  good.  The  danger  is  chiefly  from 
the  nephritis  which  follows  or  complicates  the  process.  In  cases  de- 
pending upon  local  conditions,  the  prognosis  will  depend  upon  the 
nature  of  the  exciting  cause.  Here,  also,  the  principal  danger  is  from 
nephritis.  If  calculi  are  present  and  if  pyonephrosis  develops,  the 
patient  may  die  from  exhaustion  before  a  serious  degree  of  nephritis  has 
developed. 

Treatment.— In  all  cases  the  diet  should  be  fluid.  Water  should  be 
given  freely,  and  alkalies  up  to  the  point  of  neutralizing  the  excessive 
acidity  of  the  urine.  In  infants,  from  twelve  to  twenty-four  grains  of,tlie 
citrate  of  potash  are  required  daily  for  this  purjDose.  If  the  urine  is  alkaline, 
benzoic  acid  may  be  used  in  the  same  doses.  In  acute  cases,  counter-irri- 
tation over  the  kidney  by  means  of  poultices  or  dry  cups  may  be  employed. 
If  calculi  are  present  the  same  treatment  is  indicated.  Surgical  interfer- 
ence is  called  for  if  pyonephrosis  develops,  or  if  the  disease  is  evidently 
unilateral  and  the  kidney  is  becoming  disabled.  The  advisability  of 
surgical  interference  will  depend  upon  the  clearness  and  severity  of  the 
symptoms. 


630  DISEASES  OF  THE    URO-GENITAL   SYSTEM. 


RENAL   CALCULI. 

Small  renal  calculi  are  very  common  iu  infancy.  In  the  autopsy- 
room  of  the  Babies'  Hospital  we  frequently  see,  on  opening  the  kidneys 
of  young  infants,  fine  brown  granules  in  the  pelvis  and  calices,  and  oc- 
casionally a  calculus  as  large  as  a  small  pea  is  found.  They  are  usually 
composed  of  uric  acid.  Only  once  in  over  one  thousand  autopsies  of 
which  I  have  records,  was  a  stone  of  any  considerable  size  seen  iu  an  in- 
fant. In  this  case  it  was  an  inch  in  length  and  half  an  inch  wide.  It  is 
surprising  that  these  are  so  rare,  when  we  consider  how  very  frequently 
the  minute  calculi  are  met  with.  The  probable  explanation  is,  that  the 
majority  of  them  have  been  dissolved  or  washed  down  into  the  bladder 
and  passed  per  urethram  because  of  the  fluid  diet  of  the  first  two  years. 
The  granular  deposits  are  usually  lodged  in  the  pelvis  of  the  kidney,  and 
are  generally  seen  upon  both  sides.  With  the  larger  collections  there  is 
often  a  slight  catarrhal  pyelitis. 

Symptoms. — The  small  deposits  give  no  symptoms,  and  even  quite 
large  calculi  may  be  found  at  autopsy  where  no  indication  of  their  pres- 
ence had  existed  during  life,  as  in  the  case  above  mentioned.  At  other 
times  symptoms  are  produced  which  resemble  those  of  renal  calculi  in 
the  adult. 

There  may  be  tenderness  with  pressure,  pain  localized  over  the  affected 
kidney,  or  radiating  to  the  bladder,  the  perina3um,  and  even  the  opposite 
kidney,  and  there  may  be  irritation  and  retraction  of  the  testicle.  The 
urine  may  show,  especially  after  exercise,  a  trace  of  blood  ;  there  may  be 
the  added  symptoms  of  i^yelitis,  with  some  fever,  localized  tenderness, 
and  the  appearance  in  the  urine  of  pus  and  epithelial  cells  from  the  pelvis 
of  the  kidney. 

Renal  colic  is  produced  when  a  stone  of  any  considerable  size  passes 
from  the  kidney  to  the  bladder.  It  is  characterized  by  symptoms  similar 
to  those  seen  in  the  adult.  There  are  sudden  attacks  of  severe  sickening 
pain  in  the  loins,  shooting  down  the  thigh  or  to  the  testicle.  There  may 
be  vomiting  and  even  collapse.  The  urine  is  passed  frequently,  in  small 
quantities,  and  contains  blood.  The  symptoms  quickly  subside  when  the 
stone  reaches  the  bladder.  The  calculus  may  sometimes  become  impacted 
in  the  ureter  and  give  rise  to  hydronephrosis  or  pyonephrosis,  which  soon 
becomes  pyelo-nepliritis. 

Treatment  — The  treatment  of  renal  calculi  iu  children  is  to  be  con- 
ducted upon  the  same  general  principles  as  in  adults.  vSmall  calculi  may 
be  suspected,  but  a  positive  diagnosis  is  impossible  except  by  the  passage 
of  gravel  in  the  urine.  When  these  conditions  exist  the  diet  should  be 
largely  fluid,  and  alkaline  waters  freely  given.  When  the  calculi  are  large 
enough  to  give  positive  symptoms,  which  continue  to  increase  in  severity, 
a  surgical  operation  should  be  considered,  and  it  should  be  urged  in  propor- 


PERINEPHRITIS.  631 

tion  to  the  severity  of  the  symptoms  and  the  clearness  of  the  diagnosis. 
If  calculous  pyelitis  exists,  it  is  certain  sooner  or  later  to  lead  to  serious 
nephritis,  and  it  is  only  a  question  of  time  when  the  kidney  will  be  dis- 
abled. The  same  is  true  of  hydronephrosis  from  the  impaction  of  a  cal- 
culus in  the  ureter.  Aldibert  has  collected  four  cases  of  nephrectomy  in 
children  for  renal  calculi  in  which  the  kidney  was  healthy,  with  three 
recoveries  and  one  death  from  shock.  In  nine  cases  of  operation  for  cal- 
culous pyonephrosis,  there  were  six  recoveries  and  three  deaths.  This  is 
certainly  an  encouraging  showing,  and  should  lead  one  to  consider  opera- 
tion seriously  in  many  cases  for  which  formerly  nothing  was  done.  The 
earlier  the  operation  the  greater  the  chances  of  success,  because  of  the 
better  condition  of  the  other  kidney.  Although  the  continued  use  of 
water  and  the  so-called  solvents  may  relieve  some  of  the  symptoms,  it 
is  very  questionable  whether  they  do  more. 

TRAUMATIC    HYDRONEPHROSIS. 

In  addition  to  the  hydronephrosis  wdiich  results  from  congenital  mal- 
formations and  from  the  impaction  of  calculi,  a  form  is  occasionally  seen 
following  severe  injury  to  the  kidney.  The  pathology  of  hydronephrosis 
in  these  cases  is  not  well  understood.  After  the  early  symptoms  of 
traumatism  have  subsided,  there  develops  in  from  two  weeks  to  two 
mouths  a  tumour  in  the  region  of  the  kidney,  which  may  reach  a  consid- 
erable size  and  present  all  the  ordinary  characteristics  of  hydronephrosis 
arising  from  other  canses.  This  tumour  may  disappear  spontaneously, 
or  it  may  increase  in  size  and  demand  surgical  intervention  for  its  cure. 
In  seventeen  cases  which  Aldibert  has  collected  there  was  only  one  of 
spontaneous  recovery ;  aspiration  was  done  in  seven  cases,  with  six  cures 
and  one  death ;  incision  with  or  without  nephrectomy  was  practised  in 
nine  cases,  with  seven  recoveries  and  two  deaths. 

PERINEPHRITIS. 

This  consists  in  an  inflammation  in  the  cellular  tissue  surrounding  the 
kidney,  which  may  terminate  in  resolution  or  in  suppuration.  It  is  not 
of  very  uncommon  occurrence,  and  is  of  importance  chiefly  from  the  fre- 
quency with  which  it  is  confounded  with  disease  of  the  hip  or  spine. 
Perinephritis  may  be  secondary  to  suppurative  processes  in  the  kidney 
y  itself,  whether  from  calculi  or  tuberculous  deposits,  or  it  may  be  primary. 
In  children  the  latter  is  the  common  form.  Primary  perinephritis  is 
attributed  to  traumatism,  cold,  or  exposure,  or  it  may  develop  without 
assignable  cause.  It  usually  runs  an  acute  or  subacute  course  ;  very  rarely 
it  may  be  chronic. 

For  the  clinical  picture  of  this  disease  I  am  chiefly  indebted  to  a 
paper  by  Gibney,  who  published  in  1880  a  report  of  twenty-eight  cases  of 


632  DISEASES  OP  THE    URO-GENITAL  SYSTEM. 

primary  perinephritis  in  children.  I  was  at  that  time  an  interne  in  the 
Hospital  for  the  Euptured  and  Crippled,  New  York,  where  these  cases 
were  under  observation,  and  had  an  opportunity  to  see  many  of  those 
reported  in  Dr.  Gibney's  paper.* 

The  ages  of  these  patients  were  between  one  and  a  half  and  fifteen 
years,  the  majority  being  between  three  and  six  years.  The  two  sides 
and  the  two  sexes  were  about  equally  affected.  About  one  third  of  the 
cases  were  clearly  traceable  to  traumatism  ;  in  the  others  no  adequate 
exciting  cause  could  be  discovered.  The  majority  of  the  cases  were  re- 
ferred to  the  hospital  with  the  diagnosis  of  hip-joint  disease  or  caries  of 
the  spine.  Kesolution  followed  in  twelve  of  these  cases,  and  sixteen  ter- 
minated in  suppuration. 

When  abscess  forms,  it  usually  burrows  between  the  lumbar  muscles 
and  comes  to  the  surface  posteriorly  near  the  middle  of  the  ilio-costal 
space ;  it  may  burrow  forward  between  the  abdominal  muscles  and  point 
just  above  Poupart's  ligament ;  very  rarely  it  may  follow  the  psoas  muscle 
and  appear  at  the  upper  and  inner  aspect  of  the  thigh,  like  an  ordinary 
psoas  abscess ;  or  it  may  open  into  the  peritoneal  cavity. 

Symptoms, — The  onset  of  acute  perinephritis  may  be  quite  abrupt, 
with  chill,  fever,  and  localized  pain ;  or  it  may  be  gradual,  with  stiffness  of 
the  spine,  lameness  referred  to  the  hip,  and  deformity  due  to  contraction 
of  the  flexoi's  of  the  thigh.  The  pain  is  usually  felt  in  the  loin,  but  may 
be  referred  to  the  groin,  to  the  inner  side  of  the  thigh,  or  to  the  knee. 
It  is  often  severe,  and  increased  by  using  the  limb.  It  is  in  most  cases 
accompanied  by  localized  tenderness  in  the  neighbourhood  of  the  kidney. 
There  is  lameness  upon  the  affected  side  which  may  come  on  gradually, 
being  sometimes  referred  to  the  hip  and  sometimes  to  the  spine.  These 
symptoms  often  develop  slowly  in  the  course  of  two  or  three  weeks.  They 
are  usually  accompanied  by  a  slight  elevation  of  temperature.  In  the 
most  acute  cases  the  temperature  is  high  (102°  to  10-4°  F.),  and  prostration 
severe. 

As  the  disease  progresses  fever  is  a  constant  symptom,  the  temperature 
usually  varying  between  101°  and  103°  F.  There  is  in  most  cases  increas- 
ing deformity,  and  finally  the  patient  may  be  unable  to  walk  at  all.  On 
examination  at  the  height  of  the  disease  there  is  found  in  a  typical  case 
a  deviation  of  the  spine  with  Ihe  concavity  toward  the  affected  .side  ;  the 
thigh  may  be  held  flexed  to  a  right  angle ;  passive  extension  is  resisted 
and  causes  pain,  although  all  the  other  movements  at  the  hip  joint  are 
normal.  In  the  lumbar  region  there  is  tenderness,  and  there  may  be  an 
area  of  infiltration  filling  the  ilio-costal  space.  At  first  this  is  only  ap- 
preciable   by   percussion,    but   later   a   distinct    tumour   is   present.      In 

*  Chicago  Medical  Journal  and  Examiner,  1880.  where  will  be  found  a  very  full 
bibliography. 


PERINEPHRITIS.  633 

addition  to  the  tumour  in  the  usual  region,  there  is  sometimes  one  at 
the  upper  and  inner  aspect  of  the  thigh,  owing  to  a  burrowing  of  pus,  and 
the  sacs  may  communicate. 

Lameness,  pain,  deformity,  and  fever  sometimes  exist  for  two  or  three 
weeks  before  any  tumour  can  be  made  out.  The  constitutional  symp- 
toms are  often  severe,  and  symptoms  of  the  typhoid  condition  may  even 
be  present.  The  bowels  are  usually  constipated.  The  size  of  the  abscess 
is  sometimes  very  great.  In  one  case  I  have  seen  it  extend  from  the  spine 
to  the  median  line  in  front,  and  from  the  crest  of  the  ilium  nearly  to  the 
free  border  of  the  ribs.  The  amount  of  pus  varies  from  a  few  ounces  to 
two  or  three  pints.  Urinary  symptoms  are  sometimes  wanting ;  at  other 
times  there  is  increased  frequency  of  micturition,  accompanied  by  pain 
from  an  irritation  referred  to  the  bladder.  The  nrine  may  contain  pus 
from  a  complicating  pyelitis.  In  only  one  of  Gibney's  cases  was  this 
present.     It  developed  in  the  fourth  week,  and  the  case  recovered. 

The  duration  of  the  disease  in  the  acute  cases  varies  from  three  to 
eight  weeks ;  in  the  subacute  it  may  be  five  or  six  months.  When  sup- 
puration occurs  the  symptoms  subside  quite  rapidly  after  the  pus  has  been 
evacuated,  and  recovery  is  complete.  Where  resolution  takes  place,  there 
is  a  gradual  subsidence  of  the  symptoms,  and  often  some  stiffness  of  the 
thigh,  with  slight  lameness  for  several  months.  In  the  series  of  cases 
above  referred  to,  65  per  cent  recovered  completely  in  three  months. 

Diagnosis. — In  many  cases  a  diagnosis  of  hip-joint  disease  is  made,  and 
they  are  reported  as  "  hip-joint  disease  cured  without  deformity,"  etc. 
The  points  of  differential  diagnosis  are  quite  distinct,  and  if  a  careful  ex- 
amination is  made  there  is  no  excuse  for  confounding  the  two  conditions. 
Hip-joint  disease  develops  more  insidiously,  is  very  much  more  chronic, 
and  rarely  produces  so  great  deformity  in  a  year  as  is  often  seen  in  peri- 
nephritis in  two  or  three  weeks;  abscess  is  infrequent  during  the  first 
year  of  the  disease ;  on  examination,  there  is  found  limitation  of  all  the 
movements  of  the  joint,  and  not  of  extension  alone ;  atrophy  of  the  thigh 
and  joint  tenderness  are  present.  In  perinephritis,  on  the  other  hand,  we 
have  a  tolerably  acute  onset,  sometimes  with  chill,  fever,  marked  lameness, 
and  deformity,  developing  in  two  or  three  weeks ;  abscess  often  forms  in 
a  month,  and  complete  and  permanent  recovery  usually  follows  after  a 
few  months  at  most ;  the  deformity  is  due  solely  to  flexion  of  the  thigh ; 
all  other  movements  at  the  hip  may  be  free,  and  joint  tenderness  is  absent. 
Psoas  abscess  from  Pott's  disease  may  cause  deformity,  tumour,  and  lame- 
ness similar  to  that  seen  in  perinephritis,  but  on  examination  there  is 
found  the  angular  prominence  and  other  signs  of  disease  of  the  lumbar 
vertebra?. 

Prognosis. — Primary  perinephritis  in  children  almost  invariably  termi- 
nates in  complete  recovery.  Of  the  twenty-eight  cases  referred  to,  and 
eight  subsequently  observed  by  Gibney,  all  recovered  perfectly.     The  only 


634  DISEASES   OF   THE   URO-GENITAL   SYSTEM. 

condition  liable  to  prove  fatal  is  rupture  of  the  abscess  into  the  peritoneal 
cavity- 
Treatment. — The  patient  should  be  put  to  bed  and  kept  as  quiet  as 
possible  throughout  the  attack.  In  the  early  stage,  a  blister,  hot  fomen- 
tations, or  an  icebag,  should  be  applied  over  the  affected  side;  heat  is 
generally  to  be  preferred.  When  suppuration  is  inevitable  and  pain  severe, 
a  poultice  may  be  used.  Abscesses  should  be  opened  early,  to  prevent 
burrowing,  and  danger  of  a  possible  rupture  into  the  peritoneal  cavity. 

GENERAL  (EDEMA   NOT   DEPENDENT   ON   RENAL  DISEASE. 

This  is  of  not  very  infrequent  occurrence  in  infants  and  young  chil- 
dren. In  the  Babies'  Hospital,  during  the  last  seven  years,  over  fifty  cases 
have  been  observed.  Nearly  all  were  in  infants  under  six  months  of  age, 
and  the  majority  have  been  under  three  months.  This  general  dropsy 
was  invariably  associated  with  extreme  malnutrition  and  anaemia.  It 
comes  on  gradually  in  the  course  of  four  or  five  days,  often  the  first  thing 
noticed  being  that  a  wasting  child  has  unexpectedly  increased  half  a 
pound  or  a  pound  in  weight.  On  closer  inspection  there  will  be  found 
oedema  of  the  feet,  ankles,  thighs,  face,  hands,  and  sometimes  of  the 
abdominal  walls,  and  the  back.  This  may  be  quite  marked,  so  that  it 
may  be  almost  impossible  to  open  the  eyes,  and  the  extremities  may  be 
nearly  double  their  normal  size.  I  have  occasionally  seen  dropsy  in  the 
serous  cavities.  No  explanation  of  this  oedema  is  found  in  the  urine.  It 
is  not  albuminous;  it  is  frequently  very  scanty,  but  is  sometimes  appar- 
ently normal  in  amount.  Opportunities  for  the  examination  of  the  kid- 
neys have  been  afforded  in  several  instances,  and  these  organs  have  been 
in  all  cases  normal,  even  upon  microscopical  examination. 

The  cause  of  this  oedema  was  ascribed  by  Tarnier,  who  had  observed 
it  in  connection  with  premature  infants  fed  by  gavage,  to  the  giving  of 
too  much  fluid  food.  He  states  that  it  disappeared  when  the  amount  of 
food  was  reduced.  This  has  not  been  my  experience.  Many  children 
who  were  fed  by  gavage  showed  no  signs  of  it,  and  others  who  took  a 
comparatively  small  quantity  of  food  became  oedematous.  The  best  expla- 
nation seems  to  me  to  be  that  it  depends  upon  a  condition  of  hydremia, 
associated  with  feeble  resistance  in  the  walls  of  the  small  blood-vessels, 
through  which  a  transudation  of  serum  readily  takes  place.  The  degree 
of  anaemia  noted  in  these  patients  is  sometimes  extreme. 

The  prognosis  in  this  condition  is  extremely  bad,  as  it  rarely  occurs 
except  in  hopeless  cases  of  marasmus.  This  is  not,  however,  invariably 
the  case.  The  dropsy  may  disappear  to  return  again,  or  it  may  disappear 
permanently  and  the  case  go  on  to  recovery. 

If  the  urine  is  scanty,  such  diuretics  as  the  citrate  of  potash  and  the 
sweet  spirits  of  nitre  often  cause  a  diminution  and  sometimes  even  a 
disappearance  of  the  dropsy  in  a  short  time.     The  best  of  all  remedies, 


MALFORMATIONS   OP  THE   GENITAL   ORGANS.  635 

however,  is  digitalis.     To  an  infant  of  two  months,  TTi,  J^   of  the  fluid 

extract  may  be  given  every  two  hours  for  two  or  three  days ;  and  for  a 
short  period  somewhat  larger  doses  may  be  employed. 


CHAPTER   III. 

DISEASES  OF   THE   GENITAL   ORGANS. 

MALFORMATIONS. 

Adherent  Prepuce. — This  condition  is  sometimes  called  false  phimosis. 
It  is  so  constantly  present  that  it  can  hardly  be  regarded  as  a  malforma- 
tion. It  is,  however,  a  condition  needing  attention  in  every  male  infant. 
The  prepuce  should  be  forcibly  retracted  so  as  to  expose  the  glans  com- 
pletely. The  smegma  should  then  be  washed  away,  the  glans  covered 
with  a  drop  of  oil,  and  the  skin  drawn  forward.  This  should  be  repeated 
daily  until  there  is  no  disposition  to  a  recurrence  of  the  adhesions. 

Phimosis. — This  is  such  a  narrowing  of  the  prepuce  that  it  can  not  be 
retracted  over  the  glans.  The  degree  of  phimosis  varies  greatly.  In  very 
rare  cases  there  is  no  preputial  opening.  In  other  cases  the  orifice  is  so 
small  that  no  part  of  the  glans  can  be  exposed,  and  there  is  obstruction  to 
the  outflow  of  urine ;  but  usually  a  small  part  of  the  glans  can  be  seen. 
Phimosis  may  be  complicated  by  an  elongated  prepuce  (hypertrophic  phi- 
mosis), and  the  elongation  may  exist  without  any  narrowing  of  the  orifice, 
although  this  is  usually  present  to  some  degree. 

The  presence  of  phimosis  makes  cleanliness  impossible  in  many  cases, 
and  want  of  cleanliness  leads  to  infection  and  to  balanitis.  This  is  quite 
frequent  even  in  infants.  It  may  be  complicated  by  urethritis,  and  even 
by  cystitis.  Another  consequence  of  the  straining  induced  by  phimosis 
is  hernia,  which  may  be  either  inguinal  or  umbilical.  To  cure  the 
hernia  is  often  impossible,  unless  the  phimosis  is  relieved.  Straining 
also  leads  to  prolapsus  ani,  and,  from  pressure  on  the  spermatic  vessels,  to 
hydrocele.  More  important  even  than  these  mechanical  results  of  phimo- 
sis are  the  reflex  conditions  resulting  from  the  irritation.  Such  symptoms 
may  come  from  preputial  adhesions  as  well  as  from  phimosis.  The 
hyperaesthetic  condition  and  the  resulting  pruritus  cause  frequent  pria- 
pism, and  are  among  the  most  common  causes  of  masturbation.  It  may 
produce  other  nervous  symptoms,  such  as  insomnia,  night  terrors,  etc. 
Phimosis  often  causes  frequent  micturition,  dysuria,  and,  in  fact,  most  of 
the  symptoms  of  stone  in  the  bladder.  It  sometimes  leads  to  vesical 
spasm  and  retention  of  urine,  but  more  frequently  to  nocturnal  inconti- 
nence. 


636  DISEASES  OF   THE  URO-GENITAL  SYSTEM. 

The  list  of  reflex  phenomena  which  have  been  attributed  to  phimosis 
is  a  long  one,  and  includes  most  of  the  functional  nervous  diseases  of 
childhood.  There  is  abundant  evidence  that  phimosis  may  be  a  cause, 
although  a  rare  one,  of  chorea,  convulsions,  epilepsy,  hysterical  mani- 
festations, pseudo-paralysis,  spasm  of  the  muscles  about  the  hip  causing 
symptoms  resembling  the  early  stage  of  hip-joint  disease,  strabismus, 
amaurosis,  diarrhoea,  and  many  other  nervous  conditions.  There  is,  how- 
ever, no  evidence  that  cases  of  spastic  diplegia  or  paraplegia  are  ever 
caused  by  phimosis  or  improved  by  circumcision.  There  has  been  in  the 
past  a  disposition  on  the  part  of  some  writers  to  attribute  nearly  all  the 
nervous  disturbances  of  boyhood  to  phimosis,  and  an  exaggerated  im- 
portance has  certainly  been  attached  to  this  condition.  Still,  in  a  delicate, 
ansemic  child  with  unstable  nervous  centres,  phimosis  is  capable  of  giving 
rise  to  nervous  symptoms  of  a  most  serious  and  alarming  character.  It 
is  an  important  etiological  factor  in  many  neuroses,  and  one  which 
should  not  be  overlooked.  On  the  other  hand,  a  very  marked  degree  of 
phimosis  often  exists  in  robust  children  without  producing  any  symp- 
toms whatever. 

Treatment. — Every  case  of  phimosis  should  receive  attention  in  in- 
fancy. Often  very  little  treatment  is  needed ;  but  trouble  is  likely  to 
come  sooner  or  later  if  it  is  neglected.  When  there  is  a  very  long  prepuce 
with  phimosis,  the  operation  of  circumcision  should  invariably  be  done, 
even  when  the  degree  of  phimosis  is  slight.  Many  cases  of  phimosis  in 
which  the  prepuce  is  not  long  can  be  relieved  by  stretching.  If  no  part 
of  the  glans  can  be  exposed,  the  simplest  plan  is  to  slit  up  the  dorsum 
of  the  prepuce  with  a  pair  of  scissors  and  forcibly  break  up  the  adhesions. 
The  corners  of  the  flaps  thus  made  can  then  be  snipped  off  and  one  stitch 
inserted  on  either  side.  This  is  very  easily  done,  and  gives  most  ex- 
cellent results.  In  the  case  of  obscure  nervous  symptoms  in  older  boys, 
the  condition  of  the  prepuce  should  be  examined  and  the  same  rules  of 
treatment  applied.  In  all  cases  of  hernia,  hydrocele,  or  prolapsus  ani, 
when  phimosis  is  present  it  should  be  relieved  as  the  first  step  in  the 
treatment. 

Hypospadias. — In  this  condition  the  urethra  is  not  continued  to  the 
tip  of  the  penis,  but  opens  on  the  inferior  surface  some  distance  back, 
being  represented  in  front  of  this  only  by  a  shallow  furrow.  In  more 
severe  cases  there  is  a  deep  fissure  which  divides  the  scrotum,  and  some- 
times even  the  perinaeuni.  Into  this  fissure  the  urethra  opens.  This  is  a 
condition  likely  to  be  mistaken  for  that  of  hermaphrodism,  especially  as 
the  testicles  are  frequently  in  the  abdominal  cavity.  It  may  be  impossible 
to  decide  the  sex  of  the  child  until  puberty.  Surgical  operations  for  the 
relief  of  these  deformities  are  not  very  successful. 

Epispadias. — This  is  a  condition  in  which  the  urethra  opens  on  the 
dorsal  surface  of  the  penis.     It  is  much  less  frequent  than  hypospadias. 


MALFORMATIONS   OP  THE   GENITAL   ORGANS.  637 

There  may  be  simply  a  division  of  the  glans,  or  the  fissure  may  extend  tlie 
whole  length  of  the  organ  and  be  complicated  by — 

Exstrophy  of  the  Bladder. — This  deformity  is  met  with  in  all  degrees  of 
severity.  In  the  complete  form  there  is  a  median  fissure  from  the  umbili- 
cus to  the  tip  of  the  penis.  It  includes  the  anterior  abdominal  wall,  the 
pelvic  bones,  and  the  urethra.  The  bones  are  entirely  separated  at  the 
symphysis,  or  connected  behind  the  bladder  by  a  fibrous  band.  The  hypo- 
gastric region  is  occupied  by  a  red,  mucous  surface,  slightly  corrugated, 
which  is  all  there  is  of  the  bladder.  This  is  generally  surrounded  by  a 
narrow  rim  of  integument.  In  the  lower  lateral  portions  of  the  red 
mucous  membrane  two  slightly  rounded  elevations  are  seen,  from  which 
urine  oozes.  These  are  the  openings  of  the  ureters.  The  penis  is  short, 
and  presents  a  shallow  furrow  on  its  dorsal  surface.  With  this  deformity, 
also,  the  testes  are  often  in  the  abdominal  cavity. 

An  analogous  deformity  is  sometimes  seen  in  girls.  There  is  a  division 
of  the  clitoris  and  the  labia  minora  and  majora.  The  fissure  may  be  so 
deep  as  to  reach  nearly  to  the  anus.  The  vagina  is  usually  absent.  The 
rectum  may  open  into  the  prolapsed  bladder. 

All  these  deformities  are  compatible  with  long  life.  In  most  of  them 
the  individual  is  incapable  of  procreation.  In  exstrophy  of  the  bladder, 
whether  complete  or  partial,  patients  are  a  nuisance  to  themselves  and  to 
all  about  them.  It  is  almost  impossible  to  prevent  the  clothing  from 
being  soaked  with  urine,  which  gives  everything  connected  with  the  pa- 
tient a  strong  ammoniacal  odour.  The  skin  is  often  excoriated.  Opera- 
tion for  the  relief  of  these  cases  should,  I  think,  always  be  undertaken. 
Brilliant  results  have  been  obtained  even  in  some  of  the  most  severe  cases. 

Undescended  Testicle — Cryptorchidism. — In  foetal  life  the  testes  are 
situated  in  the  abdominal  cavity  below  the  kidneys.  They  usually  descend 
into  the  scrotum  during  the  ninth  month,  but  in  children  born  at  full 
term  the  testicle  may  be  in  the  inguinal  canal,  or  even  in  the  abdomen. 
The  former  condition  is  quite  a  frequent  one,  being  present,  according  to 
good  authorities,  in  fully  ten  per  cent  of  all  children.  In  the  great 
majority  of  these  the  descent  takes  place  without  difficulty  during  the 
first  weeks  of  life,  and  causes  no  symptoms.  In  others  the  condition  per- 
sists. The  testicle  may  be  found  in  the  abdominal  cavity  or  at  any  point 
in  the  canal.  If  the  latter,  it  may  be  felt  as  a  small,  hard  tumour,  slightly 
painful  upon  pressure.  Even  in  some  of  these  cases  a  natural  descent 
takes  place  about  puberty,  usually  without  symptoms.  The  testicle  occa- 
sionally makes  for  itself  a  false  passage,  and  is  found  in  the  perinajum. 
When  in  the  inguinal  canal,  descent  of  the  testicle  into  the  scrotum 
may  sometimes  be  facilitated  by  manipulation.  In  other  situations  it 
had  best  be  left  alone,  unless  it  gives  rise  to  much  pain  or  tenderness, 
as  may  happen  when  a  false  passage  has  been  made.  It  should  then  be 
removed. 


^38  DISEASES   OF  THE   URO-GENITAL  SYSTEM. 

With  the  exceptions  ah-eady  mentioned,  deformities  of  the  female  geni- 
tals belong  rather  to  gynaecology  than  to  pediatrics,  since  they  are  chiefly 
of  the  internal  organs,  and  do  not  usually  give  symptoms  before  puberty. 

DISEASES   OF   THE   MALE   GENITALS. 

Balanitis. — Balanitis,  or  inflammation  of  the  prepuce,  is  one  of  the 
results  of  phimosis.  It  may  follow  decomposition  of  the  smegma,  infec- 
tion of  the  mucous  membrane,  injury,  or  masturbation.  The  parts  are 
swollen,  cfidematous,  red,  painful,  and  sometimes  bathed  in  pus.  Eetrac- 
tion  of  the  prepuce  is  impossible.  Under  proper  treatment  the  inflamma- 
tion usually  subsides  in  two  or  three  days,  but  there  may  be  some  dis- 
charge for  a  considerable  time.  Abscess  may  follow,  and  even  gangrene 
of  the  prepuce.  The  most  severe  cases  are  likely  to  be  complicated  with 
anterior  urethritis. 

The  object  of  treatment  is  to  remove  the  irritating  and  infectious 
material  lodged  beneath  the  foreskin.  This  may  be  quite  difficult.  It  is 
best  accomplished  by  syringing  with  a  l-to-5,000  bichloride  solution. 
This  should  be  repeated  several  times  a  day,  the  prepuce  being  held  in 
contact  with  the  syringe,  so  that  it  is  distended  by  the  injection.  Where 
it  is  impossible  to  do  this,  an  antiseptic  lotion  may  be  used  and  ice  applied 
until  the  oedema  has  subsided.  It  is  sometimes  necessary  to  slit  up  the 
prepuce  before  the  parts  can  be  thoroughly  cleansed,  and  in  severe  cases 
this  is  often  the  quickest  method  of  cure.  Circumcision  should  not  be 
done  during  an  attack. 

Urethritis, — This,  like  the  same  disease  in  females,  may  be  simple  or 
specific.  Both  forms  are  less  frequent  in  little  boys  than  in  the  other  sex. 
In  simple  urethritis  the  inflammation  usually  affects  only  the  anterior  part 
of  the  canal,  the  fossa  navicularis.  There  is  a  slight  discharge  of  pus,  and 
sometimes  pain  on  micturition.  The  most  frequent  cause  is  want  of 
cleanliness. 

Gonorrhoeal  inflammation  is  more  common.  This  occurs  even  in  boys 
as  young  as  eighteen  months,  but  most  of  the  cases  are  in  those  over 
seven  years  old.  The  usual  cause  is  direct  contagion.  The  symptoms  are 
more  severe  than  in  the  simple  form,  and  resemble  the  same  disease  in 
the  adult,  with  the  exception  that  constitutional  symptoms  are  usually  ab- 
sent. A  microscopical  examination  of  the  discharge  (page  643)  is  the  only 
positive  means  of  diagnosis  between  the  two  varieties.  In  these  cases  it 
reveals  the  gonococcus  in  great  numbers.  Conjunctivitis  and  arthritis 
are  seen  as  complications,  just  as  in  the  female.  Orchitis  is  very  rare, 
but  balanitis  and  bubo  are  not  infrequent.  Poynter  has  reported  a  case 
in  a  boy  of  three  years,  who,  when  five  years  old,  required  treatment  for  a 
urethral  stricture.     He  was  infected  by  a  nurse. 

The  first  thing  in  the  treatment  is  always  to  keep  the  parts  covered, 
otherwise  the  infection  is  almost  certain  to  be  carried  by  the  hands  to 


HYDROCELE.  639 

other  raucous  membranes,  usually  the  conjunctiva.     In  other  respects  the 
treatment  is  the  same  as  in  the  adult. 

Hydrocele. — Hydrocele  consists  in  an  accumulation  of  serum  in  some 
part  of  the  serous  pouch  brought  down  by  the  testicle  in  its  descent.  In 
infants  it  is  usually  due  to  the  imperfect  closure  of  this  pouch  at  some 
point,  where  a  fluid  accumulation  occurs.  Four  varieties  of  hydrocele  are 
met  with  in  young  children  : 

1.  Congenital  hydrocele. — In  this  the  condition  is  a  congenital  one, 
although  the  tumour  is  not  necessarily  present  at  birth.  The  tunica  vagi- 
nalis communicates  with  the  general  peritoneal  cavity.  There  is  present 
an  elongated  tumour,  extending  from  the  bottom  of  the  scrotum  through- 
out the  whole  length  of  the  cord.  The  tumour  is  reducible,  sometimes 
spontaneously  by  position,  sometimes,  when  the  opening  is  smaller,  only 
by  pressure.  It  reduces  slowly,  without  gurgling,  never  going  back  en 
masse  like  a  hernia.  The  tumour  is  translucent,  and  is  flat  on  percus- 
sion. The  testicle  is  above  and  posterior,  and  usually  indistinctly  felt. 
Congenital  hydrocele  may  be  complicated  by  hernia. 

2.  Hydrocele  of  the  tunica  vaginalis  with  the  canal  closed. — In  this 
form  the  accumulation  of  fluid  is  in  the  scrotum,  communication  with  the 
peritoneal  cavity  having  been  entirely  cut  off  by  the  complete  obliteration 
of  this  pouch  in  the  canal  in  the  normal  way.  This  is  one  of  the  most 
frequent  forms.  It  gives  rise  to  an  oval  or  pear-shaped  tumour,  quite 
tense  and  firm,  usually  about  two  inches  in  length.  The  cord  is  distinctly 
felt  above  it,  the  testicle  is  behind  and  somewhat  above  it,  and  not  always 
felt  very  distinctly.  This  variety  gives  translucency  and  the  usual  elastic 
feeling  of  a  hydrocele. 

3.  Hydrocele  of  the  cord. — This  is  one  of  the  rare  forms.  The  serous 
pouch  which  accompanies  the  spermatic  cord  is  open  above,  and  com- 
municates with  the  peritoneal  cavity;  but  below  it  is  closed.  The  scrotum 
is  normal,  and  the  testicle  is  in  its  usual  position.  The  tumour  is  small, 
elongated,  and  reducible,  and  entirely  above  the  scrotum.  Usually  it  stops 
at  some  point  in  the  inguinal  canal.  This  hydrocele  also  may  be  compli- 
cated by  hernia.  The  diagnostic  points  are  the  same  as  in  the  form  first 
mentioned. 

4.  Encysted  hydrocele  of  the  cord. — The  peritoneal  pouch  of  the  cord 
in  this  variety  is  closed  for  some  distance  above,  and  again  below,  but 
somewhere  in  its  course  it  is  open,  and  here  the  fluid  accumulates  in 
the  form  of  a  cyst.  When  small  it  resembles  an  undescended  testicle ; 
but  on  examination  this  organ  is  found  below  and  in  its  normal  posi- 
tion. When  in  the  canal,  it  is  often  mistaken  for  a  lymph  gland,  some- 
times for  a  small  hernia.  The  tumour  is  usually  about  the  size  of  an 
almond.  It  is  elastic  and  irreducible,  and  gives  translucency  like  the 
other  varieties.     In  cases  of  doubt  it  may  be  punctured  by  a  hypodermic 

needle. 

42 


(540  DISEASES  OF   THE   URO-GENITAL  SYSTEM. 

Treatment  of  Hydrocele. — In  the  congenital  form  the  first  point  is  to 
cause  obliteration  of  the  canal,  so  as  to  shut  ofiE  the  hydrocele  sac  from  the 
general  peritoneal  cavity.  This  is  usually  done  by  the  use  of  a  truss,  and, 
if  applied  early,  it  may  be  accomplished  in  the  course  of  a  few  months. 
It  is  subsequently  managed  like  an  ordinary  hydrocele  of  the  tunica 
vaginalis.  In  infants  and  young  children  it  is  rare  that  active  operative 
measures  are  called  for  in  any  variety  of  hydrocele,  as  these  tend,  in  a 
great  majority  of  cases  at  least,  to  disappear  spontaneously  in  the  course 
of  a  few  months.  Absorption  is  often  facilitated  by  the  application  of 
collodion.  In  many  cases  the  internal  administration  of  iodide  of  po- 
tassium, twelve  grains  a  day,  causes  a  rapid  disappearance  of  the  effusion. 
Iodine  may  be  applied  locally  over  a  hydrocele  of  the  cord,  but  should 
not  be  applied  to  the  scrotum.  In  some  cases  which  do  not  disappear 
promptly,  simple  puncture  with  the  needle,  allowing  the  fluid  to  drain  off 
into  the  cellular  tissue  of  the  scrotum  from  which  it  is  absorbed,  is  an 
excellent  means  of  treatment.  Others  are  cured  by  a  single  aspiration 
with  hypodermic  syringe.  I  have  treated  in  the  neighbourhood  of  one 
hundred  of  these  hydroceles  in  infants  and  young  children,  and  have 
never  yet  seen  one  in  which  it  was  necessary  to  resort  to  the  injection  of 
irritants  like  iodine  or  carbolic  acid. 


DISEASES  OF  THE  FEMALE  GENITALS. 

VULVO-VAGINITIS. 

This  is  a  catarrhal  inflammation,  usually  affecting  the  mucous  mem- 
brane of  the  vulva,  vagina,  urethra,  and  often  that  of  the  cervix  uteri. 
It  may  be  simple  or  specific  (gonorrhoeal).     Neither  form  is  very  rare. 

Simple  Vulvo-vaginal  Catarrh. — This  may  be  seen  at  any  age,  even  in 
infancy.  It  is,  however,  most  frequent  after  the  second  year.  It  more 
often  occurs  in  girls  who  are  aufemic,  or  suffering  from  malnutrition, 
than  in  those  whose  general  health  is  good,  being  especially  common  in 
those  who  live  in  unhygienic  surroundings  or  where  personal  cleanliness 
is  neglected.  It  may  follow  any  of  the  infectious  diseased,  particularly 
measles.  There  seems  to  be  little  doubt  that  even  this  form  may  be 
spread  by  contagion.  It  is  common  in  children  in  institutions,  where 
small  epidemics  are  sometimes  seen.  It  may  be  communicated  by  direct 
contact,  or  by  handling  the  parts,  or  through  clothing,  diapers,  sponges, 
towels,  etc.  The  disease  may  be  traumatic,  as  from  attemj^ted  rape,*  or 
the  introduction  of  foreign  bodies.     It  may  be  secondary  to  the  presence 

*  See  "  Twenty-one  Cases  of  Rape  in  Young  Girls,"  by  Walker,  Archives  of  Paedia- 
trics, vol.  iii,  1886,  where  the  medico-legal  points  with  reference  to  this  condition  are 
fully  discussed. 


VULVO-VAGIXITIS.  641 

of  pinworms,  or  to  scabies,  and  it  is  sometimes  the  cause,  sometimes  the 
result,  of  masturbation. 

Symptoms. — The  disease  generally  begins  as  a  subacute  catarrhal  in- 
flammation, the  discharge  being  the  first  thiug  noticed.  In  the  milder 
cases  this  is  thin  and  yellowish- white,  with  some  pain  on  locomotion,  itch- 
ing, and  burning  on  micturition.  In  the  more  severe  form  it  is  abundant 
and  of  a  yellowish-green  colour,  causing  the  labia  to  adhere,  and  the  secre- 
tion, drying,  forms  crusts.  The  odour  is  sometimes  extremely  fetid,  and 
the  skin  of  the  thighs  may  be  excoriated.  The  local  examination  shows 
the  mucous  membrane  to  be  red,  swollen,  oedematous,  and  bathed  in  pus. 
All  the  visible  parts — urethra,  hymen,  vagina,  etc. — are  involved.  By 
using  an  ordinary  urethral  speculum  in  the  vagina,  pus  may  be  seen  in 
most  of  the  severe  cases  to  come  from  the  cervix  uteri  (Koplik).  There 
are  no  constitutional  symptoms.  There  may  be  swelling,  and  even  sup- 
puration, of  the  inguinal  glands.  The  disease  has  no  definite  course,  but 
usually  with  proper  treatment  lasts  from  one  to  three  weeks,  when  there 
may  be  complete  recovery,  or  there  may  persist  for  a  long  time  a  leucor- 
rhoeal  discharge.  In  children  who  are  in  poor  general  condition,  and 
where  proper  means  of  treatment  are  neglected,  vulvo-vaginitis  may  last 
for  months. 

Gonorrhoeal  Vulvo-vaginitis  (Uro-genital  Blennorrhcea). — Recent  studies 
of  the  micro-organisms  in  the  discharge  have  shown  cases  of  true  gonor- 
rhoea in  young  girls  to  be  very  much  more  numerous  than  was  formerly 
suspected.*  While  indirect  infection  is  no  doubt  possible,  and  in  certain 
cases  proved,  nearly  all  writers  agree  that  this  is  very  exceptional,  and 
that  the  most  common  origin  of  the  disease  is  direct  contact,  either  inten- 
tional or  accidental,  with  another  case  of  gonorrhoea,  sometimes  sexual 
and  sometimes  by  the  hands.  In  this  way  the  disease  may  be  conveyed 
from  one  child  to  another,  or  from  adults  to  children,  very  often  from 
parents  who  occupy  the  same  bed  with  the  child.  Pott  states  that,  in  90 
per  cent  of  his  forty-four  cases,  the  mothers  were  found  to  be  suffering 
from  leucorrhoea.  The  mode  of  contagion  may  be  difficult  to  trace,  but 
this  fact  should  cast  no  doubt  upon  the  diagnosis  in  the  case.  The  dis- 
ease occurs  in  girls  of  all  ages,  but  chiefly  between  three  and  eight  years. 
Epstein  has  reported  cases  in  the  newly-born.  The  incubation  in  three 
cases  in  which  it  could  be  definitely  traced,  was  exactly  three  days  (Cahen- 
Brach). 

Symptoms. — The  disease  is  believed  to  begin  usually  in  the  urethra, 
although  this  is  in  most  cases  difficult  to  establish,  as  there  are  generally 
found  on  the  first  examination  evidences  of  inflammation  of  all  the  mucous 


*  For  an  excellent  resume  of  this  subject,  with  references  to  recent  Hteraturc,  see 
Koplik,  Journal  of  Cutaneous  and  Genito-Urinary  Diseases,  June,  1893;  also  Heiman, 
New  York  Medical  Record,  June  22,  1895, 


642  DISEASES  OP  THE  URO-GENITAL  SYSTEM. 

membranes  of  this  region.  There  is  a  copious  secretion  of  thick,  yellow 
pus.  There  may  be  erosions  of  the  vaginal  mucous  membrane,  so  that 
the  parts  bleed  readily.  Crusts  form  on  the  labia.  When  a  view  of  the 
cervix  can  be  obtained  by  means  of  a  small  speculum,  this  is  almost  inva- 
riably seen  to  be  involved.  For  the  first  day  or  two,  in  the  most  severe 
cases,  there  may  be  slight  fever  and  general  indisposition,  but  more  fre- 
quently— and  this  is  one  of  the  most  striking  points  of  difference  from 
the  disease  as  seen  in  adults — constitutional  symptoms  are  wanting  alto- 
gether. Micturition  is  painful,  and  sometimes  frequent,  there  are  also 
excoriations  of  the  skin,  and  difficulty  in  walking,  all  these  symptoms 
being  usually  more  severe  than  in  simple  catarrh.  Tlie  duration  of  these 
cases  is  indefinite,  being  from  one  to  six  months.  Under  the  most  favour- 
able conditions  it  is  several  weeks,  largely  owing  to  the  great  difficulties 
in  the  way  of  a  thorough  application  of  local  treatment.  It  is  always 
more  obstinate  than  is  a  simple  catarrh. 

A  positive  diagnosis  between  the  simple  and  gonorrhoeal  catarrh  can  be 
made  with  certainty  only  by  a  microscopical  examination  of  the  discharge. 
The  pus  for  examination  should  be  taken  from  as  high  a  point  in  the 
tract  as  possible,  preferably  the  orifice  of  the  urethra,  in  order  to  avoid 
contamination.  In  a  simple  catarrh  the  discharge  is  made  up  of  epithelial 
and  pus  cells,  with  quite  a  variety  of  bacterial  forms — bacilli,  cocci,  and 
diplococci.  These  bacteria  are  found  in  the  epithelial  cells  and  in  the 
pus  cells,  but  they  are  generally  associated,  and  the  diplococci  are  few  in 
number.  In  cases  of  gonorrhoeal  inflammation  there  are  found  in  the 
pus  cells  large  masses  of  diplococci,  these  being  usually  the  only  bacteria 
present.  It  should  then  be  emphasized  that  the  mere  presence  of  a  few 
diplococci,  even  though  found  in  the  pus  cells,  is  not  enough  to  establish 
the  diagnosis  of  gonorrhoea,  since  there  are  varieties  of  diplococci  found 
in  the  simple  catarrh,  and  even  in  the  normal  vaginal  secretion,  which 
morphologically  closely  resemble  the  gonococcus  of  Neisser.  It  is  the 
presence  of  these  in  large  masses  in  the  pus  cells  which  is  the  character- 
istic feature  (Koplik).  According  to  the  very  careful  observations  of 
Heiman,  the  two  varieties  of  diplococci  may  be  positively  differentiated 
by  staining  by  Gram's  method.  The  gonococcus  is  decolourized,  while 
the  otlier  form  is  not. 

Nearly  all  the  complications  of  gonorrhoea  which  are  seen  in  the  adult 
have  been  observed  in  young  children,  but  the  majority  of  them  are  rare. 
The  most  frequent  one  is  conjunctivitis,  infection  being  carried  by  the 
hands  from  the  vaginal  discharge  to  the  eyes.  Gonorrhoeal  arthritis  is  not 
common,  but  may  affect  the  knee,  ankle,  wrist,  or  elbow.  The  symptoms 
of  arthritis  resemble  those  of  ordinary  rheumatism.  Cystitis  is  extremely 
rare.  Bubo  is  occasionally  seen,  and  may  be  simple  or  suppurative.  As 
already  stated,  the  disease  in  many,  probably  in  nearly  all  the  severe 
cases,  affects  the  lining  of  the  uterus.     Infection  may  extend  from  the 


HERPES  OF  THE  VULVA.  643 

nterus  to  the  tubes  and  cause  pyosalpinx,  or  even  peritonitis.  Sanger 
reports  a  case  of  pyosalpinx  from  gonorrhojal  infection  in  a  little  girl  of 
three  years,  and  Huber  a  fatal  case  of  peritonitis  of  similar  origin  in  one 
of  seven.  I  have  myself  seen  one  of  severe  pelvic  peritonitis  in  a  girl  of 
seven.  In  all  these  cases  the  diagnosis  of  the  gonorrhceal  origin  of  the 
disease  must  rest  upon  the  presence  of  gonococci  in  the  vaginal  discharge. 

Treatment  of  Vulvo-Vaginitis. — The  first  thing  is  proper  isolation,  and 
care  to  j)revent  the  spread  of  infection  by  means  of  clothing,  linen,  etc. 
In  institutions,  and  in  families  where  there  are  many  children,  the  great- 
est care  is  necessary  even  in  catarrhal  cases. 

Simple  vaginal  catarrh  requires  cleanliness,  which  is  best  secured  by 
irrigating  twice  daily  with  a  warm  saturated  solution  of  boric  acid,  or  1  to 
10,000  bichloride.  A  pad  of  sterilized  absorbent  cotton,  the  meshes  of 
which  are  filled  with  boric  acid  and  starch,  or  iodoform,  may  be  placed 
between  the  labia  in  the  most  severe  cases,  the  patients  being  kept  in  bed. 
The  skin  should  be  protected  by  ointments.  In  obstinate  cases,  irrigation 
with  astringent  solutions,  snch  as  sulphate  of  zinc  or  tannic  acid,  may  be 
used.  More  radical  means  are  rarely  required.  Attention  to  the  general 
condition  of  the  patient  must  not  be  overlooked,  and  the  health  should 
be  built  up  by  iron,  cod-liver  oil,  and  other  tonics.  Every  young  child 
should  wear  a  napkin,  to  prevent  carrying  the  disease  to  the  eyes  by  the 
hands. 

In  the  gonorrhceal  cases  nothing  is  so  efficient  as  the  irrigation  with 
the  solutions  above  referred  to.  They  should,  however,  be  employed  more 
frequently;  in  the  early  stage,  where  the  secretion  is  abundant,  as  often  as 
three  or  four  times  a  day.  In  cases  passing  to  the  chronic  stage,  a  solution 
of  nitrate  of  silver,  ten  grains  to  the  ounce,  may  be  applied  to  the  vagina 
through  a  speculum.  This  should  be  repeated  every  second  or  third  day. 
In  all  circumstances  these  cases  are  tedious,  and  require  the  closest  atten- 
tion to  detail  to  insure  the  best  results.  Eelapses  are  not  uncommon  in 
eases  which  had  apparently  recovered. 

HERPES   OF   THE   VULVA. 

This  may  occur  on  the  cutaneous  surface  onh',  or  there  may  be  a 
herpetic  condition  of  the  mucous  membrane.  The  skin  of  the  perinjeum 
may  be  involved,  and  the  disease  may  extend  quite  to  the  anus.  On  the 
skin,  the  eruption  runs  the  ordinary  course  of  herpes  elsewhere.  Vesicles 
form  and  rupture  or  dry,  forming  crusts  or  leaving  small  ulcers,  which 
heal  in  a  week  or  ten  days  if  the  parts  are  simply  protected.  On  the 
mucous  membrane  the  vesicles  are  succeeded  by  small  ulcers,  which  may 
coalesce  and  form  larger  ones,  the  appearance  resembling  the  same  con- 
dition in  the  mouth.  The  symptoms  are  itching,  burning  pain,  and  a 
slight  discharge.  The  herpetic  ulcer  may  be  confounded  with  a  mucous 
patch.     These  cases  usually  recover  promptly  if  dusted  with  some  absorb- 


644:  DISEASES  OF  THE   URO-GEXITAL  SYSTEM. 

ent  powder  like  boric  acid  and  oxide  of  zinc,  or  talcum.  In  addition, 
cleanliness  should  be  secured.  It  is  important  that  this  condition  should 
be  attended  to,  as  it  is  sometimes  followed  by  more  serious  disease. 

GANGRENOUS  VLTLVITIS  (NOMA). 

This  is  the  same  process  as  that  seen  in  the  mouth  and  known  as 
cancrum  oris.  It  usually  follows  one  of  the  infectious  diseases,  most  fre- 
quently measles,  occurring  in  patients  whose  general  vitality  has  been 
greatly  reduced.  The  condition  may  succeed  a  simple  catarrh  or  a  her- 
petic vaginitis.  There  is  first  noticed  a  tense,  brawny  induration,  the 
skin  being  shiny  and  swollen  over  a  circumscribed  area.  In  the  centre  of 
this  there  soon  appears,  usually  upon  one  of  the  labia  majora,  a  dark,  cir- 
cumscribed spot.  Day  by  day  the  gangrenous  area  advances,  preceded  by 
the  induration.  It  may  involve  the  whole  labium,  extending  even  to  the 
mons  veneris  and  the  perin^eum.  These  cases  are  generally  fatal.  If  re- 
covery takes  place,  it  is  with  considerable  deformity  of  the  parts  in  conse- 
quence of  the  extensive  sloughing  and  cicatrization.  As  sequelae,  there 
may  be  fistulee,  stenosis,  or  atresia  of  the  vagina.  The  prognosis  is  very 
bad.  The  only  radical  treatment  is  early  excision  of  the  gangrenous  part, 
and  the  application  of  the  actual  cautery  or  nitric  acid. 


CHAPTER  IV. 

ENURESIS. 

Synonyms  :  Incontinence  of  urine  ;  bed-wetting'. 

Enuresis  may  be  due  to  some  malformation  of  the  genital  tract,  such 
as  an  abnormal  opening  of  the  bladder  into  the  vagina,  to  extroversion  of 
the  bladder,  or  to  the  persistence  of  the  urachus ;  in  the  latter  case  the 
urine  is  discharged  from  the  umbilicus.  It  also  occurs  in  organic  dis- 
eases of  the  central  nervous  system,  such  as  idiocy,  cerebral  palsy,  acute 
meningitis,  tumours  of  the  brain,  certain  forms  of  myelitis,  and  in  in- 
juries of  the  cord.  In  many  of  these  conditions  there  is  associated  in- 
continence of  fasces.  Both  of  the  groups  of  cases  mentioned  are  quite 
distinct  from  the  ordinary  form  of  incontinence  of  urine  which  is  seen  in 
childhood.  The  latter  is  to  be  regarded  as  a  neurosis,  and  is  the  only 
variety  which  will  be  considered  here. 

In  early  infancy,  evacuation  of  the  bladder  is  purely  a  reflex  act.  An 
impulse  is  sent  from  the  nerves  of  the  bladder  to  the  spinal  centre,  and  a 
reflex  impulse  from  this  centre  produces  simultaneously  a  contraction  of 
the  detrusor  urinae  and  a  suspension  of  the  contraction  of  the  vesical 


ENURESIS.  645 

sphincter.  It  is  often  possible  to  teach  infants  to  control  the  evacuation 
of  the  bladder  before  the  end  of  the  first  year ;  usually,  however,  control 
is  not  acquired  even  during  waking  hours  until  some  time  during  the  sec- 
ond year,  and  in  some  healthy  infants  not  before  the  end  of  the  second 
year.  The  time  depends  very  much  upon  the  training.  If  a  child  during 
its  third  year  can  not  control  the  evacuation  of  the  bladder  during  its 
waking  hours,  incontinence  may  be  said  to  exist. 

Etiology. — Incontinence  of  urine  may  be  due  to  a  continuance  of  the 
infantile  condition,  to  anything  which  increases  the  irritability  of  the 
spinal  centre,  or  which  interferes  with  the  cerebral  control  over  this 
centre,  or  to  anything  which  increases  the  irritability  of  the  terminal  fila- 
ments of  the  vesical  nerves  or  of  those  in  the  neighbourhood,  in  conse- 
quence of  which  too  many  or  too  strong  impulses  are  sent  to  the  spinal 
centre.  The  causes  of  incontinence  thus  may  be  in  the  central  nervous 
system,  in  the  urine,  in  the  bladder,  or  in  any  of  the  adjacent  organs. 

The  causes  relating  to  the  central  nervous  system  are  in  the  main 
those  of  the  other  neuroses  of  childhood  ;  these  are  aneemia,  malnutrition, 
an  inherited  nervous  constitution,  or  a  condition  of  extreme  nervousness 
or  neurasthenia,  the  result  of  the  child's  surroundings.  In  such  cases 
incontinence  is  often  associated  with  chorea,  epilepsy,  hysteria,  headaches, 
neuralgia,  and  other  nervous  symptoms.  In  these  conditions  there  may 
be  not  only  an  increased  irritability  of  the  nerve  centres,  but  also  of  the 
peripheral  nerves,  accompanied  by  loss  of  tone  of  the  vesical  sphincter. 
A  similar  condition  may  exist  with  almost  any  form  of  acute  illness, 
usually,  however,  being  only  temporary. 

The  causes  referable  to  the  urine  are  chiefly  a  highly-acid  urine,  gen- 
erally associated  with  lithuria.  In  such  cases  the  incontinence  is  very 
often  due  more  to  the  constitutional  than  the  local  condition. 

In  the  bladder  itself,  cystitis  and  vesical  calculus,  although  infrequent, 
should  not  be  overlooked  as  possible  causes.  In  a  few  cases,  where  incon- 
tinence has  existed  a  long  time,  the  bladder  becomes  so  contracted  that  it 
will  hold  only  an  ounce  or  two  of  urine.  This  condition,  although  not 
the  primary  cause  of  enuresis,  may  be  enough  to  continue  it. 

Local  irritation  in  the  neighbouring  organs  may  be  due  to  adherent 
prepuce,  balanitis,  phimosis,  or  to  a  narrow  meatus.  All  of  these  condi- 
tions are  frequently  associated  with  incontinence.  Rectal  irritation  may 
be  caused  by  pin  worms,  anal  fissure,  or  rectal  polypus;  and  vaginal  irrita- 
tion by  vulvo- vaginitis  or  adherent  clitoris,  both,  however,  being  extremely 
rare.  Often  we  have  incontinence  as  the  result  of  a  combinatioa  of  sev- 
eral causes,  no  one  of  which  alone  would  have  been  sufficient  to  produce 
it.  Thus,  in  a  healthy  child  phimosis  may  give  rise  to  no  symptoms,  while 
in  one  who  is  anaemic  or  neurasthenic  it  may  produce  enough  local  irri- 
tation to  cause  incontinence.  In  many  cases  heredity  seems  to  be  a 
factor  of  some  importance,  parents  often  having  suffered  in  their  child- 


64:6  DISEASES   OF  THE   URO-GENITAL  SYSTEM. 

hood  from  the  same  disease  ;  quite  frequently  there  are  seen  two  and 
sometimes  even  three  children  in  the  same  family  affected.  In  many 
cases  the  condition  seems  to  be  mainly  the  result  of  habit,  and  in  all  cases 
habit  is  a  potent  factor  in  continuing  the  incontinence,  sometimes  after 
the  original  exciting  cause  has  been  removed.  Frequently  no  adequate 
cause  can  be  found.  Both  sexes  are  about  equally  liable  to  enuresis,  and 
it  may  be  seen  in  all  ages  up  to  puberty.  ^  ' 

Symptoms. — Enuresis  may  be  nocturnal  or  diurnal,  or  both.  Of  194 
cases,  73  were  nocturnal,  9  diurnal,  and  102  were  both  nocturnal  and 
diurnal.  Cases  differ  greatly  in  severity.  Incontinence  may  be  habitual, 
occurring  every  night,  often  several  times  during  the  night,  and  frequently 
during  the  day ;  or  it  may  be  only  occasional  under  tlie  influence  of  some 
special  exciting  cause,  where  it  continues  a  few  days  or  weeks  until  the 
cause  is  removed.  In  a  considerable  number  of  cases,  the  condition  lasts 
from  infancy  until  the  sixtli  or  seventh  year.  It  may  even  continue  until 
puberty;  but  it  generally  ceases  at  that  period, unless  its  cause  is  mechan- 
ical, or  depends  upon  some  organic  disease  of  the  brain  or  cord.  In  ordi- 
nary enuresis  there  is  never  dribbling  of  the  urine,  but  usually  a  contrac- 
tion of  the  walls  of  the  bladder  follows  almost  immediately  upon  the  desire, 
before  the  patient  can  make  his  wants  known  or  reach  a  convenient  place 
for  micturition.  At  night  the  same  thing  may  occur  without  wakening 
the  child,  the  contraction  being  of  purely  reflex  origin. 

Prognosis. — The  condition  is  usually  hopeless  when  it  depends  upon 
organic  disease  of  the  brain  and  cord ;  also  in  cases  due  to  malformation, 
unless  these  are  amenable  to  surgical  treatment.  In  the  ordinary  cases 
seen,  the  prognosis  depends  upon  the  age  of  the  child,  the  duration  of  the 
symptom,  and  the  nature  of  the  exciting  cause.  As  a  rule,  it  is  better  in 
children  only  four  or  five  years  old  than  in  those  of  eight  or  nine,  for  the 
obvious  reason  that  a  case  which  has  lasted  to  the  latter  age  is  usually  an 
intractable  one.  If  a  cause  c^n  be  discovered  and  if  this  is  one  that  can 
be  removed,  the  prognosis  is  much  better  than  if  no  cause  can  be  found. 
In  the  great  majority  of  the  cases  a  cure  is  possible,  provided  the  patient 
can  be  held  long  enough  to  a  regular  plan  of  treatment.  The  treatment 
must  in  most  cases  be  continued  from  three  months  to  a  year,  and  always 
for  several  months  after  the  incontinence  has  ceased,  on  account  of  the 
strong  tendency  to  relapses. 

Treatment. — The  first  indication  is  to  remove  the  cause,  where  one  can 
be  found.  If  there  are  preputial  adhesions,  they  should  be  broken  up 
and  irritating  smegma  removed.  If  phimosis  is  present,  it  should  be  re- 
lieved by  stretching  or  circumcision.  A  narrow  meatus  should  be  cut  to 
proper  dimensions.  If  stone  in  the  bladder  is  suspected,  as  it  should  be 
when  the  incontinence  is  worse  by  day  and  accompanied  by  straining  and 
painful  spasm  of  the  bladder,  the  patient  should  be  sounded  for  stone. 
Pinworms  in  the  rectum   should  receive  the  appropriate  treatment  by 


ENURESIS.  647 

injections.  A  urine  of  high  acidity,  with  deposits  of  uric  acid,  calls  for 
alkalies  and  the  free  use  of  fluids,  especially  water.  While  the  local  con- 
ditions mentioned  should  always  be  attended  to,  the  fact  remains  that  few 
cases  are  cured  simply  by  relieving  them,  except  those  due  to  vesical  cal- 
culi. The  explanation  of  this  is  that  habit  is  so  important  a  factor  in 
keeping  up  incontinence  where  it  has  existed  a  long  time.  In  most  cases, 
therefore,  we  must  depend  upon  general  measures  and  drugs  directed 
toward  the  relief  of  the  symptom,  either  in  conjunction  with  local  treat- 
ment or  alone. 

Care  should  be  taken  to  secure  for  the  child  a  simple,  natural  life, 
preferably  in  the  country.  There  should  be  no  overtaxing  of  the  nervous 
system  at  home  or  in  school.  Every  cause  of  unnatural  excitement  should 
be  avoided.  Early  hours  and  plenty  of  sleep  must  be  insisted  upon. 
Certain  articles  of  diet  are  to  be  avoided,  and  coffee,  tea,  and  beer 
should  be  absolutely  prohibited.  Sweets  and  all  highly  seasoned  food 
should  be  very  sparingly  allowed,  or  not  at  all.  Although  it  is  believed 
by  many  that  a  diet  into  which  meat  enters  largely  is  injurious,  from  per- 
sonal experience  I  have  not  found  the  exclusion  of  meat  to  be  of  any  ad- 
vantage; nor  is  anything  to  be  gained  by  limiting  the  amount  of  water 
which  the  child  takes,  except  possibly  in  cases  of  nocturnal  incontinence, 
where  it  is  well  to  restrict  the  quantity  taken  late  in  the  afternoon.  When 
incontinence  is  associated  with  highly-acid  urine,  it  is  often  aggravated 
by  cutting  down  the  fluids.  The  diet  which  succeeds  best  is  a  simple  one 
composed  of  milk,  vegetables,  fruits,  meats,  and  cereals.  Punishments, 
whether  corporal  or  otherwise,  do  no  good,  and  are  in  most  cases  abso- 
lutely harmful.  They  should  never  be  allowed.  Eewards  are  much  more 
etfectual.  The  moral  treatment  of  a  case  is  important ;  it  is  well  to 
work  upon  a  child's  pride,  and  use  every  means  to  strengtlien  his  will. 
Where  the  incontinence  is  solely  or  chiefly  at  night,  the  child  should  be 
taught  to  hold  his  water  as  long  as  possible,  during  the  day,  in  order  to 
accustom  the  bladder  to  full  distention. 

Measures  which  are  directed  toward  the  patient's  general  condition 
are  quite  as  important  as  those  employed  for  the  control  of  the  inconti- 
nence. Anaemia,  chlorosis,  malnutrition,  indigestion,  and  constipation 
should  each  receive  careful  attention.  Any  local  condition,  such  as  ade- 
noid growths  of  the  pharynx,  which  might  serve  to  increase  the  general 
nervous  irritability,  should  be  removed. 

Of  the  drugs  used  for  the  purpose  of  affecting  the  incontinence,  bella- 
donna stands  at  the  head  of  the  list;  but  it  must  be  given  in  full  doses, 
usually  sufficient  to  produce  the  physiological  effects,  and  continued  for  a 
long  time,  in  most  cases  for  many  months.  Either  the  fluid  extract  or 
the  alkaloid,  atropine,  should  be  employed.  My  preference  is  for  the 
latter,  because  of  its  more  uniform  strength.  A  convenient  method  of 
administration  is  to  use  a  solution  of  atropine,  one  grain  to  two  ounces  of 


648  DISEASES   OF   THE   URO-GENITAL  SYSTEM. 

water,  of  which  one  drop  (yo^^  of  a  graiu)  may  be  given  for  each  year  of 
the  child's  age.  For  nocturnal  incontinence  this  dose  should  at  first  be 
given  at  4  and  10  p.  m.  ;  after  a  few  days,  at  4,  7,  and  10  p.  m.  Usually 
this  may  be  gradually  increased  until  double  the  quantity  is  given.  A 
child  of  five  years  would  then  be  taking  ten  drops  (y^-g-  of  a  graiu)  at  each 
of  the  hours  mentioned.  I  have  rarely  found  it  advisable  to  go  above 
these  doses.  As  the  larger  doses  are  reached  the  increase  should  be  more 
gradual.  When  the  condition  is  under  control,  or  when  the  full  physio- 
logical effects  of  the  drug  are  produced,  the  same  dose  should  be  con- 
tinued for  some  time  and  then  reduced,  the  atropine  being  given  for  at 
least  two  months  in  gradually  diminishing  doses  after  the  incontinence 
has  ceased.  This  is  very  important  if  the  cure  is  to  be  permanent,  as 
there  is  so  strong  a  tendency  in  these  cases  to  relapse.* 

Strychnine  may  be  added  in  cases  not  yielding  to  the  atropine  alone. 
It  is  particularly  advantageous  when  there  is  diurnal  as  well  as  nocturnal 
incontinence,  for  under  these  conditions  there  is  usually  a  lack  of  tone  in 
the  sphincter,  as  well  as  increased  irritability  in  the  mucous  membrane  of 
the  bladder.  The  initial  dose  for  a  child  of  five  years  should  be  ^-J-g-  of  a 
grain  twice  daily  ;  this  may  be  gradually  increased  to  -gig-  of  a  grain  three 
times  a  day  ;  but  there  is  rarely  any  advantage  in  pushing  it  further. 
Ergot  is  sometimes  useful,  but  rarely  gives  relief  when  both  strychnine 
and  atropine  have  failed.  The  indications  for  its  administration  are  the 
same  as  for  strychnine,  but  it  is  objectionable  for  prolonged  use  on 
account  of  the  disturbance  of  the  stomach.  Rhus  aromatica,  although 
inferior  to  the  drugs  already  mentioned,  possesses  a  certain  amount  of 
value,  and  may  be  tried  in  case  the  others  fail.  From  three  to  twenty 
drops  of  the  fluid  extract  should  be  given  three  times  a  day.  Like  strych- 
nine, it  is  indicated  in  atonic  cases.  Of  the  other  measures  recommended, 
raising  the  foot  of  the  bed  at  night  to  keep  the  urine  away  from  the  neck 
of  the  bladder,  may  give  temporary  relief,  as  may  also  some  of  the  various 
contrivances  for  preventing  the  child  from  sleeping  upon  the  back ;  but 

*  As  an  illustration  of  the  success  which  may  be  obtained  by  this  plan  of  treatment 
when  faithfully  carried  out,  our  experience  in  the  New  York  Infant  Asylum  may  be 
cited.  Twelve  obstinate  cases,  in  none  of  which  could  any  local  cause  be  found,  were 
selected  and  treated  by  Dr.  Kerley,  then  resident  physician,  in  the  manner  indicated. 
After  five  months'  treatment,  seven  of  the  cases  were  so  much  improved  that  inconti- 
nence rarely  occurred.  The  atropine  was,  however,  continued  in  smaller  doses  for  four 
months  longer,  at  the  end  of  which  time  the  cases  were  well.  In  the  remaining  five 
cases  but  little  improvement  was  seen  after  five  months'  treatment,  and  not  until  the 
end  of  ten  months  could  it  be  said  that  much  improvement  had  occurred.  In  these 
cases  the  drug  was  continued  for  two  months  longer  and  all  treatment  discontinued,  as 
the  cases  were  cured.  None  of  these  had  relapsed  six  months  afterward.  It  was  here 
of  great  advantage  that  the  children  were  under  close  observation  in  an  institution 
where  the  treatment  could  be  continued.  In  dispensary  and  private  practice  the  want 
of  earlv  success  would  no  doubt  have  deterred  mothers  from  continuing  the  medicine. 


VESICAL  SPASM.  649 

none  of  these  are  in  any  sense  curative.  Some  obstinate  cases  have  been 
relieved  by  galvanism,  the  positive  pole  being  placed  over  the  lumbar 
spine  and  the  negative  pole  over  the  bladder.  If  there  is  reason  to  sus- 
pect a  contracted  bladder,  as  when  the  incontinence  has  lasted  for  years 
and  the  bladder  will  never  hold  more  than  an  ounce  or  two  of  urine,  cure 
is  sometimes  accomj)lished  by  daily  distending  the  organ  u^^  to  its  normal 
capacity  with  warm  water. 

VESICAL   SPASM. 

This  is  quite  a  common  condition,  and  often  passes  under  the  name  of 
genital  irritation.  It  is  characterized  by  frequent,  sometimes  by  difficult 
and  painful,  micturition.  It  occurs  in  children  of  all  ages,  even  in  infants, 
but  is  especially  frequent  between  the  ages  of  two  and  five  years.  This 
symptom  has  already  been  referred  to  in  connection  with  uric-acid  infarc- 
tions in  very  young  infants. 

The  usual  cause  is  the  irritation  of  the  bladder  by  a  concentrated, 
highly-acid  urine.  It  often  results  from  cold  ;  it  may  accompany  acute 
febrile  processes,  and  is  sometimes  merely  a  symptom  of  nervous  irrita- 
bility. The  cause  may  thus  be  in  the  bladder  or  in  the  urine.  It  may  be 
accompanied  by  enuresis,  but  usually  occurs  without  it.  It  is  sometimes 
symptomatic  of  disease  in  adjacent  parts,  as  in  the  rectum  or  the  pelvic 
peritonaeum,  or  it  may  be  associated  with  inflammation  of  the  vulva  or 
urethra.     It  is  also  one  of  the  symptoms  of  vesical  calculus. 

The  stjmptoms  of  vesical  spasui  are  local  only.  The  child  passes  water 
very  frequently,  often  several  times  an  hour.  The  accompanying  pain 
may  be  intense,  not  infrequently  sufficient  to  cause  the  child  to  cry  out. 
Often  there  are  pain  and  severe  vesical  tenesmus  with  the  passage  of  only 
a  few  drops  of  urine  at  a  time,  but  blood  is  not  present.  If  the  condition 
depends  upon  the  character  of  the  urine,  or  is  only  an  expression  of  an 
extreme  vesical  irritability,  the  symptoms  are  generally  of  short  duration, 
possibly  a  day  or  two.  If  it  depends  upon  vesical  calculus,  it  may  be 
intermittent.  If  it  is  associated  with  disease  of  the  adjacent  pelvic  viscera, 
it  is  inconstant,  and  may  continue  for  a  considerable  period,  depending 
upon  the  nature  of  the  cause. 

The  treatment.,  in  the  ordinary  cases,  consists  in  the  administration  of 
an  abundance  of  water,  with  alkaline  diuretics,  and  either  belladonna  or 
hyoscyamus.  The  following  formula  is  one  that  I  have  usually  found 
efficient : 

5     Tincturfp  hyoscyami 3  ss. 

Potassii  citratis 3  j 

Aquae  destillat §  i] 

M.     Sig. :  Half  a  teaspoonfiil  in  water  every  hour  to  a  child  of  two  years. 

If  the  cause  is  outside  the  bladder,  it  should  receive  appropriate 
treatment. 


650  DISEASES  OP  THE  URO-GENITAL  SYSTEM. 

VESICAL  CALCULI. 

The  nucleus  of  a  vesical  calculus  is  usually  a  renal  calculus  which  has 
passed  the  ureter,  but  has  been  prevented  by  its  size  from  going  farther. 
Stone  in  the  bladder  is  extremely  rare  in  infancy,  probably  owing  to  the 
fluid  diet,  but  it  is  not  infrequent  in  children  from  two  to  ten  years  of 
age.  The  most  common  variety  of  calculus  at  this  time  is  the  uric  acid. 
The  other  forms,  although  occasionally  seen,  are  all  quite  rare. 

The  symptoms  in  children  are  somewhat  different  from  those  in 
adults,  and  the  condition  is  often  overlooked.  There  is  frequently  pain 
upon  micturition,  especially  at  the  end  of  the  act,  which  may  be  felt  at 
the  end  of  the  penis  or  in  the  perinfeum.  There  may  be  a  sudden  stop- 
page in  the  flow  of  urine.  The  straining  often  leads  to  rectal  tenesmus 
and  even  to  prolapse.  This  complication  is  so  frequent  that,  in  a  case  of 
persistent  prolapse,  stone  should  always  be  suspected.  Incontinence  of 
urine  is  a  prominent,  and  often  the  principal,  symptom  ;  in  many  cases  it 
is  noticed  only  during  the  day.  The  urinary  changes  are  not  generally 
marked  ;  haematuria  is  rare,  and  mucus  and  pus  are  infrequent  and  in 
small  quantity.  The  genital  irritation  may  lead  to  the  habit  of  masturba- 
tion. A  stone  of  any  considerable  size  may  often  be  felt  by  a  bimanual 
examination,  one  finger  being  placed  in  the  rectum  and  the  other  hand 
above  the  pubes.  'J'his  is  easier  in  males  than  in  females,  but  it  is  not 
very  trustworthy,  and  not  conclusive  when  it  gives  a  negative  result.  A 
positive  diagnosis  is  made  only  by  exploring  the  bladder  with  a  sound. 

The  treatment  of  calculus  is  purely  surgical.  In  young  children  the 
suprapubic  is  now  generally  preferred  by  surgeons  to  the  perineal  opera- 
tion, if  the  calculus  is  too  small  to  be  easily  removed  by  crushing. 


SECTION   VII. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 

CHAPTER   I. 

INTRODUCTORY. 

The  Weight  of  the  Brain. — From  ninety-eight  observations  made  in 
the  post-mortem  room  of  the  New  York  Infant  Asylum,  the  following 
were  the  average  weights  noted  : 

At  three  months 21    oz.  (602  grammes). 

At  six  months 25^   "   (712         "       ). 

At  twelve  months 32^   "   (916         "        ). 

At  two  years 35      "   (990         "        ). 

The  following  are  the  figures  given  bv  Bovd  and  Schiifer:* 


Age. 


At  birth  (full  term) 

Under  three  months 

From  three  to  six  months  .... 
From  six  to  twelve  months  . . . 

From  one  to  two  years 

From  two  to  four  years 

From  four  to  seven  years 

From  seven  to  fourteen  years  . 
From  fourteen  to  twenty  years 


Males. 


Ounces. 

IH 

17^- 

21 

27 

38 

39 

40 

46 

48i 


Grammes. 

330 

493 

603 

776 

941 
1.095 
1,138 
1.301 
1.374 


Females. 


Ounces. 
10 
16 
20 
26 
30 
35 
40 
40^^ 
44' 


Grammes. 

283 

451 

560 

727 

843 

990 
1.135 
1,154 
1,244 


At  birth  the  weight  of  the  brain  to  that  of  the  body  is  nearly  1  :  8. 
During  infancy  and  childhood  the  following  is  the  ratio,  according  to 
Bischoff:  during  the  first  year,  1:6;  the  second  year,  1:14;  the  third 
year,  1:18;  at  the  fourteenth  year,  1 :  15  to  1 :  25  ;  in  adults,  1 :  43. 

The  Spinal  Cord. — The  weight  of  the  cord  to  the  weight  of  the  body 
at  birth  is  1 :  500  ;  in  adult  life  it  is  1 :  1500,  According  to  Kolliker,  the 
spinal  cord  and  the  vertebral  column  are  the  same  length  until  the  end  of 
the  third  month  of  foetal  life,  there  being  at  this  time  no  cauda  equina. 
At  the  ninth  month  the  lower  end  of  the  cord  is  opposite  the  third  lum- 
bar vertebra;  in  the  adult  it  is  opposite  the  first. 


*  Quoted  by  Sachs. 
651 


652  DISEASES  OP  THE  NERVOUS  SYSTEM. 

Some  Peculiarities  in  the  Diseases  of  the  Nervous  System  in  Infancy 
and  Childhood.* — The  relatively  hirge  size,  the  rapid  growtli,  and  the  im- 
maturity of  the  brain  and  cord  during  early  life,  explain  much  that  is 
peculiar  in  the  nervous  diseases  of  this  period. 

At  this  time,  apparently  trivial  causes  are  enough  to  produce  quite  pro- 
found nervous  impressions,  because  of  the  instability  of  the  nervous  centres 
and  the  greater  irritability  of  the  motor,  sensor}-,  and  vaso-motor  nerves. 
These  are  conditions  which  are  very  much  increased  by  all  disturbances  of 
nutrition.  These  disturbances  may  be  manifold  in  character,  but  they  lie 
at  the  root  of  very  many  of  the  neuroses  of  early  life, — e.  g.,  extreme  nervous- 
ness, disorders  of  sleep,  stuttering,  chorea,  incontinence  of  urine,  tetany, 
and  convulsions.  The  great  liability  to  convulsions  depends  not  only 
upon  the  greater  irritability  of  the  peripheral  nerves,  but  on  the  instability 
of  the  nervous  centres  and  the  lack  of  inhibition  over  the  motor  ganglion 
cells  of  the  spinal  cord.  The  nervous  centres  are  more  easily  exhausted 
than  later  in  life.  Prolonged  or  continuous  overstrain  from  any  cause 
whatsoever,  frequently  leads  to  headache  and  chorea,  and  sometimes  even 
to  epilepsy  and  insanity. 

Another  peculiarity  is  the  serious  consequences  which  often  follow 
reflex  irritation,  although  this  is  rarely  the  only  factor  in  the  case. 
Conditions  which  in  adult  life  produce  almost  no  effect  may  in  infancy 
be  the  cause  of  most  alarming  symptoms.  As  a  few  examples  may  be 
cited,  reflex  symptoms  due  to  phimosis,  to  intestinal  worms,  convulsions 
from  disturbances  of  digestion,  nervous  symptoms  due  to  eye-strain,  or  to 
adenoid  growths  of  the  pharynx.  In  the  production  of  some  of  these, 
especially  attacks  of  convulsions,  there  are  several  factors,  such  as  the 
great  irritability  of  the  peripheral  nerves,  the  instability  of  the  nervous 
centres — often  a  result  of  disturbed  nutrition,  as  in  rickets — and  the  lack 
of  inhibitory  action  of  the  cortex  of  the  brain. 

As  a  third  point  of  importance  may  be  mentioned  the  grave  permanent 
results  which  often  follow  relatively  small  organic  lesions.  A  good  illus- 
tration is  seen  in  the  lesions  which  produce  cerebral  birth-palsy.  Here 
the  damage  is  only  in  small  part  the  immediate  effect  of  the  haemorrhage, 
for  this  often  is  not  great,  but  it  is  the  interference  with  the  development 
of  certain  parts  of  the  cortex  that  makes  this  condition  so  serious. 

From  what  has  been  said,  it  follows  that  the  hygiene  of  the  nervous 
system  is  of  the  utmost  importance  in  infancy  and  childhood.  It  is 
essential  for  the  healthy  development  of  the  nervous  system  that  all 
stimulants  should  be  avoided, — not  only  tea,  coffee,  and  alcohol,  but 
undue  and  unnatural  excitement,  the  effect  of  which  in  infancy  is  almost 
as  serious.     A  normal  development  can  take  place  only  in  the  midst  of 

*  See  Rachford  ;  Some  Physiological  Factors  in  the  Neuroses  of  Childhood.  Cin- 
cinnati, 1895. 


CONVULSIONS.  653 

quiet  and  peaceful  surroundings,  with  plenty  of  time  for  rest  and  sleep. 
The  conditions  of  modern  life,  especially  in  cities,  are  such  that  these 
laws  are  almost  invariably  violated,  and  the  consequences  of  this  are  seen 
in  the  marked  and  steady  increase  in  nervous  diseases  among  children. 


CHAPTER   II. 

GENERAL  AND  FUNCTIONAL  NERVOUS  DISEASES. 
CONVULSIONS— ECLAMPSIA. 

UxDER  this  head  are  included  attacks  of  acute  transient  nervous  dis- 
turbance, characterized  by  involuntary  rhythmical  spasm  of  the  muscles, 
either  of  the  face,  trunk,  or  extremities,  or  all  of  them,  usually  accom- 
panied by  loss  of  consciousness.  They  may  be  regarded  as  "  motor  dis- 
charges "  from  the  cortex  of  the  brain. 

Etiology. — The  principal  predisposing  causes  are  infancy,  conditions 
affecting  the  nutrition  of  tiie  brain,  and  hereditary  influences.  Of  all  these 
factors,  the  most  important  one  is  the  instability  of  the  nerve  centres  which 
is  characteristic  of  infancy  and  is  associated  with  the  non-development  of 
the  voluntary  centi'cs  of  the  cortex.  The  brain  grows  more  during  the 
first  year  than  in  all  later  life,  and  this  rapidity  of  growth  is  in  itself  an 
important  predisposing  cause  of  functional  derangement.  After  infancy, 
attacks  of  convulsions  are  much  less  frequent,  and  after  seven  years  they 
are  relatively  rare.  While  convulsions  occasionally  occur  in  children  pre- 
viously healthy,  the  majority  of  attacks  are  in  those  in  whom  there  is  at 
least  some  disturbance  of  the  nutrition  of  the  brain, — the  cerebral  insta- 
bility of  infancy  being  greatly  exaggerated  by  such  nutritive  disorders.  The 
most  frequent  one  is  rickets,  which  may  be  regarded  as  altogether  the  most 
important  predisposing  cause  of  infantile  convulsions.  They  are  often 
one  of  the  eai'liest  symptoms  of  that  disease,  and  where  convulsions  occur 
in  infancy  without  evident  cause,  rickets  should  always  be  looked  for. 
Any  disturbance  of  nutrition  may  predispose  to  convulsions,  such  as  ex- 
haustion, anasmia,  malnutrition,  syphilis,  and  debility  resulting  from  any 
acute  disease,  especially  those  of  the  digestive  tract.  Children  who  in- 
herit from  their  parents  a  peculiarly  nervous  temperament  are  more  liable 
to  convulsions  than  are  others.  This  predisposition  is  often  seen  in  sev- 
eral members  of  the  same  family.  Females  are  rather  more  frequently 
affected  than  males. 

The  exciting  causes  include  a  wide  variety  of  pathological  conditions, 
among  which  disturbances  of  digestion  take  the  first  place.  Where  the 
susceptibility  is  very  great,  the  exciting  cause  may  be  a  trivial  one.    These 


654  DISEASES  OP  THE   NERVOUS  SYSTEM. 

causes  may  be  grouped  under  three  general  heads:  (1)  direct  irritation  of 
the  cortex  of  the  brain ;  (2)  reflex  irritation ;  (3)  toxic  influences. 

Under  the  head  of  direct  irritation  may  be  included  all  convulsions 
occurring  with  the  various  forms  of  cerebral  disease ;  the  most  frequent  are 
meningitis,  meningeal  or  cerebral  haemorrhage,  tumour,  abscess,  hydro- 
cephalus, embolism,  and  thrombosis.  As  examples  of  reflex  irritation 
may  be  classed  the  convulsions  following  severe  injuries,  like  compound 
fi-actures  or  burns,  renal  or  intestinal  colic,  retention  of  urine,  phimosis,  a 
foreign  body  in  the  ear,  or  intestinal  strangulation.  A  case  has  been  re- 
lated to  me  in  which  the  application  of  cold  to  the  skin  repeatedly  induced 
convulsions.  Other  conditions  classed  under  this  head  are  dentition  and 
worms,  but  both  must  be  regarded  as  exceedingly  rare  causes  of  convul- 
sions. The  exciting  cause  is  very  frequently  the  presence  in  the  stomach 
or  intestines  of  undigested  food ;  such  attacks  are  sometimes  ascribed 
to  reflex  irritation,  but  the  majority  are  better  regarded  as  toxic.  Acute 
and  chronic  indigestion  are  to  be  ranked  among  the  most  frequent 
causes  of  convulsions,  both  in  infants  and  older  children.  In  either 
there  may  be  but  one  attack,  or  attacks  may  recur  at  intervals  of  a 
few  months  with  a  repetition  of  the  cause.  Of  toxic  origin  may  be 
considered  not  only  the  convulsions  resulting  from  conditions  like 
uraemia  and  asphyxia,  but  also  those  which  occur  at  the  onset  or  in  the 
course  of  various  infectious  diseases,  sometimes  classed  as  febrile  con- 
vulsions. Tliey  are  very  frequent  at  the  onset  of  certain  diseases,  particu- 
larly pneumonia,  scarlet  fever,  malaria,  acute  indigestion,  and  gastro-enteric 
infection ;  less  frequently  of  measles,  typhoid  fever,  ileo-colitis,  and  diph- 
theria. In  these  cases  the  convulsions  seem  due  partly  to  the  intensity. 
of  the  poison  and  partly  to  the  suddenness  with  which  it  affects  the 
nervous  system.  Convulsions  occurring  late  in  the  course  of  many  diseases 
may  be  due  to  toxic  influences,  especially  when  associated  with  exhaus- 
tion of  the  nerve  centres,  from  the  prolonged  disturbances  of  nutrition 
accompanying  the  febrile  condition. 

In  pertussis — which,  of  all  infectious  diseases,  is  the  one  in  which  con- 
vulsions are  most  frequent — several  factors  may  be  present  :  asphyxia  due 
to  a  severe  paroxysm,  cerebral  congestion  or  hemorrhage  resulting  from 
such  a  paroxysm,  or  simply  from  the  peculiar  susceptibility  of  the  patient 
brought  about  by  the  disease  itself. 

Convulsions  may  be  associated  with  enlargement  of  the  thymus  gland. 
I  have  notes  of  three  cases  of  fatal  convulsions  where  there  Avas  found  at 
autopsy  great  enlargement  of  this  body,  which  weighed  from  one  to  one 
and  a  half  ounces.  Two  of  these  infants  were  previously  healthy  ;  one 
was  rachitic.  The  similarity  of  all  these  cases  convinced  me  that  the 
convulsions  were  in  some  way  due  to  the  enlarged  thymus,  probably  from 
pressure  either  upon  the  bronchi  and  lungs,  or  upon  the  pneumogastric 
(page  43). 


CONVULSIONS.  655 

There  are  some  cases  of  convulsions  for  which  no  cause  can  be  dis- 
covered even  at  autopsy,  and  for  the  present  we  must  be  content  to  class 
them  as  idiopathic.  One  attack  of  convulsions  renders  the  patient  more 
liable  to  a  second,  and  where  there  have  been  several,  they  occur  from 
causes  which  are  less  and  less  marked. 

Pathology. — The  "nervous  discharge "  which  occurs  in  an  attack  of 
convulsions  differs  in  no  essential  particulars  from  that  of  ordinary  epi- 
lepsy. In  the  latter  disease  there  is  seen  a  tendency  to  recurrence  with 
greater  or  less  frequency,  until  the  discharge  may  take  place  from  very 
slight  causes. 

The  part  of  the  brain  most  intimately  concerned  in  the  production  of 
convulsions  is  the  cortex.  Such  attacks  may  be  regarded  as  involuntary 
discharges  of  nerve  force  from  the  cortical  motor  centres,  which,  result 
from  direct  irritation  of  these  parts  by  disease  ;  or  from  an  irritation  aris- 
ing in  some  other  part  of  the  brain,  as  from  the  vaso-motor  centres  of 
the  medulla ;  or  from  a  reflex  irritation  in  a  distant  part  of  the  body. 
Convulsions  may  depend  upon  the  fact  that  while  nerve  cells  may  be  able 
to  generate  nerve  force  they  can  not  control  its  discharge,  as  in  the  con- 
vulsions of  rickets.  An  important  element  in  the  convulsions  of  infancy, 
according  to  Hughliugs  Jackson,  is  the  lack  of  development  of  the  higher 
cerebral  functions,  in  consequence  of  which  they  do  not  exert  the  control- 
ling influence  over  the  discharge  of  nerve  force  which  they  do  in  later  life. 

The  condition  of  the  brain  in  the  beginning  of  an  attack  of  convul- 
sions is  one  of  anaemia;  this  is  shortly  followed  by  venous  hyperfemia 
which  may  be  very  intense.  In  infants  who  die  during  convulsions  the 
brain  and  its  meninges  are  usually  found  intensely  congested.  They  may 
be  the  seat  of  punctate  haemorrhages,  and  sometimes  of  more  extensive 
ones.  The  lungs  are  also  deeply  congested,  and  the  right  heart  is  generally 
distended  with  dark  clots.     The  other  lesions  found  are  accidental. 

Symptoms. — In  some  cases  prodromal  symptoms  are  present,  such  as 
extreme  restlessness,  irritability,  slight  twitchings  of  the  muscles  -of  the 
face,  hands,  feet,  or  eyelids.  More  frequently,  however,  the  attack  comes 
quite  suddenly  with  but  momentary  warning.  Usually  the  first  thing 
noticed  is  that  the  face  is  pale,  the  eyes  fixed,  sometimes  rolled  up  in 
their  orbits ;  in  a  moment  or  two  convulsive  twitchings  begin  in  the 
muscles  of  the  eye  or  face,  or  in  one  of  the  extremities,  which  usually 
rapidly  extend  until  all  parts  of  the  body  participate.  In  most  cases  the 
convulsions  become  general,  but  they  may,  however,  remain  unilateral 
even  when  not  due  to  a  local  cause, — a  point  which  is  often  forgotten. 
The  contraction  of  the  facial  muscles  causes  a  succession  of  grimaces ;  the 
neck  is  thrown  back ;  the  hands  are  clenched  ;  the  thumbs  buried  in  the 
palms ;  and  a  quick  spasmodic  contraction  of  the  extremities  occurs. 
There  may  be  some  frothing  at  the  mouth,  and  in  all  true  convulsions 
there  is  loss  of  consciousness.  Respiration  is  feeble,  shallow,  and  may  be 
43 


656  DISEASES   OF   THE   NERVOUS  SYSTEM. 

spasmodic.  The  pulse  is  weak ;  it  may  be  slow  or  rapid  ;  often  it  is  irreg- 
ular. The  forehead  is  covered  with  cold  perspiration.  The  face  is  first 
pale,  then  becomes  slightly  blue,  especially  about  the  lips.  Unnatural 
rattling  sounds  may  be  produced  in  the  larynx.  The  bladder  and  rec- 
tum may  be  evacuated.  The  convulsive  movements  consist  in  an  alter- 
nation of  flexion  and  extension  occurring  rhythmically.  All  varieties 
of  tonic  and  clonic  spasm  may  be  seen,  and  in  all  degrees  of  severity. 
The  contractions  of  the  two  sides  of  the  body  are  usually  synchronous. 
After  a  variable  time,  from  a  few  moments  to  half  an  hour,  the  convulsive 
movements  are  gradually  less  frequent,  and  finally  cease  altogether,  usually 
leaving  the  patient  in  a  condition  of  stupor.  They  may  recur  after  a 
short  time  or  there  may  be  but  one  attack.  A  period  of  general  relaxa- 
tion usually  follows  the  convulsive  seizures,  frequently  accompanied  by 
marked  evidences  of  prostration.  Transient  paralysis,  apparently  due  to 
exhaustion  of  the  nerve  centres,  is  not  an  uncommon  sequel. 

Death  may  take  place  from  a  single  attack ;  this,  however,  is  rare  ex- 
cept in  very  young  infants,  especially  those  who  are  rachitic.  There  may 
be  no  sequel  to  the  convulsions  if  the  cause  is  a  temporary  one,  or  they 
may  produce  some  serious  brain  lesion,  particularly  meningeal  hgemor- 
rhage.  Death  from  convulsions  is  generally  due  to  asphyxia,  or  to  exhaus- 
tion from  the  rapidly  recurring  attacks.  Many  cases  recover  in  which 
the  children  for  several  minutes  had  the  appearance  of  being  moribund. 

One  attack  of  convulsions  is  very  apt  to  be  followed  by  others ;  for 
the  occurrence  of  the  first  one  usually  reveals  a  peculiar  susceptibility 
of  the  nervous  system,  and  each  succeeding  attack  comes  from  a  less 
powerful  exciting  cause  than  the  previous  one.  The  longer  the  interval 
which  has  passed,  the  less  likely  is  there  to  be  a  repetition,  especially  if 
the  child  has  passed  its  third  year.  The  number  of  attacks  may  be  very 
great.  In  a  case  recently  under  the  care  of  Dr.  A.  M.  Thomas  and  my- 
self, an  infant  during  the  latter  part  of  its  second  year  had  during  six 
months  over  thirty-five  hundred  distinct  attacks  of  convulsions.  For  a 
considerable  period  they  reached  the  almost  incredible  number  of  eighty 
a  day,  and  yet  the  mental  condition  of  the  child  in  the  interval  was  appar- 
ently normal.* 

Diagnosis. — There  can  rarely  be  any  difficulty  in  recognizing  an  at- 
tack of  convulsions.  The  difficulty  consists  in  determining  with  which 
of  the  many  possible  exciting  causes  we  have  to  do  in  the  case  before  us. 
Is  it  epilepsy  ?  Does  it  depend  upon  cerebral  disease  ?  Does  it  mark  the 
onset  of  some  other  acute  disease  ?     Is  it  reflex,  and  if  so  to  what  is  it 


*  The  post-mortem  examination  of  this  case  has  not  yet  been  completed,  but  thus 
far  there  have  been  found  only  degenerative  changes  in  the  nerve  cells  of  the  cortex  in 
the  motor  area  and  an  increase  in  the  neuroglia.  These  changes  existed  over  quite  an 
extensive  area,  and  were  more  marked  upon  one  side. 


CONVULSIONS.  657 

due  ?  To  answer  these  questions  a  careful  history  must  be  obtained,  and  all 
the  circumstances  surrounding  the  patient,  the  character  of  the  convulsions, 
and  all  the  other  symptoms  present  must  be  taken  into  consideration. 

In  infancy,  epilepsy  is  certainly  the  least  probable  diagnosis.  In  older 
children  the  most  important  points  indicating  that  disease  are :  the  pres- 
ence of  some  of  the  stigmata  of  degeneration  (page  757),  a  history  of 
previous  attacks,  a  distinct  aura  preceding  the  seizure,  or  a  sudden  onset 
with  a  cry  or  fall,  biting  of  the  tongue,  a  tonic  spasm  preceding  the  clonic, 
and,  finally,  perfect  recovery  in  the  course  of  a  few  hours  after  the  attack. 
Convulsions  which  come  on  with  high  fever,  even  though  a  patient  may 
have  repeated  attacks,  are  seldom  epileptic.  However,  in  some  cases  only 
prolonged  observation  can  enable  one  to  decide  positively  whether  or  not 
epilepsy  is  present. 

Convulsions  occurring  in  brain  disease,  except  acute  meningitis,  are 
not  as  a  rule  accompanied  by  any  marked  rise  in  temperature.  Focal 
symptoms  are  often  present,  such  as  localized  paralysis  or  rigidity, 
changes  in  the  pupils,  and  strabismus.  The  convulsive  movements  are  fre- 
quently limited  to  one  side  of  the  body.  It  should,  however,  be  borne  in 
mind  that  unilateral  convulsions,  even  when  repeated,  do  not  always  mean 
a  local  lesion,  as  I  have  seen  proved  by  autopsy  more  than  once.  In 
hsemorrhage  or  meningitis,  convulsions  are  likely  soon  to  recur.  In  tu- 
mour they  may  recur  after  a  longer  interval. 

Convulsions  may  be  thought  to  indicate  the  onset  of  .some  acute  dis- 
ease when  they  occur  in  a  child  over  two  years  old,  and  when  they  come 
on  suddenly  or  with  only  slight  premonition  in  a  child  previously  well ; 
but  the  most  important  point  is  that  they  are  accompanied  by  a  high  tem- 
perature,— 104°  to  106°  F.  Acute  meningitis  is  the  only  other  condition 
likely  to  produce  these  symptoms.  Whether  the  convulsions  mark  the 
onset  of  lobar  pneumonia,  scarlet  fever,  malaria,  or  some  other  disease, 
can  be  determined  only  by  carefully  watching  the  patient's  symptoms  for 
twenty-four  or  thirty-six  hours. 

In  convulsions  depending  upon  some  disorder  of  the  alimentary  tract, 
one  may  get  a  history  of  chronic  constipation,  of  improper  feeding,  and 
in  nursing  infants  sometimes  of  passion,  or  even  intoxication,  in  the  wet- 
nurse.  Convulsions  are  so  frequently  due  to  digestive  derangements  that 
the  condition  of  these  organs  should  be  one  of  the  first  things  to  be  looked 
into. 

Examination  of  the  urine  should  never  be  omitted  in  any  case  of  con- 
vulsions of  doubtful  origin,  even  where  no  dropsy  is  present.  This,  both 
in  infants  and  older  children,  is  too  often  overlooked.  Asphyxia  may  be 
suspected  in  the  case  of  convulsions  occurring  in  the  newly  born,  late  in 
pneumonia,  in  some  cases  of  pertussis,  in  spasmodic  or  membranous 
laryngitis,  or  in  laryngismus  stridulus.  Dentition  and  worms  should  be 
considered  among  the  least  probable,  never  as  the  most  probable,  causes  of 


658  DISEASES  OF  THE  NERVOUS  SYSTEM. 

reflex  irritation,  and  should  not  be  so  accepted  without  positive  evidence. 
Worms  are  so  rare  in  infancy  that  at  this  period  they  may  be  practically 
ignored.  Dentition  seldom,  if  ever,  causes  convulsions  except  in  patients 
who  are  markedly  rachitic.  In  all  cases  of  convulsions  of  doubtful  or 
obscure  origin  occurring  in  infants,  rickets  should  be  suspected  as  the 
underlying  cause,  and  the  child  carefully  examined  for  other  evidences  of 
that  disease. 

Prognosis. — This  depends  upon  the  age  of  the  patient  and  the  cause 
of  the  convulsions.  Idiopathic  or  reflex  convulsions  are  rarely  dangerous 
to  life  except  in  very  young  or  in  rachitic  infants.  In  such  patients  death 
from  convulsions  is  not  at  all  uncommon.  Convulsions  occurring  at  the 
onset  of  acute  febrile  diseases  are  seldom  fatal,  and  not  often  serious ; 
they  may  not  even  indicate  an  unusually  severe  type  of  the  disease.  Espe- 
cially fatal  are  the  convulsions  of  pertussis  and  of  asphyxia  when  they 
occur  late  in  any  form  of  laryngeal  or  pulmonary  disease.  In  nephritis, 
while  always  serious,  convulsions  are  by  no  means  invariably  fatal.  The 
conditions  during  an  attack  which  should  lead  one  to  make  a  bad  prognosis 
are  when  the  convulsions  are  prolonged  or  recur  frequently ;  also  the  pres- 
ence of  very  great  prostration,  a  feeble  pulse  with  cyanosis,  or  deep  stupor. 

In  the  prognosis  one  must  take  into  account  not  only  the  immediate 
result  of  the  attack,  but  its  possible  outcome.  Except  where  convulsions 
mark  the  beginning  of  epilepsy,  they  are  much  less  serious  than  they  are 
generally  supposed  by  the  laity.  In  a  highly  nervous  or  susceptible  child 
a  convulsion  may  often  mean  no  more  than  an  attack  of  severe  migraine 
in  an  older  person.  Such  are  undoubtedly  most  of  the  attacks  seen  in 
practice.  Permanent  injury  to  the  brain,  simply  as  a  result  of  an  attack, 
although  possible,  is  still  rare.  But  when  convulsions  are  repeated  the' 
development  of  epilepsy  is  to  be  feared.  There  is  little  doubt  that  some 
cases  of  epilepsy  have  their  origin  in  attacks  of  convulsions,  which  in  the 
beginning  were  the  result  simply  of  digestive  derangements ;  by  a  constant 
repetition  of  the  exciting  cause  the  convulsive  habit  finally  becomes  estab- 
lished. This  possibility  is  therefore  to  be  borne  in  mind  in  all  cases 
where  children  have  had  several  convulsions,  although  it  is  unusual  that 
this  result  is  seen.  The  farther  apart  the  attacks  are  and  the  more  defi- 
nite the  exciting  cause,  the  less  likely  is  this  to  be  the  case. 

Treatment. —  Summoned  to  a  child  in  conv-ulsions,  it  is  a  physician's 
duty  to  go  at  once  and  remain  with  the  patient  until  the  attack  has  sub- 
sided. He  should  take  with  him  chloroform,  a  hypodermic  syringe  with 
morphine,  and  a  solution  of  chloral.  In  order  to  treat  convulsions  intelli- 
gently one  must  have  in  mind  the  prominent  pathological  conditions. 
These  are  acute  cerebral  hyperasmia,  a  more  or  less  severe  asphyxia  with 
pulmonary  congestion,  an  overtaxed  right  heart,  and  in  fact  a  tendency 
to  congestion  of  all  the  internal  organs.  The  nervous  centres  are  in  a  con- 
dition of  such  unnatural  excitability  that  the  slightest  irritation  may  bring 


CONVULSIONS.  659 

on  convulsive  movements  when  they  have  temporarily  subsided.  The 
patient  should  therefore  be  kept  perfectly  quiet,  and  every  unnecessary  dis- 
turbance avoided.  Cold  should  be  applied  to  the  head — best  by  means  of 
an  ice  cap  or  cold  cloths^and  dry  heat  and  counter-irritation  to  the  surface 
of  the  body  and  extremities.  The  time-honoured  mustard  bath  causes  so 
much  disturbance  of  the  patient  that  it  may  well  be  dispensed  with  and  the 
mustard  pack  (page  53)  substituted.  The  feet  may  be  placed  in  mustard 
water  while  the  child  lies  in  its  crib.  The  mustard  pack  and  footbath 
should  be  continued  until  the  skin  is  well  reddened.  The  degree  to  which 
counter-irritation  of  the  skin  should  be  carried  will  depend  upon  the  con- 
dition of  the  pulse  and  the  cyanosis. 

In  controlling  convulsions  the  three  remedies  which  may  be  depended 
upon  are  the  inhalation  of  chloroform,  morphine  hypodermically,  and 
chloral  by  the  rectum.  Chloroform  is  undoubtedly  the  most  reliable 
remedy  for  an  immediate  effect,  and  should  be  used  even  in  the  youngest 
infant.  At  the  same  time  that  it  is  being  administered,  chloral  should 
be  given  per  rectum.  The  initial  dose  should  be,  at  six  months,  four 
grains;  at  one  year,  six  grains;  at  two  years,  eight  grains,  dissolved 
in  one  ounce  of  warm  milk.  It  should  be  injected  high  into  the  bowel 
through  a  catheter,  and  prevented  from  escaping  by  pressing  the  buttocks 
together.  It  may  be  repeated  in  an  hour  if  necessary.  The  effect  of  the 
drug  is  generally  obtained  in  twenty  minutes.  If,  in  spite  of  the  chloral, 
the  convulsions  show  a  marked  tendency  to  continue  as  soon  as  the  chloro- 
form is  withdrawn,  or  if  the  enema  of  chloral  has  been  expelled,  morphine 
should  be  given  hypodermically.  Where  the  heart's  action  is  weak,  this 
is  probably  the  best  of  all  remedies.  Objections  are  urged  against  it  only 
by  those  who  have  had  no  experience  with  its  use.  To  a  well-grown  child 
two  years  old,  ^^g-  of  a  grain  may  be  given ;  one  year  old,  -^-^  of  a  grain ; 
six  months  old,  -^^  of  a  grain.  This  dose  may  be  repeated  in  half  an 
hour  if  no  effect  is  seen.  The  tolerance  of  opium  in  cases  of  convulsions 
is  very  marked,  and  sometimes  double  the  doses  mentioned  may  be  re- 
quired. The  only  other  agent  of  much  value  is  oxygen.  I  have  seen  con- 
vulsions which  continued  in  spite  of  all  other  means,  yield  immediately 
to  oxygen.  This  is  most  likely  to  be  valuable  in  cases  of  convulsions  due 
to  asphyxia. 

When  once  -under  control,  the  recurrence  of  the  convulsions  may  be 
prevented  by  keeping  the  patient  for  two  or  three  days  under  the  influ- 
ence of  chloral  with  bromide  of  sodium,  the  amount  of  chloral  being 
gradually  reduced.  If  it  is  badly  borne  by  the  stomach  and  not  easily  re- 
tained by  the  rectum,  either  antipyrine  or  phenacetine  may  be  used  with 
the  bromide.  Where  there  is  a  strong  tendency  to  recurrence  of  the  con- 
vulsions, urethan  is  sometimes  even  more  efficient  than  chloral.  It  may 
be  given  in  the  same  or  in  slightly  larger  doses. 

As  soon  as  the  convulsions  have  ceased,  the  cause  should  be  sought 


QQO  DISEASES  OF  THE   NERVOUS  SYSTEM. 

and  treated.  In  infancy  it  is  wise  in  every  case  to  irrigate  the  colon  thor- 
'oughly  with  warm  water,  to  remove  any  possible  source  of  irritation.  If 
there  is  reason  to  suspect  the  presence  of  indigestible  food  in  the  stom- 
ach, this  may  be  washed  out.  Much  more  frequently  it  is  in  the  intestines, 
and  free  purgation  by  calomel  is  advisable.  If  there  is  high  temperature, 
this  should  be  reduced  by  the  cold  bath  or  pack.  Secondary  attacks  are 
to  be  prevented  by  careful  feeding,  by  improving  the  general  nutrition 
by  means  of  fresh  air,  iron,  cod-liver  oil,  and  phosphorus.  The  last  two 
are  especially  valuable  in  cases  due  to  rickets. 

EPILEPSY. 

Epilepsy  may  be  defined  as  a  disease  in  which  there  is  an  established 
disposition  to  convulsions  of  a  certain  type,  with  loss  of  consciousness, 
which  have  recurred  until  a  habit  of  convulsions  has  become  fixed. 

A  distinction  must  be  made  between  cases  of  so-called  "  idiopathic  " 
epilepsy  and  those  which  are  secondary  to  a  definite  lesion  of  the  brain, 
such  as  tumour,  sclerosis,  or  abscess.  Convulsions  of  the  latter  character 
are  designated  as  "  symptomatic  "  epilepsy,  and  are  discussed  in  connection 
with  the  various  diseases  in  which  they  occur.  The  nature  of  the  attack 
may,  however,  be  identical  in  both  varieties,  and  may  not  differ  from  an 
ordinary  attack  of  convulsions  or  eclampsia. 

The  proportion  of  idiopathic  cases  in  children  is  not  so  large  as  was 
formerly  supposed ;  for  many  of  these  have  been  shown  to  depend  upon 
lesions  once  overlooked,  particularly  infantile  cerebral  paralyses  of  a  mild 
type. 

Etiology. — From  a  consideration  of  1,450  cases  of  epilepsy.  Growers 
states  that  12  per  cent  begin  in  the  first  three  years  of  life,  and  46  per  cent 
between  ten  and  twenty  years.  The  greatest  tendency  to  the  development 
of  the  disease  is  shown  about  the  time  of  puberty.  Females  are  rather 
more  liable  to  be  affected  than  males,  although  the  difference  in  sex  is 
slight.  Heredity  plays  an  important  role  in  the  production  of  the  disease. 
In  one  third  of  the  cases,  according  to  Gowers,  there  is  a  family  history 
either  of  epilepsy  or  insanity.  Not  infrequently  more  than  one  child  in 
the  family  is  affected.  All  hereditary  nervous  diseases  predispose  to  epi- 
lepsy, but  it  is  a  question  whether  other  hereditary  diseases  have  any 
special  influence. 

Not  very  infrequently  epilepsy  may  be  traced  to  convulsions  occurring 
during  infancy.  In  what  proportion  of  the  cases  this  is  true  it  is  impossible 
to  state  with  accuracy.  Infantile  convulsions  are  very  common,  and  usu- 
ally the  cause  which  produces  them  is  a  transient  one.  The  proportion  of 
such  cases  which  develop  epilepsy  later  in  life  is  certainly  small.  In  the 
second  and  third  years,  however,  the  occurrence  of  convulsions  not  infre- 
quently marks  the  beginning  of  true  epilepsy.  Given  a  strong  predispo- 
sition to  epilepsy,  it  is  easy  to  see  how  early  infantile  convulsions  so  often 


EPILEPSY.  QQi 

associated  with  rickets  may  have  been  the  first  of  the  epileptic  series. 
The  first  seizure  is  sometimes  traceable  to  fright,  great  excitement, 
heat-stroke,  or  blows  or  falls  upon  the  head  even  without  any  gross 
lesion.  It  may  follow  any  of  the  acute  diseases  of  childhood,  particu- 
larly scarlet  fever,  rarely  measles  or  typhoid.  In  none  of  these,  however, 
is  it  often  seen.  As  reflex  causes  may  be  mentioned  intestinal  worms, 
phimosis,  adenoid  vegetations  of  the  pharynx,  delayed  or  difficult  men- 
struation, and  masturbation.  Most  of  these  are  rare  causes,  but  they  may 
be  sufficient  to  produce  the  disease  where  a  strong  predisposition  exists. 
Syphilis  may  be  the  cause  of  epilepsy  even  when  there  is  no  local  disease 
of  the  brain. 

Among  the  most  important  factors  in  producing  a  paroxysm,  is  intes- 
tinal putrefaction  associated  with  chronic  constipation  and  chronic  intes- 
tinal indigestion.  This  subject  has  been  lately  investigated  with  great 
care  by  Herter  and  Smith,*  who  studied  238  specimens  of  urine  from  31 
epileptics.  In  72  per  cent  of  their  observations  there  was  unmistakable 
evidence  of  excessive  intestinal  putrefaction,  as  shown  by  the  presence 
of  ethereal  sulphates  in  the  urine  in  large  amount,  just  before  the  occur- 
rence of  the  paroxysm.  The  inference  seems  warranted  that  this  intestinal 
condition  was  closely  connected  with  the  epileptic  seizures.  The  state- 
ment of  Haig,  that  there  is  an  excessive  elimination  of  uric  acid  preceding 
the  paroxysm,  was  not  borne  out  by  the  observations  of  Herter  and  Smith. 
The  association  of  intestinal  putrefaction  with  seizures  of  epilepsy  is  very 
important  as  furnishing  a  clew  to  the  management  of  many  of  these 
cases.  I  believe  it  to  be  one  of  the  most  important  etiological  factors  in 
cases  occurring  in  children,  particularly  as  an  exciting  cause  of  the  first 
attacks. 

Pathology. — It  is  not  within  the  scope  of  this  work  to  discuss  the 
various  theories  which  have  been  advanced.  The  following  are  the  con- 
clusions reached  by  Gowers :  f 

"  The  muscular  spasm  is  to  be  regarded  as  the  result  of  the  sudden 
overaction  (discharge)  of  nerve  cells,  the  violent  liberation  of  nerve  force, 
and  the  sensations  which  the  patient  experiences  before  losing  conscious- 
ness must  be  due  directly  or  indirectly  to  the  same  cause.  The  disease 
which  excites  convulsions  is  most  frequently  at  the  cortex,  and  when 
organic  disease  causes  convulsions  that  begin  locally,  the  disease  is  almost 
invariably  at  the  cortex.  In  idiopathic  epilepsy  the  convulsions  some- 
times begin  in  this  way,  and  this  suggests  very  strongly  that  in  such  cases 
the  change  occurs  in  the  cortex.  Epilepsy  must  then  be  regarded  as  a 
disease  of  the  gray  matter,  most  frequently  of  the  gray  matter  of  the 
cortex." 


*  New  York  Medical  Journal,  August  and  September,  1892. 
f  Diseases  of  the  Nervous  System,  American  ed.  1888,  p.  1098. 


662  DISEASES  OP  THE   NERVOUS  SYSTEM. 

While  there  is  pretty  general  agreement  that  the  seat  of  the  morbid 
changes  in  true  epilepsy  are  in  the  cortex,  but  little  is  yet  definitely 
known  as  to  the  nature  of  these  changes.  Van  Gieson  has  published  * 
some  very  careful  observations  made  upon  portions  of  the  cortex  removed 
at  a  surgical  operation  from  two  epileptic  patients.  In  one  of  these  the 
disease  was  primarily  due  to  a  foreign  body ;  in  the  other,  to  an  old  cica- 
trix. The  conditions  found  represent  the  earlier  changes  of  the  disease, 
and  were  essentially  the  same  in  both  cases.  There  were  degenerative 
changes  in  certain  of  the  ganglion  cells,  which  in  places  had  resulted  in 
almost  complete  dissolution  of  these  cells.  In  addition  there  was  a  distinct 
hyperplasia  of  the  neuroglia  tissue.  Diffuse  neuroglia  sclerosis  starting 
from  the  focus  of  disease  has  been  reported  by  certain  French  writers — 
Marie,  Fere,  and  Chaslin. 

Symptoms. — Two  distinct  types  of  epileptic  seizures  are  met  with  :  the 
major  attacks,  or  grand  mcd,  in  which  there  are  severe  convulsions  lasting 
from  two  to  ten  minutes,  with  loss  of  consciousness,  etc. ;  and  minor 
attacks,  or  petit  mal,  in  which  the  convulsive  movements  are  slight  and 
may  be  absent,  and  in  which  the  loss  of  consciousness  is  often  but  mo- 
mentary.    Between  these  two  extremes  all  gradations  are  seen. 

Grand  mat. — The  onset  may  be  sudden,  without  premonition,  or  it 
may  be  preceded  by  certain  prodromal  symptoms  known  as  the  aura. 
The  aura  may  be  motor,  such  as  a  local  spasm  of  the  hand,  face,  or  leg ;  or 
sensory,  such  as  numbness  and  tingling  in  any  part  of  the  body,  or  some 
abnormal  sensation  rising  gradually  to  the  head,  at  which  time  loss  of 
consciousness  occurs.  The  variety  of  sensations  described  by  patients  as 
indicating  an  attack  is  endless.  There  may  be  a  sensation  in  one  finger, 
in  the  face,  tongue,  eye,  or  in  any  part  of  the  body ;  or  the  warning  may 
be  of  a  general  character,  like  a  tremor  or  a  shivering  sensation,  or  a  feeling 
of  faintness.  There  has  also  been  described  a  visceral  or  pneumogastric 
aura,  in  which  there  is  epigastric  pain,  sometimes  nausea,  and  a  sensation 
of  a  ball  in  the  throat;  or  there  may  be  palpitation,  or  cardiac  distress. 
There  may  be  general  giddiness  or  vertigo,  or  a  sensation  of  fulness  in 
the  head ;  or  feelings  of  strangeness,  or  a  dreamy,  dazed  condition  ;  and, 
finally,  the  aura  may  have  reference  to  any  of  the  special  senses,  most 
frequently  to  sight.  Sparks  may  appear  before  the  eyes,  or  flashes  of  light 
or  colour,  or  strange  objects  may  be  seen  ;  or  there  may  be  a  momentary 
loss  of  hearing ;  or  strange  sounds  may  be  heard.  In  most  cases  the  aura 
is  peculiar  to  the  individual,  whose  attacks  are  likely  to  be  preceded  by 
the  same  symptoms. 

At  the  beginning  of  the  seizure  the  face  becomes  pale,  the  pupils 
widely  dilated,  the  eyes  rolled  up  in  their  orbits  and  fixed.  Speedily  there 
is  loss  of  consciousness.     Simultaneously  with  these  symptoms,  or  imme- 

*  New  York  Medical  Record,  April  24,  1893. 


EPILEPSY.  6^3 

diately  following  them,  there  occurs  a  violent  tonic  spasm  to  which  are 
due  the  characteristic  symptoms  of  the  early  part  of  the  seizure — viz.,  the 
fall,  cry,  biting  of  the  tongue,  cyanosis,  and  evacuation  of  the  bladder  or 
rectum.  The  fall  is  forcible,  violent ;  in  fact,  the  patient  is  precipitated 
usually  forward,  and  frequently  suffers  injury,  never  sinking  down  as  in  a 
faint.  The  head  is  often  strongly  rotated  to  one  side.  The  position  of  the 
hands  is  that  assumed  in  tetany.  The  cry  is  a  hoarse,  inarticulate  sound, 
not  very  loud,  and  is  due  to  forcible  expiration,  owing  to  spasm  of  the 
muscles  of  respiration  with  the  glottis  partly  closed.  The  cyanosis  is  the 
result  of  tonic  spasm  of  the  muscles  of  respiration ;  it  may  be  quite  intense, 
so  that  the  face  is  livid,  bloated,  and  the  features  distorted.  The  spasm 
of  the  muscles  of  mastication  causes  the  biting  of  the  tongue.  Evacuation 
of  the  bladder  and  rectum  may  result  from  contraction  of  their  walls,  or 
from  spasm  of  the  abdominal  muscles.  The  violence  of  the  muscular 
spasm  in  this  stage  may  be  very  great ;  it  has  caused  fracture  of  bones, 
rupture  of  muscles,  and  even  dislocation  of  joints. 

The  stage  of  tonic  spasm  may  be  only  momentary,  the  patient  passing 
almost  at  once  into  the  stage  of  clonic  convulsions.  The  usual  duration 
is  from  ten  seconds  to  half  a  minute.  In  the  stage  of  clonic  spasm  which 
follows,  the  symptoms  are  those  of  an  ordinary  attack  of  convulsions.  The 
muscular  contractions  are  violent,  and  there  is  often  frothing  at  the 
mouth.  Gradually  the  muscles  of  respiration  relax,  air  enters  the  chest, 
and  the  cyanosis  passes  off.  After  the  clonic  spasm  has  continued  for  a 
variable  time — from  two  or  three  minutes  to  half  an  hour — the  muscular 
contractions  become  less  and  less  frequent,  and  finally  cease  altogether. 
In  a  few  minutes  the  patient  may  regain  consciousness,  look  vacantly 
around,  and  in  a  dazed  way  perhaps  ask  what  has  happened,  he  being  com- 
pletely oblivious  to  all  that  has  occurred.  More  frequently,  however,  he 
passes  at  once  into  a  deep  sleep,  which  continues  for  an  hour  or  more, 
but  from  which  he  can  be  aroused.  From  this  he  usually  wakens  with  a 
severe  headache,  which  may  continue  for  several  hours.  After  this  he  often 
feels  better  than  for  several  days  preceding  the  attack.  During  the  seizure 
the  temperature  may  be  elevated  one  or  two  degrees,  but  rarely  more. 
The  attack  may  be  followed  by  a  slight  temporary  paresis,  or  aphasia, 
hysterical  phenomena,  vomiting,  and  intense  hunger.  In  very  rare  cases 
the  urine  may  contain  a  trace  of  sugar. 

Petit  mal. — The  minor  attacks  of  epilepsy  may  present  a  very  great 
variety  of  symptoms,  and  at  times  it  is  almost  impossible  to  decide  that 
these  are  epileptic,  except  from  their  periodical  occurrence.  They  pass 
under  the  names  of  "  spells,"  "  attacks  of  dizziness,"  "  fainting  turns,"  etc. 
The  most  striking  thing  which  stamps  them  as  epileptic  is  the  loss  of  con- 
sciousness, and  this  may  be  of  short  duration,  sometimes  only  momentary, 
and  so  pass  unnoticed.  In  some  cases  it  is  absent  altogether.  There  is 
no  fall,  but  there  may  be  a  slight  dropping  of  the  head,  a  fixed  stare  for  a 


gg4  DISEASES  OF  THE   NERVOUS  SYSTEM. 

moment  or  two,  and  that  is  all.  This  may  or  may  not  be  preceded  by  an 
aura.  After  such  a  mild  attack  the  patient's  mind  may  be  somewhat 
confused,  and  he  may  do  or  say  strange  things.  All  sorts  of  curious  acts 
have  been  performed  in  an  automatic  way  by  patients  in  the  condition 
which  follows  an  attack  of  epilepsy,  which  may  perhaps  be  regarded  as 
part  of  the  attack.     In  rare  instances  even  acts  of  violence  may  be  done. 

The  mental  condition  of  epileptics. — In  this  connection  a  careful  dis- 
tinction must  be  made  between  cases  in  which  epilepsy  is  secondary  to 
some  organic  brain  disease,  such  as  infantile  cerebral  palsy,  which  may 
itself  be  a  cause  of  mental  impairment,  and  the  mental  disturbances  seen 
in  cases  of  idiopathic  epilepsy.  The  children  who  are  the  subjects  of  the 
latter  disease,  and  who  are  perfectly  normal  mentally,  are  certainly  few. 
All  degrees  of  disturbance  may  be  seen,  from  those  who  are  simply  dull, 
apathetic,  backward  in  development,  and  uncontrollable  in  temper,  to 
those  who  are  melancholic,  idiotic,  and  even  maniacal.  The  earlier  in 
childhood  epilepsy  develops,  the  greater  is  usually  the  mental  disturbance 
seen,  because  of  the  effect  of  the  seizures  upon  the  brain  during  its  period 
of  active  growth.  Speech  and  all  mental  development  may  be  greatly  re- 
tarded. The  more  frequent  and  more  severe  are  the  attacks,  the  more 
marked  are  the  mental  symptoms  present. 

Symptomatic  epilepsy. — This  occurs  most  frequently  in  children  as  a 
sequel  of  cerebral  palsy,  usually  with  hemiplegia,  and  it  may  follow  either 
the  congenital  or  acquired  form.  Epilepsy  may  come  on  at  any  time  after 
the  onset  of  the  paralysis — from  a  few  months  to  five  or  six  years.  At 
first  the  attacks  may  be  separated  by  long  intervals,  but  they  gradually 
become  more  frequent  as  time  passes.  The  convulsions  in  post-hemiplegic 
epilepsy  begin,  as  a  rule,  on  the  paralyzed  side,  and  for  a  long  time  they 
may  be  confined  to  that  side ;  but  later  they  may  become  general,  in  which 
cases  thev  are  indistinguishable  from  attacks  of  idiopathic  epilepsy.  Se- 
vere seizures  are  more  likely  to  be  seen  than  are  the  mild  ones. 

Course  of  the  disease. — This  is  extremely  irregular.  In  most  cases 
seizures  at  first  occur  at  long  intervals,  of  perhaps  a  year,  but  later  they 
become  more  and  more  frequent.  Either  the  mild  or  the  severe  attacks 
may  be  first  seen,  and  may  remain  throughout  as  the  only  type  present,  or 
they  may  be  associated  in  the  same  case.  There  are  most  frequently  seen, 
occasional  major  attacks  with  a  large  number  of  minor  ones.  The  inter- 
val between  the  epileptic  seizures  in  most  cases  is  from  two  to  four  weeks, 
although  they  may  be  of  daily  occurrence.  Sometimes  three  or  four 
seizures  will  follow  one  another  closely,  and  then  there  will  occur  a  long 
interval  of  immunity.  The  seizures  may  come  on  either  during  sleep  or 
in  the  waking  hours,  and  in  some  cases  for  a  long  time  they  may  occur 
only  in  sleep.  Such  cases  present  peculiar  difficulties  in  diagnosis,  and 
are  often  long  unrecognised  as  epileptic.  The  general  health  of  patients 
may  be  quite  normal. 


EPILEPSY.  665 

Death  rarely,  if  ever,  results  from  epilepsy,  except  from  some  acci- 
dent at  the  time  of  the  seizures,  or  from  the  condition  known  as  the 
status  epilepticus;  in  this  the  attacks  come  on  with  great  frequency  and 
severity,  the  patient  at  times  passing  rapidly  from  one  convulsion  into 
another,  the  temperature  rising  to  105°  or  106°  F.,  and  death  occurring 
either  from  exhaustion,  owing  to  the  severity  of  the  convulsions,  or  from 
coma. 

Diagnosis. — In  most  cases  there  is  little  difficulty  in  recognising  the 
major  attacks  when  they  occur  by  day.  Nocturnal  attacks  may  be  diag- 
nosticated by  the  cry,  the  biting  of  the  tongue,  blood  upon  the  pillow, 
sub-conjunctival  extravasation,  evacuation  of  the  bladder  or  rectum,  and 
the  severe  headache.  Minor  attacks  present  the  greatest  difficulties,  and 
a  positive  diagnosis  is  often  impossible  until  the  patient  has  been  watched 
for  a  long  time.  The  most  important  points  to  be  noted  are  sudden 
pallor,  dilatation  of  the  pupils,  temporary  loss  of  consciousness,  or  sim- 
ply mental  confusion,  and  sometimes  the  evacuation  of  the  bladder. 
The  duration  of  the  attack  is  shorter  than  is  usual  in  an  ordinary  faint. 
The  difficulty  of  distinguishing  epilepsy  from  hysteria  rarely  occurs  in 
childhood. 

It  is  not  always  possible  to  distinguish  between  secondary  or  symp- 
tomatic epilepsy  and  the  idiopathic  or  hereditary  form,  particularly  if  the 
case  comes  under  observation  late  in  the  course  of  the  disease.  The  points 
which  go  to  establish  the  first  form  are  :  that  the  convulsive  movements  are 
partial,  or  limited  to  one  side ;  that  when  they  are  general,  they  always 
begin  in  the  same  part  of  the  body ;  or  that  there  is  a  history  of  partial  or 
unilateral  attacks  for  some  time  before  the  occurrence  of  any  general 
convulsions.  It  is  important  in  all  cases  to  examine  the  patient  care- 
fully for  signs  of  an  old  hemiplegia,  the  symptoms  of  which  may  be  so 
slight  as  to  be  readily  overlooked.  A  marked  increase  in  the  reflexes  of 
one  side  is,  according  to  Sachs,  quite  as  conclusive  evidence  as  a  distinct 
weakness  of  the  arm  or  leg.  In  idiopathic  epilepsy  some  of  the  stigmata 
of  degeneration  (page  758)  are  usually  present.  The  sudden  development 
of  epileptic  seizures  in  a  child  previously  healthy,  and  in  whom  tliere  is 
no  hereditary  history  of  the  disease,  should  always  arouse  the  suspicion  of 
organic  brain  disease,  especially  tumour ;  and  if  there  are  besides,  severe 
headache,  vomiting,  and  optic  neuritis,  the  existence  of  tumour  is  reason- 
ably certain. 

Prognosis. — The  danger  to  life  in  epilepsy  is  very  slight.  Death  is 
generally  due  to  some  accident,  particularly  drowning,  at  the  time  of  a 
seizure.  The  tendency  to  spontaneous  cessation  of  the  attacks  is  small, 
while  the  tendency  to  recurrence  is  very  great. 

The  prognosis  in  any  given  case  depends  upon  the  cause  of  the  disease 
and  the  duration  of  the  symptoms.  Where  the  cause  can  be  removed, 
and  where  the  symptoms  have  lasted  less  than  a  year,  the  prospects  of  per- 


QQQ  DISEASES  OF  THE   NERVOUS  SYSTEM. 

manent  cure  are  fairly  good.  This  is  particularly  true  of  cases  in  which 
the  epilepsy  clearly  depends  upon  gross  errors  in  diet,  with  chronic  intes- 
tinal indigestion.  In  such  cases,  if  the  patient  can  be  placed  under  proper 
control  and  dietetic  measures  well  carried  out,  the  development  of  chronic 
epilepsy  can  be  arrested  in  a  considerable  number  of  cases.  If,  on  the 
contrary,  the  hereditary  tendency  to  the  disease  is  marked,  if  the  epileptic 
seizures  have  developed  apart  from  any  adequate  exciting  cause,  and  if 
they  have  continued  untreated  or  in  spite  of  treatment  for  two  or  three 
years,  the  symptoms  may  perhaps  be  relieved,  but  there  is  no  prospect 
whatever  of  permanent  cure.  In  the  cases  also  which  are  due  to  local  irri- 
tation, like  that  resulting  from  an  old  meningeal  haemorrhage,  the  prog- 
nosis is  invariably  bad,  and  only  temporary  relief  is  to  be  expected.  A 
few  cases  of  traumatic  epilepsy  have  been  cured  and  many  have  been 
greatly  improved  by  a  surgical  operation. 

Treatment. — The  first  indication  is  to  remove  the  cause  where  one  can 
be  found.  If  in  the  male  phimosis  exists,  or  other  evidence  of  genital 
irritation,  circumcision  should  be  done,  or  the  prepuce  retracted  and  ad- 
hesions broken  up.  Adenoid  growths  of  the  pharynx  should  be  removed, 
and  likewise  every  other  cause  of  reflex  irritation.  Particular  attention 
should  be  given  to  the  digestive  organs.  The  most  hopeful  cases  are  those 
associated  with  acute  and  chronic  disturbances  of  digestion,  especially 
chronic  intestinal  indigestion  with  constipation.  These  cases  are  to  be 
managed  like  others  of  the  same  sort  in  which  epileptic  attacks  are  not 
present  (page  368).  Meat  should  be  allowed  once  a  day  and  in  mod- 
erate quantity.  Milk  should  be  given,  diluted  if  necessary,  also  kumyss 
and  matzoon.  Green  vegetables,  except  peas  and  beans,  may  be  given 
freely ;  also  all  fresh  fruits.  Tea,  coffee,  and  alcohol  in  every  form  must 
be  absolutely  prohibited ;  also  potatoes  and  oatmeal.  The  most  careful 
attention  should  be  given  to  the  bowels.  Under  no  circumstances  should 
a  condition  of  chronic  constipation  be  neglected.  A  dose  of  calomel 
once  a  week  and  intestinal  irrigation  two  or  three  times  a  week  are  of 
great  value  in  manj  cases.  Where  the  symptoms  of  intestinal  putrefac- 
tion are  marked,  borax  is  at  times  of  decided  value — two  grains  three 
times  a  day  to  a  child  of  five  years — or  salicylate  of  sodium,  salol,  or  the 
benzoate  of  sodium  may  be  given ;  the  dose  of  each  being  from  two  to 
ten  grains,  according  to  the  age  of  the  child,  after  each  meal.  The  gen- 
eral hygiene  of  the  patient  must  receive  careful  attention.  He  must  lead 
a  simple,  regular  life,  as  much  as  possible  out  of  doors,  away  from  the  ex- 
citements of  a  large  city,  or  from  association  with  many  children,  and  in 
short  the  nervous  system  should  be  kept  as  quiet  as  possible. 

All  the  foregoing  means  of  treatment  are  of  equal  importance  with  the 
use  of  specific  drugs.  The  most  common  mistake  is  to  rely  only  upon 
drugs,  ignoring  the  other  measures  mentioned.  It  not  infrequently  hap- 
pens that  drugs  are  without  any  avail  when  they  are  the  only  means  of 


EPILEPSY.  gg7 

treatment  employed,  whereas  in  conjunction  with  other  measures  marked 
improvement  is  seen. 

The  bromides  are  unquestionably  the  best  means  of  combating  the  epi- 
leptic habit.  Either  the  sodium  salt  alone  or  a  combination  of  the  sodium 
and  ammonium  bromides  is  to  be  preferred.  The  purpose  should  be  to 
give  the  smallest  doses  which  will  control  the  seizures.  Children  require 
proportionately  larger  doses  than  adults,  and  in  most  cases  a  child  of  five 
years  will  need  from  twenty-five  to  fifty  grains  a  day.  Seguin's*  method  of 
administering  the  bromides  is  largely  followed  in  New  York,  and  is  of  great 
value.  It  is  to  give  the  larger  part  of  the  quantity  for  twenty-four  hours, 
shortly  before  the  time  when  the  s^zures  have  usually  occurred ;  in  the  inter- 
val to  give  much  smaller  doses,  and  in  all  cases  to  give  the  dose  largely  di- 
luted,— in  from  six  to  eight  ounces  of  water.  He  gives  a  full  dose  early  in  the 
morning,  and,  where  the  seizures  are  apt  to  come  at  night,  one  at  bedtime. 

Cases  ot  petit  mal  are  especially  difficult  to  control.  For  such  there  is 
often  an  advantage  in  combining  belladonna  with  the  bromides.  In  all 
cases  the  treatment  must  be  continued  for  a  long  time  if  anything  is  ac- 
complished. The  bromide  should  be  gradually  reduced  after  the  attacks 
are  controlled,  but  must  be  given  in  moderately  large  doses  for  at  least 
two  years  after  the  seizures  have  ceased.  The  addition  of  borax  seems 
occasionally  better  than  the  bromides  alone  in  cases  where  there  is  ex- 
cessive intestinal  putrefaction.  Sometimes  the  combination  of  chloral  or 
antipyrine  with  bromides  is  advantageous,  particularly  if  the  latter  are 
badly  borne  or  cause  an  annoying  amount  of  acne.  Seguin  states  that  he 
has  been  able  to  control  the  acne  in  many  cases  by  giving  at  the  same 
time  moderate  doses  of  arsenic.  Other  drugs  occasionally  useful  as  adju- 
vants to  the  bromides  are  str3'chnine  and  digitalis. 

The  surgical  treatment  of  epilepsy  has  of  late  attracted  much  atten- 
tion. An  operation  is  to  be  considered  in  cases  in  which  the  paroxysms 
are  very  frequent  and  severe,  and  when  there  is  present  a  definite  local 
cause,  such  as  an  old  fracture  of  the  skull,  or  where  epilepsy  has  followed 
an  injury  to  the  head  even  without  fracture.  Sachs  sums  up  the  present 
status  of  this  question  as  follows  :  "  In  a  case  due  to  a  traumatic  or  organic 
lesion  an  early  operation  may  prevent  the  development  of  cerebral  sclerosis. 
If  early  operation  is  not  done,  the  occurrence  of  epilepsy  is  a  warning  that 
secondary  sclerosis  has  been  established  and  an  operation  may  prevent  it 
from  increasing.  Operation  must  include  the  removal  of  the  diseased 
area ;  here,  if  all  other  parts  are  normal,  a  cure  may  result.  Under  favour- 
able conditions  a  few  cases  of  epilepsy  may  be  cured  by  surgery  and  many 
more  improved." 

The  education  of  epileptic  children  is  a  subject  of  great  difficulty  and 
is  often  neglected.     There  are  many  reasons  why  it  is  impracticable  to 

*  New  York  Medical  Journal,  March  29,  1890. 


egg  DISEASES  OF   THE  NERVOUS  SYSTEM. 

send  them  to  ordinary  schools,  and  it  is  very  desirable  that  special  schools 
for  them  should  be  established. 

The  management  of  the  attack. — Abortive  measures  are  sometimes 
successful  in  cases  with  a  distinct  aura,  the  most  reliable  being  the  inhala- 
tion of  nitrite  of  amyl.  While  the  seizure  lasts,  the  patient  should  be 
prevented  from  injuring  himself.  The  clothing  should  be  loosened,  a 
spool  or  cork  should  be  placed  between  his  teeth  to  protect  the  tongue, 
but  no  effort  made  to  restrain  his  movements  unless  he  is  liable  to  do  vio- 
lence to  himself.  An  epileptic  child  should  never  be  without  some  com- 
panion. 

TETANY. 

This  is  a  condition  characterized  by  tonic  muscular  spasm,  which  may 
be  intermittent  or  continuous.  It  usually  affects  the  muscles  of  the  ex- 
tremities, especially  the  hands  and  feet,  more  rarely  the  neck,  face,  and 
trunk.  When  limited  to  the  hands  and  feet  it  is  known  as  carpo-pedal 
spasm  or  arthrogryposis ;  and  although  sometimes  classed  separately,  this 
seems  to  be  really  only  one  manifestation  of  the  same  general  condition. 
In  infants,  tetany  is  very  frequently  associated  with  laryngismus  stridulus, 
this  being  present  in  fully  two  thirds  of  the  cases  ;  but  in  older  children 
this  association  is  quite  rare.  General  convulsions  occur  in  from  twenty 
to  thirty  per  cent  of  the  cases.  Tetany  is  rare  in  this  country,  as  shown 
by  the  fact  that  Griffith  *  in  1895  could  find  reported  only  fifty  cases,  of 
which  thirty-eiglit  were  in  children. 

Etiology. — While  tetany  may  occur  at  any  age,  it  is  most  frequent  in 
infancy.  Of  eighty-seven  cases  reported  by  Barthez  and  Sanne,  fifty  per 
cent  were  observed  in  the  first  two  years,  twenty  per  cent  from  three  to 
six  years,  and  twenty-five  per  cent  from  twelve  to  fifteen  years.  Of  the 
cases  in  children  collected  by  Griffith,  sixty-six  per  cent  were  under  two 
years  of  age.  In  infancy  males  are  much  more  frequently  affected  ;  but 
when  the  disease  occurs  in  older  children,  females  seem  much  more  liable 
to  it.  Tetany  rarely  occurs  as  a  primary  disease.  It  is  most  frequently 
associated  with  rickets ;  in  fact,  rickets  is  almost  invariably  found  in  the 
infantile  cases.  It  sometimes  occurs  with  chronic  diarrhoea  and  with 
marasmus.  It  has  been  known  to  follow  broncho-pneumonia,  pertussis,  ty- 
phoid fever,  rheumatism,  and  measles.  Of  the  exciting  causes,  the  most 
frequent  one  is  some  irritation  in  the  gastro-enteric  tract.  This  may  be 
the  products  of  chronic  indigestion,  or  of  acute  diarrhoea,  worms,  and 
sometimes  even  intussusception.  Attacks  in  older  children  are  frequently 
ascribed  to  cold.  In  girls,  tetany  may  occur  at  the  time  of  puberty,  espe- 
cially where  menstruation  is  delayed ;  it  has  followed  removal  of  the 
thyroid  gland  ;  and  it  has  been  known  to  occur  epidemically  in  much  the 
same  way  as  chorea. 


*  American  Journal  of  the  Medical  Sciences,  February,  1895. 


TETANY.  669 

Pathology. — Up  to  the  present  time  no  constant  anatomical  lesions 
have  been  demonstrated  in  tetany.  The  circumstances  in  which  it  occurs, 
its  symptoms  and  course,  all  indicate  that  it  is  a  neurosis  probably  depend- 
ent upon  disturbances  of  nutrition  in  the  nerve  cells  of  the  spinal  cord 
and  medulla. 

Symptoms. — The  spasm  may  occur  quite  suddenly,  or  it  may  be  pre- 
ceded by  various  sensory  disturbances,  such  as  pain,  numbness,  or  ting- 
ling. The  upper  extremities  are  usually  first  affected,  the  spasm  grad- 
ually becoming  more  severe  and  finally  involving  the  lower  extremities. 
Both  sides  of  the  body  are  equally  affected.  The  position  assumed  by  the 
hands  is  very  characteristic  :  The  fingers  are  flexed  at  the  metacarpo- 
phalangeal joint  and  the  phalanges  extended ;  the  thumbs  are  adducted  al- 
most to  the  little  finger ;  the  wrist  is  flexed  at  an  acute  angle,  and  the 
whole  hand  drawn  somewhat  to  the  ulnar  side  (Fig.  108).  No  motion  is 
allowed  at  the  wrist,  but  movements  at  the  elbow  and  shoulder  are  usually 
normal.  The  feet  are  strongly  extended,  sometimes  in  the  position  of  typical 
equino-varus.  The  first  phalanges  of  the  toes  are  flexed,  and  the  second 
and  third  rows  extended ;  the  plantar  surface  is  strongly  arched,  and  the 
dorsum  of  the  foot  is  very  prominent,  standing  out  like  a  cushion.  The 
typical  position  of  the  feet  is  well  shown  in  the  accompanying  illustration. 
There  are  rigidity  of  the  muscles  of  the  calf  and  tension  of  the  plantar  fas- 
cia. The  tendo-Achillis  stands  out  prominently.  Motion  at  the  hip  and 
knee  is  generally  free.  The  spasm  in  many  cases  is  limited  to  the  hands 
and  feet ;  more  rarely  the  muscles  of  the  thigh,  usually  the  adductors,  may 
be  involved.  I  have  seen  three  or  four  cases  in  which  the  spasm  affected 
only  the  cervical  muscles,  producing  marked  opisthotonus.  This  form  is 
generally  mild,  and  may  be  associated  with  marasmus.  In  very  rare  cases 
the  muscles  of  the  trunk,  the  face,  or  the  eye  may  be  involved. 

Where  the  spasm  is  intermittent,  and  in  some  cases  where  it  has  sub- 
sided, it  may  be  excited  by  making  pressure  upon  the  large  nerve  trunks 
and  arteries  of  the  parts  affected.  This  is  known  as  "  Trousseau's  symp- 
tom," and  is  characteristic  of  the  disease. 

Pain  owing  to  the  spasm  is  frequently  present.  It  is  usually  sharp  and 
lancinating,  and  may  be  so  severe  as  to  cause  children  to  cry  out.  Pain 
is  induced  by  any  attempt  to  overcome  the  spasm,  and  sometimes  it  is  con- 
stant. Other  disturbances  of  sensibility  are  even  more  common  than 
pain.  There  is  no  loss  of  consciousness  and  no  fever.  The  spasm  is  gen- 
erally continuous,  although  there  may  be  periods  of  remission  or  even  of 
intermission.  When  associated  with  laryngismus  stridulus,  the  spasm  is 
much  increased  during  these  attacks.  The  electrical  reactions  are  as  a  rule 
increased,  and  the  knee-jerk  and  cutaneous  reflexes  are  exaggerated. 

The  duration  of  the  disease  is  from  a  few  days  to  several  weeks.  The 
mild  form,  which  is  usually  seen  in  infants,  in  most  cases  passes  away 
spontaneously  in  one  or  two  weeks,  although  there  may  be  relapses  and 


670 


DISEASES  OP  THE   NERVOUS  SYSTEM. 


second  attacks  at  variable  intervals.     The  most  important  complication 
is  general  convulsions.     These  may  come  on  at  any  time  in  the  course  of 


Fig.  108. — Tetany,  showing  the  characteristic  position  of  the  hands  and  feet,  in  a  child  two 

years  old. 

the  disease.  Spasm  of  the  glottis  may  either  precede  or  follow  tetany. 
When  associated  they  generally  cease  at  the  same  time.  Slight  paralysis 
may  follow  or  alternate  with  the  spasm. 

Diagnosis. — The  diagnostic  features  of  the  disease  are  bilateral  spasm — 
in  infants  usually  limited  to  the  hands  and  feet — without  loss  of  conscious- 
ness, the  spasm  being  increased  or  excited  by  pressure  upon  the  nerves, 
exaggerated  reflexes,  and  the  presence  of  some  previous  disease,  especially 


LARYNGISMUS  STRIDULUS.  671 

rickets  or  some  disorder  of  the  intestines.  The  severe  form  may  be  mis- 
taken for  tetanns;  but  this  is  very  rare  except  in  the  newly  born;  and 
trismus  is  the  rule,  and  generally  it  is  the  first  symptom.  Trismus  is 
extremely  rare  in  tetany.  From  meningitis,  tetany  is  distinguished  by 
the  absence  of  cerebral  symptoms  ;  from  cerebral  tumour,  by  the  bilateral 
character  of  the  spasm,  the  absence  of  headache  and  focal  brain  symp- 
toms ;  from  haemorrhage,  by  the  absence  of  cerebral  symptoms ;  from 
malarial  spasm,  by  the  fact  that  it  is  constant,  not  intermittent. 

Prognosis. — Tetany  per  se  is  not  fatal,  but  death  may  result  from  the 
development  of  general  convulsions  or  from  the  original  disease  which 
tetany  complicates.  Eecovery  is  usually  perfect,  although  Gowers  states 
that  in  rare  cases  it  has  been  followed  by  muscular  atrophy. 

Treatment. — The  first  indication  is  to  remove  the  cause,  and  this  in 
most  cases  is  found  in  the  digestive  tract.  If  rickets  is  present  it  should 
receive  the  usual  treatment,  both  dietetic  and  medicinal.  If  worms  are 
suspected  a  vermifuge  should  be  given.  For  the  relief  of  the  spasm,  the 
hot  bath  is  a  most  valuable  remedy  ;  friction  may  also  be  employed.  Drugs 
which  have  the  power  of  allaying  spasm  should  be  given, — chloral,  bromides, 
and  autipyrine.  In  the  event  of  failure  by  these  methods  galvanism  may  be 
tried.  After  the  attack  the  child's  general  nutrition  should  receive  careful 
attention,  to  prevent  relapses. 

LARYNGISMUS   STRIDULUS— SPASM   OF   THE   GLOTTIS. 

Idiopathic  spasm  of  the  glottis,  or  laryngismus  stridulus,  is  a  rather  rare 
disease,  and  belongs  especially  to  infancy.  It  is  a  pure  neurosis,  not  often 
seen  except  in  children  who  are  rachitic.  It  is  frequently  associated  with 
carpo-pedal  spasm  and  with  general  convulsions.  The  disease  is  not  to  be 
confounded  with  ordinary  spasmodic  croup  or  catarrhal  spasm  of  the 
larynx,  which  is  of  very  frequent  occurrence. 

Spasm  of  the  larynx  may  be  seen  in  several  conditions  quite  different 
from  laryngismus  stridulus.  It  forms  one  of  the  essential  features  of  per- 
tussis. It  occurs  both  in  infants  and  in  older  children  from  pressure  upon, 
or  irritation  of ,  the  pneumogastric  or  recurrent  laryngeal  nerve  by  a  tumour 
in  the  mediastinum, — usually  a  tuberculous  lymph  node,  or  retro-oesophageal 
abscess.  Eeflex  spasm  of  the  larynx  is  also  associated  with  enlarged  ton- 
sils, adenoid  growths  of  the  pharynx,  and  elongated  uvula.  There  is 
a  form  of  reflex  spasm  which  occurs  in  the  newly- born  accompanied  by 
crowing  inspiration  ;  this  is  not  frequent,  and  is  rarely  serious. 

Idiopathic  spasm  of  the  larynx  is  quite  different  from  any  of  these.  It 
is  peculiar  to  infancy,  the  great  proportion  of  cases  occurring  between  the 
sixth  and  eighteenth  months.  Males  appear  to  be  more  susceptible  than 
females.  The  constitutional  condition  with  which  it  is  usually  associated 
is  ricket-5.  In  a  large  number  of  cases,  but  not  in  all,  there  is  cranio-tabes. 
Many  writers  believe  that  laryngismus  is  invariably  of  rachitic  origin.  Of 
44 


672  DISEASES  OP   THE   NERVOUS  SYSTEM. 

fifty  cases  observed  by  Gee,  there  were  found  in  all  but  two  unmistakable 
evidences  of  rickets.  The  disease  occurs  in  delicate  infants  who  have 
been  closely  confined  in  warm  rooms,  and  it  is  probably  on  this  account 
that  it  is  more  often  seen  in  the  winter  and  spring  than  at  other  seasons. 
The  exciting  causes  of  this  spasm  may  be  a  breath  of  cold  air,  or  any  form 
of  nervous  excitement,  such  as  fright  or  crying.  Sometimes  it  is  induced 
by  swallowing,  and  it  may  be  traced  to  indigestion  or  constipation. 

Pathology. — There  are  no  anatomical  changes  in  this  disease.  It  is  a 
pure  neurosis,  and  it  is  generally  believed  to  be  of  central  origin,  depending 
essentially  upon  imperfect  nutrition  of  the  motor  centres  of  the  spinal 
cord  and  medulla. 

Symptoms. — The  disease  is  often  unnoticed  by  the  parents  until  the 
attacks  have  become  quite  frequent,  the  first  ones  being  mild,  and  the  later 
ones  more  and  more  severe.  Occasionally  the  very  first  paroxysms  may  be 
severe.  The  attack  comes  on  suddenly.  The  child  throws  back  its  head, 
the  face  becomes  pale,  then  livid,  and  for  the  time  there  is  complete  arrest 
of  respiration.  This  continues  for  a  few  moments,  during  which  the 
cyanosis  deepens,  and  the  child  seems  in  great  distress,  making  violent 
efforts  to  breathe.  If  the  paroxysm  is  a  severe  one,  the  asphyxia  may 
be  so  great  as  to  lead  to  loss  of  consciousness,  and  it  may  even  be  fatal,  or 
the  attack  may  terminate  in  general  convulsions.  In  milder  attacks, 
after  fifteen  or  twenty  seconds  the  muscular  spasm  relaxes,  the  glottis 
opens,  and  a  long,  deep  inspiration  occurs,  with  the  production  of  a  crow- 
ing sound.  Such  attacks  may  occur  as  frequently  as  every  fifteen  or 
twenty  minutes,  or  there  may  be  only  six  or  eight  during  the  day.  Be- 
tween them  the  condition  of  the  child  may  be  normal,  or  carpo-pedal 
spasm  may  be  present.  It  is  important  to  note  that  in  this  disease 
there  is  not  a  stridor  due  to  narrowing  of  the  glottis,  as  in  ordinary 
croup,  but  a  condition  of  apnoea  fron\  its  complete  closure.  Not  all  the 
paroxysms  in  the  same  case  are  equally  severe.  A  child  may  have  in  the 
course  of  a  day  a  great  many  mild  attacks,  but  only  a  few  severe  ones. 
General  convulsions  are  seen  in  over  one  third  of  the  cases,  and  carpo- 
pedal  spasm  or  tetany  complicates  a  still  larger  proportion.  While  this  is 
present  in  the  interval,  it  is  always  increased  during  the  attacks. 

The  duration  of  the  disease  varies  from  a  few  days  to  several  weeks,  or 
even  months.  In  cases  which  terminate  in  recovery  there  is  a  gradual 
diminution  in  the  frequency  and  severity  of  the  paroxysms,  until  they 
finally  cease  altogether. 

Prognosis. — This  is  good,  except  when  there  ai-e  general  convulsions. 
The  cases  in  which  fatal  asphyxia  occurs  are  very  rare.  Usually  with 
proper  treatmeiit  marked  improvement  begins  in  the  course  of  a  few 
days. 

Diagnosis. — This  is  to  be  made  from  catarrhal  spasm  of  the  larynx. 
The  differential  points  have  been    mentioned  under  the    latter  disease 


CHOREA.  673 

(page  440).  Owing  to  the  occurrence  of  paroxysms  and  the  crowing 
sounds,  the  disease  may  be  mistaken  for  whooping-cough,  and  in  fact 
this  diagnosis  is  not  infrequently  made  by  parents.  A  careful  examina- 
tion of  the  patient  during  the  attacks,  the  absence  of  cough,  and  the  fre- 
quent association  of  tetany,  are  sufficient  to  differentiate  this  from  per- 
tussis. 

Treatment. — During  the  attack  the  object  is  to  break  the  spasm.  In 
mild  cases  this  may  be  done  by  sprinkling  water  in  the  face.  In  severe 
cases  inhalations  of  chloroform  may  be  required,  and  even  intubation. 
Between  the  attacks  the  patient  should  be  given  either  bromide  and  chloral, 
or  antipyrine.  Sodium  bromide,  gr.  v,  and  chloral,  gr.  ij,  may  be  given 
every  three  or  four  hours  to  a  child  a  year  old  until  the  frequency  and 
severity  of  the  attacks  are  controlled  ;  afterward  three  times  a  day.  My 
recent  exj^erience  with  antipyrine  in  this  disease  leads  me  to  the  belief 
that  it  is  more  effective  than  bromide  and  chloral.  When  the  symptoms 
are  severe,  two  grains  of  antipyrine  may  be  given  every  four  hours  to  a 
child  a  year  old,  the  dose  being  gradually  diminished  as  the  symptoms 
improve. 

The  general  treatment  of  the  child  is  quite  as  important  as  drugs  di- 
rected toward  relieving  the  spasm.  Cold  sponging  should  be  used  in 
every  case  unless  it  occasions  so  much  fright  as  to  increase  the  number  of 
paroxysms.  Careful  attention  should  be  given  to  the  diet.  Children 
should  be  kept  in  the  open  air  as  much  as  possible,  and  those  who  are 
rachitic  should  receive  phosphorus.  Cod-liver  oil  is  needed  in  most  cases. 
Any  source  of  local  irritation,  such  as  enlarged  tonsils,  elongated  uvula, 
or  adenoid  growths,  should  be  removed ;  for,  if  not  the  actual  cause  of  the 
attack,  they  may  be  the  means  of  aggravating  the  symptoms.  In  all  cases 
the  treatment  should  be  continued  for  several  weeks  after  the  paroxysms 
have  subsided. 

CHOREA— SAINT  VITUS'S  DANCE. 

Chorea  is  a  functional  nervous  disease  characterized  by  aimless,  irregu- 
lar movements  of  any  or  all  the  voluntary  muscles.  Choreic  movements 
are  of  a  somewhat  spasmodic  character,  often  accompanied  by  an  apparent 
or  real  loss  of  power  in  the  groups  of  muscles  affected,  and  by  a  mental 
condition  of  extreme  irritability. 

Etiology. — Chorea  is  most  frequently  seen  between  the  ages  of  seven 
and  fourteen  years.  Of  146  cases,  6  were  under  five  years,  72  between  five 
and  nine  years,  and  68  between  ten  and  fourteen  years.  The  youngest 
case  of  which  I  have  record  was  that  of  a  child  four  years  old.  It  is  ex- 
tremely rare  before  the  third  year,  although  it  may  occur  even  in  infancy, 
and  in  a  few  recorded  cases  it  was  undoubtedly  congenital.  My  own  ob- 
servations coincide  with  those  of  nearly  all  writers,  that  the  disease  is  more 
than  twice  as  frequent  in  females  as  in  males.     While  chorea  may  be  seen 


674  DISEASES  OF   THE   NERVOUS   SYSTEM. 

at  all  seasons,  it  is  much  more  frequent  in  the  spring  months.  Of  717 
attacks  studied  by  Lewis  (Philadelphia),  the  largest  number  began  in 
March,  and  the  next  largest  number  in  May  ;  in  my  own  cases  May  stood 
first. 

The  relation  of  chorea  to  rheumatism  is  of  much  importance,  and  has 
during  late  years  attracted  a  great  deal  of  attention.  Thus  far  the  inves- 
tigations of  different  writers  have  given  results  which  are  somewhat  con- 
tradictory. Some  have  found  evidences  of  rheumatism  in  but  a  small 
proportion  of  the  cases — in  not  more  than  5  or  10  per  cent — wdiile  the 
statistics  of  others  have  placed  the  percentage  of  rheumatism  as  high  as 
50  or  even  60  per  cent.  It  is  rather  striking  that  the  statistics  of  neurolo- 
gists, almost  without  exception,  have  given  a  very  much  smaller  percentage 
of  rheumatism  in  choreic  cases  than  those  taken  from  children's  clinics  and 
hospitals.  The  question  hinges  largely  upon  what  is  to  be  admitted  as 
evidence  of  rheumatism  in  a  child  ;  if  cases  of  acute  articular  inflamma- 
tion only,  then  the  number  will  be  very  small ;  if  subacute  cases  with  joint 
swellings  are  included,  the  proportion  will  be  considerably  larger ;  while 
if  we  admit  cases  of  acute  endocarditis  without  articular  symptoms,  and 
those  of  articular  pains  and  joint  stiffness  but  without  swelling,  the  pro- 
portion will  be  very  much  increased.  My  own  belief  is  that  there  is  a  very 
close  connection  between  chorea  and  the  rheumatic  diathesis  as  manifested 
by  all  the  symptoms  above  noted,  and  accompanied  by  a  family  history  of 
rheumatism.  On  careful  scrutiny,  the  number  of  cases  of  chorea  in  which 
unmistakable  evidence  of  this  diathesis  is  found,  is  very  large,  including 
in  my  own  observations  over  one  half  the  cases.  There  seems,  then,  to  be 
a  large  group  of  cases  which  may  be  classed  distinctly  as  rheumatic  chorea. 
There  are,  however,  many  others  in  which  no  such  element  can  be  found. 

My  associate,  Dr.  F.  M.  Crandall,  has  analyzed  146  cases  of  chorea 
treated  by  us  at  the  New  York  Polyclinic  and  elsewhere,  with  the  follow- 
ing results  :  Of  111  cases  in  which  the  question  of  rheumatism  was  inves- 
tigated there  was  a  definite  history  of  it  in  63.  In  41,  rheumatism  occurred 
before  the  chorea ;  in  13,  the  first  evidence  of  rheumatism  was  coincident 
with  the  chorea  ;  and  in  9  it  first  occurred  subsequently  to  the  chorea,  usu- 
ally within  three  months.  In  about  one  third  of  the  cases,  attacks  of  rheu- 
matism occurred  during  or  subsequent  to  the  chorea  as  well  as  before  it.  It 
may  then  be  stated  that  previous  rheumatism  was  evident  in  37  per  cent, 
concurrent  rheumatism  in  24  per  cent,  and  subsequent  rheumatism  in  15 
per  cent  of  the  cases.  Excluding  cases  mentioned  twice,  and  also  all  those 
in  which  there  was  a  history  only  of  "  growing  pains,"  there  was  evidence 
of  articular  rheumatism  in  56-7  per  cent  of  the  cases.  Many  of  these  pa- 
tients have  been  under  observation  now  for  several  years,  and  it  has  been 
interesting  to  see,  as  time  has  passed,  how  the  evidences  of  the  rheumatic 
diathesis  have  multiplied  the  longer  the  cases  were  followed. 

In  the  above  statistics  only  articular  symptoms  have  been  accepted  as 


CHOREA. 


6Y5 


evidence  of  rheumatism.  If  the  cases  of  endocarditis  without  articular 
symptoms  were  included,  as  I  think  they  might  fairly  be,  it  would  raise 
the  proportion  of  rheumatic  cases  still  higher.  The  great  proportion 
of  cardiac  murmurs  persisting  after  chorea,  if  not  all  of  them,  should,  I 
believe,  be  classed  as  rheumatic,  even  if  no  articular  symptoms  have  been 
present. 

Overpressure  in  school  is  often  an  important  factor  in  the  production 
of  chorea,  as  has  been  shown  by  Sturges  (London).  Anaemia,  if  not  an 
essential  factor,  is  certainly  a  very  important  one,  and  the  great  propor- 
tion of  cases  present  very  distinct  evidences  of  it.  Chorea  may  develop  as 
a  sequel  of  any  of  the  infectious  diseases,  more  particularly  scarlet  and 
typhoid  fevers.  It  is  seen  quite  often  in  cases  of  chronic  malarial  poi- 
soning. Among  the  reflex  causes  may  be  mentioned  phimosis,  either 
lumbricoids  or  pinworms,  delayed  menstruation,  and  ocular  defects, — 
although  the  latter  more  frequently  cause  a  local  spasm  of  the  muscles  of 
the  eyes,  which  can  hardly  be  considered  choreic.  It  has  been  claimed 
that  chorea  may  result  from  the  reflex  irritation  arising  from  adenoids  of 
the  pharynx  and  enlarged  tonsils.  Whether  this  is  directly  or  only  indi- 
rectly a  cause  is  not  evident.  The  association  of  the  two  conditions  is  not 
very  infrequent. 

Hereditary  influence  is  of  considerable  importance  in  the  production 
of  chorea.  It  is  much  more  frequent  in  children  of  neurotic  families,  and 
very  often  several  successh-e  generations,  or  several  children  in  the  same 
family,  may  suffer  from  the  disease. 

The  exciting  cause  of  chorea  in  a  certain  proportion  of  cases  is  fright ; 
occasionally  it  arises  from  imitation,  and  the  disease  has  been  known  to 
occur  epidemically  in  institutions.  Choreiform  movements  may  follow 
hemiplegia.  Chorea  and  epilepsy  may  be  associated  in  the  same  patient, 
or  one  disease  may  follow  the  other. 

The  causes  which  underlie  the  occurrence  of  chorea  therefore,  seem  to 
be  a  rheumatic  diathesis,  a  neurotic  constitution,  anaemia,  and  some  severe 
disturbance  of  general  nutrition.  When  these  predisposing  factors  are 
present,  an  attack  may  be  induced  by  many  things.  The  greater  the  pre- 
disposition the  less  important  may  be  the  exciting  cauSe.  A  very  large 
number  of  the  cases  of  chorea  are  in  persons  who  presgnt  distinct  evi- 
dences of  rheumatism,  although  the  explanation  of  this  relationship  is  net 
yet  understood.  In  another  group  the  neurotic  element  predominates,  and 
in  these  there  may  be  no  connection  whatever  with  rheumatism. 

Pathology. — The  exact  pathology  of  chorea  is  at  the  present  time  not 
settled.  The  seat  of  the  morbid  process  is  undoubtedly  the  central  nerv- 
ous system,  probably  the  motor  areas  of  the  cortex.  Like  epilepsy, 
chorea  may  follow  organic  brain  disease,  especially  hemiplegia  from  cor- 
tical lesions.  In  some  severe  cases  which  were  fatal,  owing  to  associa- 
tion with  acute  endocarditis,  capillary  emboli  have   been  found   in  the 


6Y6  DISEASES  OP   THE   NERVOUS  SYSTEM. 

brain.  They  have,  however,  often  been  absent,  and  probably  explain  but 
a  small  number  of  cases,  if,  indeed,  they  explain  any.  The  fact  that  in 
the  great  majority  of  the  cases  of  ordinary  chorea,  complete  recovery 
occurs  in  the  course  of  a  few  weeks  or  months,  speaks  strongly  against 
any  important  structural  change  in  the  nervous  centres.  It  seems  much 
more  in  harmony  with  what  we  know  of  the  disease  clinically,  to  seek  an 
exjDlanation  of  the  symptoms  in  vascular  changes  in  these  parts,  having 
their  origin  in  disturbances  of  nutrition. 

Symptoms. — An  attack  of  chorea  generally  comes  on  gradually.  At 
first  the  child  is  often  considered  simply  as  unusually  nervous ;  if  at  school, 
there  may  be  noticed  a  difficulty  in  writing,  drawing,  or  in  using  the 
hands  for  other  delicate  operations.  At  home,  the  child  is  continually 
dropping  things,  has  difficulty  in  feeding  himself,  sometimes  in  buttoning 
his  clothes,  and  very  frequently  he  is  not  brought  to  the  physician  until 
the  symptoms  have  lasted  a  week  or  two.  Sometimes  the  legs  are  first 
affected,  and  a  history  is  given  of  frequent  falls,  a  stumbling  gait,  diffi- 
culty in  going  upstairs,  etc.  At  other  times  the  spasm  is  first  seen  in  the 
facial  muscles,  with  disturbance  of  articulation,  twitchings  of  the  eye 
muscles,  and  the  child  may  be  punished  for  making  grimaces.  In  most 
cases  the  spasmodic  movements  soon  extend  to  all  parts  of  the  body. 
According  to  Starr,  they  remain  limited  to  one  side  of  the  body  (hemi- 
chorea)  in  about  one  third  of  the  cases.  When  fully  developed,  the  move- 
ments of  chorea  are  quite  unmistakable.  They  are  irregular,  jerking, 
spasmodic,  never  rhythmical,  rarely  symmetrical,  and  vary  in  intensity 
from  an  occasional  muscular  contraction  to  almost  constant  motion.  The 
movements  are  not  under  the  control  of  the  patient's  will,  and  are  usually 
intensified  by  efforts  to  suppress  them.  They  are  increased  by  excitement, 
embarrassment,  or  fatigue,  but  do  not  as  a  rule  continue  in  sleep. 

Very  often  there  is  some  weakness  of  the  affected  muscles,  which  may 
be  so  great  as  to  lead  to  the  suspicion  that  actual  paralysis  exists.  Not  in- 
frequently I  have  had  patients  brought  to  the  clinic  for  supposed  paralysis, 
either  of  one  extremity  or  of  one  side  of  the  body,  where  the  choreic  move- 
ments have  not  been  severe  enough  to  attract  the  attention  of  the  mother. 
This  paralysis  usually  disappears  in  the  course  of  a  few  weeks. 

In  severe  forms  of  chorea  the  patient  may  be  unable  to  help  himself 
or  even  to  walk,  from  the  inability  to  co-ordinate  muscular  movements. 
The  symptoms  may  be  so  intense  as  even  to  endanger  life.  Such  cases, 
however,  are  dangerous,  not  from  the  choreic  movements,  but  from  the 
acute  endocarditis  with  which  they  are  frequently  associated. 

The  mental  condition  of  choreic  patients  is  one  of  marked  irritability. 
They  are  fretful,  emcftional,  easily  provoked  to  tears  or  laughter,  and 
often  very  difficult  to  control.  In  extreme  cases  a  mental  disturbance 
bordering  upon  acute  mania  has  been  observed.  All  degrees  of  speech 
disturbances  may  be  met  with,  from  the  slight  difficulty  in  articulation 


CHOREA.  677 

due  to  inability  properly  to  control  the  movements  of  the  tongue  and  lips, 
to  a  condition  in  which  speech  is  almost  impossible.  In  rare  cases  speech 
has  been  temjiorarily  lost.  Heart  murmurs  are  frequent  in  chorea.  Some 
of  these  are  of  anaemic  origin,  some  possibly  are  due  to  chorea  of  the  heart- 
muscle  itself — although  this  is  a  matter  of  some  uncertainty — but  a  large 
number,  probably  the  majority,  are  due  to  concurrent  endocarditis,  as  is 
shown  by  the  fact  that  they  are  permanent,  and  are  followed  by  all  the 
signs  of  organic  heart  disease.  During  every  attack  the  heart  should  be 
closely  watched,  especially  in  children  in  whom  there  is  a  strong  predis- 
position to  rheumatism. 

The  urine  in  chorea  has  recently  been  studied  with  care  by  Herter  and 
Smith,  who  have  shown  that  in  very  many  cases  there  is  an  excessive 
elimination  of  uric  acid.  This  is  neither  the  cause  nor  the  effect  of  the 
chorea,  but  is  to  be  regarded  as  evidence  of  a  profound  disturbance  of 
nutrition,  of  which  the  choreic  movements  are  but  another  manifestation.* 
The  general  condition  of  choreic  patients  is  usually  much  below  normal. 
They  are  anaemic  ;  the  appetite  is  poor,  often  capricious ;  they  sleep  very 
badly ;  they  suffer  frequently  from  headaches ;  they  are  easily  fatigued  by 
slight  muscular  exertion  ;  and  in  short  they  have  all  the  symptoms  of  a 
greatly  disturbed  nutrition. 

Course  and  Duration. — The  ordinary  form  of  chorea  tends  to  spon- 
taneous recovery  in  from  six  to  ten  weeks.  Exceptionally  it  may  last  for 
three  or  four  months.  In  a  small  number  of  cases  the  disease  may  be- 
come chronic  and  continue  indefinitely.  Certain  forms  of  local  spasm, 
particularly  choreiform  movements  of  the  muscles  of  the  face,  eyes,  or 
neck,  may  be  permanent.  In  any  case  of  chorea  which  lasts  longer  than 
the  usual  time,  the  patient  should  be  carefully  examined  for  some  cause  of 
peripheral  irritation.  The  tendency  to  relapses  and  second  attacks  is  very 
marked.  Later  attacks  are  likely  to  occur  in  the  spring  succeeding  the 
first  illness,  and  in  a  small  number  of  patients  attacks  may  come  every 
year  for  four  or  five  years. 

Diagnosis. — There  is  little  difficulty  in  recognising  chorea  from  the 
sudden,  irregular,  spasmodic  contraction  of  the  muscles  coming  on  under 
the  circumstances  indicated.  Xo  other  movements  of  childhood  are 
likely  to  be  confounded  with  it.  The  form  of  chorea  following  hemi- 
plegia is  usually  more  athetoid  than  choreic,  yet  at  times  it  closely  simu- 
lates ordinary  chorea.  The  difficulty  in  distinguishing  between  the  two  is 
often  increased  by  the  fact  that  the  weakness  of  simple  chorea  may,  if  uni- 
lateral, closely  simulate  hemiplegia.    The  existence  of  rigidity,  contractions. 


*  Dr.  Herter  has  called  my  attention  to  the  fact  that  in  many  cases  of  well-marked 
chorea  the  urine  contains  a  peculiar  reddish  colouring  matter  called  h;emato-porphyrin. 
This  is  also  found  in  many  cases  of  rheumatism,  another  evidence  of  the  close  relation- 
ship existing  between  these  two  diseases. 


678  DISEASES   OF   THE   NERVOUS  SYSTEM. 

and  increased  reflexes  belongs  exclusively  to  liemiplegic  cases,  and  these 
will  usually  suffice  to  clear  up  all  doubt  with  reference  to  the  diagnosis. 

Prognosis. — -As  a  rule  this  is  favourable,  and  complete  recovery  can  be 
predicted,  the  exceptions  to  this  being  few  in  number.  Parents  should 
alwa\'s  be  warned  pf  the  tendency  of  the  disease  to  return  in  succeeding 
years,  and  the  fact  should  be  stated  that  in  a  certain  proportion  of  cases 
the  disease  may  be  permanent.  The  prognosis  of  the  cardiac  murmurs 
occurring  in  chorea  should  always  be  guarded,  although  some  of  these  are 
functional  and  disappear  with  recovery  from  the  chorea  ;  but  the  number 
of  those  which  do  not  disappear  is  sufficiently  large  to  make  one  always 
apprehensive  as  to  the  ultimate  result.  Acute  chorea  accomf)anied  with 
endocarditis  may  be  fatal ;  a  number  of  such  cases  are  on  record  in  which 
there  has  been  no  other  evidence  of  rheumatism. 

Treatment. — The  general  management  of  the  case  is  equally  impor- 
tant with  the  administration  of  drugs.  A  child  with  chorea  should  at 
once  be  taken  from  school,  and  should  never  be  subjected  to  punishment 
or  to  ridicule  on  account  of  the  movements.  Special  attention  should 
be  given  to  the  patient's  diet  and  general  nutrition.  Tonics,  especially 
iron,  are  indicated  in  most  cases.  The  food  should  be  simple  and  nutri- 
tious, and  all  stimulants,  particularly  tea  and  coffee,  should  be  absolutely 
prohibited.  While  fresh  air  is  desirable,  exercise  should  be  prescribed 
with  great  caution  and  its  effect  should  be  carefully  watched.  It  should 
never  be  carried  beyond  the  point  of  slight  fatigue.  A  certain  amount  of 
moral  restraint  is  absolutely  necessary ;  thus  it  often  happens  that  choreic 
patients  do  very  badly  at  home  where  they  are  indulged  and  receive  sym- 
pathy, while  in  a  hospital,  where  they  are  under  restraint  and  made  to  con- 
trol themselve.s,  they  begin  to  improve  immediately.  Gymnastics,  although 
useful  in  some  of  the  milder  cases,  may  do  positive  harm  in  those  which 
are  severe.  They  should  be  regularly  and  systematically  practised  twice 
a  day,  but  not  continued  too  long.  In  all  severe  cases  the  "  rest  treat- 
ment "  should  be  employed,  and  equal  benefit  is  also  seen  in  the  milder 
ones, — the  patient  is  put  to  bed,  and  complete  mental  and  physical  rest 
secured.  This  may  be  combined  with  gentle  massage  for  fifteen  or  twenty 
minutes  a  day.  The  daily  use  of  warm  baths,  either  alone  or  in  conjunc- 
tion with  massage,  is  decidedly  beneficial.  In  other  cases  the  regular  use 
of  cold  sponging  is  of  the  greatest  value. 

With  reference  to  the  use  of  drugs,  it  is  advisable  to  separate  from 
other  cases  those  in  which  the  connection  with  rheumatism  is  very  close. 
In  the  rheumatic  cases,  salicylate  of  soda  is  often  efficient,  while  the  drugs 
usually  employed  may  be  absolutely  without  effect.  In  a  case  recently 
under  observation,  arsenic  had  been  continued  for  two  weeks  without  the 
slightest  improvement,  when  the  patient  had  an  intercurrent  attack  of 
subacute  rheumatism  for  which  salicylate  of  soda  in  full  doses  was  given, 
with  the  effect  of  controlling  the  choreic  symptoms  promptly  and  perraa- 


HABIT  SPASM.  6Y9 

nently.  In  the  non-rheumatic  cases,  arsenic  is  almost  universally  admitted 
to  be  the  most  valuable  remedy  we  possess.  The  method  of  administra- 
tion is  important ;  failure  most  frequently  results  from  the  use  of  too  small 
doses.  Beginning  with  four  drops  of  Fowler's  solution  three  times  a  day 
for  a  child  of  eight  years,  the  daily  quantity  may  be  increased  by  two 
drops  each  day  until  a  disturbance  of  the  stomach  or  bowels  is  produced, 
with  puffiness  under  the  eyes.  The  drug  should  now  be  stopped  for  two  or 
three  days,  and  then  the  same  doses  resumed  and  gradually  increased, 
usually  up  to  twelve  drops  three  times  a  day,  sometimes  to  fifteen,  and 
even  twenty  drops,  unless  the  movements  cease  before  that  time ;  but 
when  this  occurs  the  drug  should  be  stopped.  Arsenic  should  always  be 
given  after  meals,  and  largely  diluted,  the  dose  being  taken  in  a  full  glass 
of  water,  but  not  necessarily  drunk  at  one  time.  The  possibility  of  arsenical 
poisoning  should  be  remembered,  although  it  is  extremely  rare.  Semple 
has  reported  a  case  in  which  multiple  neuritis  and  general  pigmentation 
of  the  skin  occurred  after  four  weeks'  administration  of  the  drug. 

In  the  event  of  the  failure  of  arsenic  alone,  it  should  be  combined  with 
the  rest  treatment.  Drugs  which  sometimes  succeed  where  arsenic  fails 
are  antipyrine  and  strychnine.  From  twenty  to  thirty  grains  of  antipyrine 
should  be  given  daily  in  divided  doses  to  a  child  of  eight  years.  There 
are  a  certain  number  of  cases  in  which  striking  improvement  follows  the 
use  of  this  drug  if  given  in  the  full  doses  mentioned.  To  a  child  of  eight 
years  strychnine  should  be  given  in  doses  of  -gig-  of  a  grain  three  times  a 
day,  the  dose  being  gradually  increased  until  double  this  quantity  is 
given ;  sometimes  even  larger  doses  than  these  are  well  borne.  Galvanism 
is  of  some  value  in  cases  not  relieved  by  drugs.  Acute  chorea  of  great 
severity  may  require  opium,  bromide  and  chloral,  or  even  chloroform. 

In  estimating  the  value  of  drugs  in  the  treatment  of  chorea,  the  natu- 
ral course  of  the  disease  should  be  kept  in  mind,  since,  those  drugs  which 
are  taken  after  the  third  or  fourth  week  are  much  more  likely  to  be 
thought  beneficial  than  those  used  in  the  early  period  of  the  attack. 

There  is  no  doubt  that  chorea  may  be  dejDcndent  upon  some  ocular 
defect,  and  a  correction  of  this  will  then  form  an  essential  part  of  the 
treatment,  although  few,  if  any,  cases  are  cured  by  attention  to  the  eyes 
alone. 

Chorea  has  a  strong  tendency  to  recur,  especially  in  the  spring  of  the 
year.  Children  who  have  had  one  attack  should  be  closely  watched,  par- 
ticularly with  reference  to  their  work  in  school.  They  should  not  be 
crowded  in  their  studies,  they  should  have  long  vacations,  a7id  the  nervous 
system  should  not  be  put  upon  any  severe  tension  for  a  long  time. 

OTHER  SPASMODIC   AFFECTIONS. 

Habit  Spasm. — This  term  was,  I  think,  first  suggested  by  Gowers,  to 
describe  certain  muscular  movements  of  a  spasmodic  character  which  at 


^80  DISEASES   OF   THE  NERVOUS  SYSTEM. 

first  are  only  occasionally  noticed,  but  which  sometimes  persist  until  they 
become  habitual  and  almost  entirely  involuntary.  The  condition  was  pre- 
viously called  "  habit  chorea"  by  Weir  Mitchell.  The  movements  usually 
affect  the  muscles  of  the  face,  but  they  may  be  seen  in  almost  any  part  of 
the  body.  The  most  frequent  varieties  consist  of  blinking  or  sudden 
frowning,  raising  the  eyebrows,  or  some  peculiar  grimace.  At  other  times 
there  is  sudden  twisting  of  the  head,  shrugging  of  the  shoulders,  or  jerk- 
ing of  the  hands.  It  is  not  often  seen  in  the  leg,  but  the  muscles  of 
respiration  are  quite  frequently  affected.  There  may  be  a  half-sigh,  a 
sort  of  sob,  or  a  peculiar  dry,  laryngeal  cough. 

These  movements  are  at  first  only  occasional ;  but  as  the  habit  becomes 
more  firmly  fixed  the  spasm  recurs  every  few  minutes,  and  in  severe  cases 
it  may  be  almost  continuous.  In  nearly  all  cases  it  increases  by  observa- 
tion. The  same  form  of  spasm  does  not  always  continue,  but  after  a  time 
one  may  subside  and  another  take  its  place.  The  condition  may  last  for 
months  or  years,  and  it  may  even  be  permanent. 

The  causes  are  those  of  neuroses  in  general.  In  the  beginning,  at 
least,  there  is  usually  a  somewhat  depreciated  general  health.  The  patients 
are  nervous  children  of  neurotic  antecedents.  There  may  be  a  history  of 
some  definite  exciting  cause,  such  as  illness  or  overwork  in  school.  The 
spasm  of  the  muscles  about  the  eyes  may  be  associated  with  pathological 
conditions  of  these  organs.  This  may  be  enough  to  start  the  spasm,  if  not 
to  continue  it.  Both  sexes  are  affected.  In  boys,  masturbation  may  some- 
times be  an  exciting  cause. 

Habit  spasm  is  to  be  differentiated  from  chorea :  this  is  usually  easy, 
from  the  limitation  of  the  movements  to  one  part  or  group  of  muscles  and 
from  the  duration  of  the  disease. 

Treatment  is  quite  unsatisfactory  after  the  habit  has  become  fixed, 
hence  it  is  of  the  utmost  importance  that  it  should  be  arrested  at  the 
earliest  possible  age.  Punishments  are  of  no  avail,  and  usually  aggravate 
the  condition.  Rewards  are  much  more  effectual.  The  general  health 
should  receive  attention  and  nerve  tonics  should  be  given,  especially 
strychnine. 

Athetosis  and  Athetoid  Movements.— This  term,  introduced  by  Ham- 
mond, is  used  to  describe  a  chronic  form  of  spasm  usually  seen  in  the 
hand,  but  sometimes  also  in  the  foot,  and  even  the  face.  It  may  affect 
both  sides,  but  in  most  cases  it  is  unilateral.  The  movement  is  slow, 
irregular,  and  inco-ordinate — a  sort  of  "  mobile  spasm,"  as  it  has  been 
called — and  there  may  be  associated  a  certain  amount  of  muscular  rigidity. 
Such  movements  may  occur  in  persons  otherwise  healthy,  but  are  usually 
seen  as  a  sequel  of  cerebral  palsies,  generally  hemiplegia.  Eecovery  from 
the  hemiplegia  may  be  so  nearly  complete  that  the  athetoid  movements 
are  looked  upon  as  primary.  In  some  cases  the  movements  are  more 
rapid   and   somewhat   resemble    those    of    chorea, — a    condition    which 


NYSTAGMUS.  681 

is  sometimes  classed  a,s  post-hemiplegic  chorea.  Athetosis  is  not  influenced 
by  treatment. 

Rotary  and  Nodding  Spasm  of  the  Head. — These  are  rare  forms  of 
irregular  movements  usually  observed  in  infancy.  The  condition  was 
described  long  ago  by  Henoch,  and  since  then  cases  have  been  reported  by 
Hadden,*  Peterson,  and  others.  The  most  frequent  is  the  rotary  spasm, 
which  consists  in  a  side-to-side  oscillation  of  the  head,  which  may  be  slow 
or  rapid,  and  in  some  cases  is  almost  continuous.  Some  children  have  at 
times  the  nodding  spasm  also,  and  in  others  this  is  the  only  movement 
seen.  Nystagmus  is  frequently  associated,  and  may  be  of  one  or  both  sides. 
In  a  few  of  the  reported  cases  convergent  strabismus  was  present. 

The  causes  of  the  condition  are  extremely  obscure.  It  is  usually  seen 
in  infancy  between  the  third  and  eighteenth  months,  and,  like  most  nervous 
symptoms  of  this  period,  has  been  ascribed  to  dentition,  but  without  any 
special  reason.  In  three  of  the  cases  reported  by  Hadden,  it  followed  an 
injury  to  the  head,  and  might  perhaps  be  regarded  as  a  result  of  cerebral 
concussion. 

As  a  rule,  the  condition  lasts  for  several  months  and  improves, — in  fact, 
recovery  generally  occurs.  The  prognosis  is  then  usually  favourable.  In 
most  of  the  reported  cases  improvement  has  followed  the  use  of  bromides ; 
from  ten  to  twelve  grains  daily  should  be  given. 

Nystagmus. — This  term  is  applied  to  rhythmical,  involuntary,  oscillatory 
movements  usually  of  both  eyes.  They  are  caused  by  the  alternate  con- 
traction of  opposing  muscles.  Nystagmus  may  be  either  vertical  or  hori- 
zontal. It  is  most  often  seen  in  infants  a  few  months  old,  and  is  a 
symptom  of  irritation  which  may  be  general  or  local.  In  some  cases  the 
movement  is  almost  continuous,  occurring  even  in  sleep ;  in  others,  it  is 
■only  noticed  at  times  of  special  excitement. 

The  etiology  of  nystagmus  is  obscure,  and  it  may  occur  in  quite  a 
Tariety  of  conditions, — sometimes  referable  to  the  eye,  at  other  times  to 
the  central  nervous  system.  On  the  part  of  the  eye,  nystagmus  may  be 
■due  to  blindness  from  any  cause,  to  congenital  cataract,  corneal  opacity, 
disease  of  the  choroid  or  retina,  or  to  errors  of  refraction.  It  may  be 
seen  in  almost  any  organic  disease  of  the  nervous  system,  both  with  focal 
and  diffuse  lesions,  especially  in  chronic  hydrocephalus,  insular  sclerosis, 
tuberculous  meningitis,  and  in  diseases  in  which  sight  is  impaired.  Nystag- 
mus may  be  of  reflex  origin,  as  in  a  case  recently  occurring  in  the  Babies' 
Hospital,  where  an  infant  with  a  severe  diarrhoea  had  repeated  attacks, 
which  disappeared  each  time  after  intestinal  irrigation.  While  it  is  of  no 
importance  as  a  localizing  symptom,  nystagmus  usually  indicates  some- 
thing more  than  functional  disturbance.  An  exception  to  this  may  per- 
haps be  made  when  it  follows  cerebral  concussion.     In  such  cases  it  is 

*  Lancet,  June  14,  1890. 


682  DISEASES   OP   THE   NERVOUS  SYSTEM. 

usually  temporary,  disappearing  in  a  few  days  or  weeks.  Under  most 
other  conditions  it  may  continue  indefinitely. 

The  condition  of  the  eyes  should  be  investigated  in  every  case  of 
nystagmus;  it  is  only  when  the  cause  is  here,  and  can  be  removed,'  that 
habitual  nystagmus  is  amenable  to  treatment. 

Hiccough  (Singultus). — This  is  a  spasm  of  the  diaphragm  which  is 
usually  seen  in  young  infants.  In  them  it  is  in  most  cases  due  to  some 
irritation  in  the  stomach.  It  is  seen  after  eating,  and  may  depend  upon 
overfilling  of  the  stomach  by  food,  swallowing  of  air,  etc.  In  other 
cases  it  has  no  relation  to  the  taking  of  food,  and  is  to  be  regarded  as 
a  form  of  refiex  spasm,  which  may  occur  from  a  variety  of  causes,  such  as 
cold  feet,  chilling  of  the  surface  during  bath,  or  suddenly  taking  an  in- 
fant from  a  warm  bed  into  a  cold  room.  In  cases  like  the  above,  hic- 
cough, though  sometimes  annoying,  is  of  little  importance.  It  may  be 
associated  with  gastric  indigestion,  with  intestinal  flatulence  or  inflamma- 
tion, with  peritonitis  or  intestinal  obstruction.  With  the  last  two  condi- 
tions it  is  always  an  unfavourable  symptom.  In  older  children  hiccough 
sometimes  occurs  as  a  pure  neurosis. 

The  object  of  treatment  is  to  remove  the  cause.  In  infants  this  is  to 
aid  in  the  expulsion  of  the  gas  from  the  stomach  by  manipulation,  position, 
or  the  other  means  useful  in  gastric  colic.  Where  it  is  a  nervous  symptom 
only,  it  may  be  arrested  by  holding  the  breath,  prolonged  forced  ex- 
piration, as  in  blowing  a  trumpet,  and  sometimes  may  require  the  use 
of  such  drugs  as  control  muscular  spasm — e.  g.,  antipyrine  or  chloral. 

Thomsen's  Disease  (Congenital  Myotonia). — This  rare  disease  is  usually 
congenital.  It  may  occur  in  several  members  of  the  same  family,  and  is 
often  hereditary.  The  characteristic  symptoms  are  a  peculiar  rigidity  of 
the  muscles  which  is  observed  when  they  are  first  brought  into  action  after 
repose.  This  rigidity  is  spasmodic,  and  usually  continues  but  a  few 
moments.  It  may  recur  when  voluntary  movements  are  again  attempted. 
If,  however,  muscular  effort  is  persisted  in,  it  soon  passes  off.  It  is  in- 
creased by  apprehension,  excitement,  or  cold,  and  by  observation.  The 
legs  are  most  frequently  affected,  the  condition  being  often  noticed  when 
the  patient  starts  to  walk ;  any  of  the  voluntary  muscles,  however,  may 
be  involved.  It  may  be  greater  upon  one  side  of  the  body  than  upon  the 
other.  The  muscles  are  abnormally  sensitive  to  mechanical  stimulation, 
and  often  to  galvanism.  They  are  above  normal  size,  and  the  fibres  them 
selves  are  enlarged. 

The  pathology  of  this  disease  is,  according  to  Gowers,  an  altered  func- 
tional condition  of  the  muscle  fibres,  and  an  abnormal  functional  state  of 
the  nerve  cells  of  the  cord  and  the  cortex.  It  is  incurable,  although  the 
symptoms  may  be  improved  by  active  muscular  exercise. 

Cervical  Opisthotonus. — This  is  usually  a  symptom  of  disease  at  the 
base  of  the  brain,  occurring  with  simple,  tuberculous,  and  chronic  basilar 


TORTICOLLIS. 


683 


J^ 


meningitis,  sometimes  with  tumours  of  the  posterior  fossa  of  the  skull. 
However,  in  certain  cases  it  occurs  as  a  form  of  reflex  spasm,  particu- 
larly in  young  infants  who  are  suffering  from  diarrhoeal  diseases  or  maras- 
mus. In  these  cases  it  may  last  for  days  or  weeks.  The  deformity  is 
produced  by  a  contraction  of  the  superior  fibres  of  the  trapezius  and  by  the 
posterior  group  of  cervical  muscles. 

Torticollis — Wry-Neck. — Torticollis  is  usually  produced  by  a  tonic 
spasm  of  one  steruo-mastoid  muscle,  with  which  may  be  associated  spasm 
of  the  posterior  cervical  muscles, 
including  the  trapezius.  In  re- 
cent cases  tiiere  is  simply  a  con- 
dition of  muscular  spasm ;  in  those 
of  long  standing  there  may  be 
permanent  shortening  of  the  af- 
fected muscle,  atrophy,  and  par- 
tial paralysis.  A  somewhat  simi- 
lar deformity  may  be  caused  by 
cicatricial  contraction  of  the  tis- 
sues of  the  neck  following  burns. 

The  deformity  varies  some- 
what according  as  the  sterno-mas- 
toid  muscle  is  alone  affected,  or 
the  posterior  muscles  also,  and  as 
to  which  predominates.  In  sim- 
ple sterno-mastoid  spasm  the  head 
is  inclined  to  the  affected  side  and 
rotated  toward  the  opposite  side ; 
the  chin  is  raised,  and  the  ear 
approaches  the  clavicle.  TThen 
other   muscles  are    involved   the 

deformity  is  modified.  If  the  trapezius  is  affected  (Fig.  109)  there  is  less 
rotation  of  the  head,  but  it  is  drawn  to  the  affected  side  and  somewhat 
backward,  while  the  shoulder  is  raised  and  the  spine  curved.  Both  of 
these  symptoms  may  be  seen  to  a  slight  degree  in  almost  any  marked  case 
of  sterno-mastoid  spasm.  Sometimes  the  spasm  of  the  posterior  muscles 
affects  both  sides ;  the  head  is  then  drawn  backward  and  held  rigidly  but 
without  rotation.  In  most  of  the  recent  cases  the  deformity  can  be 
partially  or  entirely  overcome  by  passive  force ;  but  after  a  time  this  is 
impossible,  owing  to  muscular  shortening.  In  recent  cases  also  localized 
pain  and  tenderness  are  frequently  present,  and  sometimes  they  are  severe. 

Btiolog I/.— Spasmodic  torticollis  may  be  produced  by  anything  causing 
irritation  of  the  trunk  or  the  branches  of  the  spinal  accessory  nerve  ;  the 
source  may  be  in  the  spinal  canal,  in  the  cranium,  along  the  course  of  the 
nerve  trunk,  or  of  any  of  its  peripheral  fibres. 


Fig.  109. — Spasinodif  torticollis  from  malaria. 
Trapezius  and  sterno-mastoid  of  the  left 
side  are  alleeted. 


(584  DISEASES   OF   THE   NERVOUS  SYSTEM. 

Cases  are  usually  divided  into  congenital  and  acquired.  Whitman,* 
from  the  records  of  the  Hospital  for  the  Ruptured  and  Crippled,  New- 
York,  for  nineteen  years,  gives  the  following  statistics  of  2G4  cases, — torti- 
collis from  Pott's  disease  not  being  included  :  Males,  109  ;  females,  155 ; 
congenital,  82  ;  under  two  years,  33  ;  from  two  to  ten  years,  153 ;  over 
ten  years,  46  ;  acute  (i.  e.,  of  less  than  two  months'  duration),  77  ;  chronic^ 
GO,  of  which  number  22  had  lasted  two  years  or  longer. 

Regarding  the  cause  of  congenital  torticollis  there  is  some  dispute. 
Such  cases  have  often  been  attributed  to  the  contraction  resulting  from 
haematoma  of  the  sterno- mastoid  (page  94).  My  own  experience  coin- 
cides with  Whitman's,  that  this  is  rarely  if  ever  the  case.  While  it  is  pos- 
sible that  the  deformity  is  sometimes  the  consequence  of  injury  received 
during  delivery,  the  cause  of  most  of  the  congenital  cases  goes  back  to  con- 
ditions existing  before  birth.  It  may  be  compared  to  club-foot,  and 
may  be  due  to  a  faulty  position  of  the  child  in  utero,  or  it  may  come 
from  more  serious  conditions,  such  as  malformations,  or  unequal  develop- 
ment of  the  two  sides  of  the  body. 

One  of  the  most  frequent  causes  in  the  acquired  cases,  is  irritation  of 
the  spinal  accessory  nerve  by  an  enlarged  cervical  lymph  gland  ;  this  was 
the  cause  assigned  in  nearly  half  of  Whitman's  cases ;  such  is  the  usual 
etiology  of  torticollis  following  scarlet  fever,  measles,  or  diphtheria.  I 
have  seen  it  in  the  early  stage  of  quinsy,  and  it  may  occur  in  cellulitis  of  the 
neck.  A  cause  which  the  physician  should  always  have  in  mind  is  cervical 
Pott's  disease ;  torticollis  may  be  the  earliest,  and  for  several  weeks  some- 
times almost  the  only,  objective  symptom  of  this  disease.  Torticollis 
coming  on  acutely  is  most  frequently  due  to  cold  (rheumatism?)  or 
malaria.  I  have  notes  of  eight  cases  clearly  traceable  to  malaria,  and  have 
seen  at  least  a  dozen  others.  In  several  of  these  there  was  a  distinct  perio- 
dicity in  the  spasm,  it  recurring  regularly  at  about  the  same  time  each 
day  until  quinine  was  given ;  in  some  cases  it  was  accompanied  by  fever, 
in  others  not.  In  the  so-called  rheumatic  torticollis,  muscular  pain  and 
soreness  are  rather  more  prominent  than  in  the  other  forms.  In  fourteen 
of  Whitman's  cases  the  spasm  was  attributed  to  injuries  other  than  burns  ; 
and  in  only  nine  was  it  associated  with  some  other  disease  of  the  nervous 
system,  most  frequently  with  chorea. 

Prognosis. — The  result  in  a  case  of  torticollis  depends  upon  the  cause,, 
the  severity,  and  the  duration  of  the  deformity.  Most  of  the  acute  cases 
from  malaria,  rheumatism,  etc.,  recover,  under  appropriate  treatment,  in 
the  course  of  a  few  weeks,  sometimes  in  a  few  days,  and  not  a  few  re- 
cover spontaneously.  The  congenital  cases  with  slight  deformity  are 
usually  amenable  to  mechanical  or  postural  treatment  if  begun  early. 
There  is,  however,  in  most  of  the  other  varieties  a  disposition  of  the  de- 

*  Observations  upon  Torticollis,  Medical  News,  October  24,  1891. 


HYSTERIA.  535 

formity,  if  untreated,  to  persist,  and  even  to  increase.  If  it  has  lasted 
several  months  the  probabilities  of  spontaneous  recovery  or  even  of  im- 
provement are  small. 

Treatment. — The  first  indication  is  to  remove  or  treat  the  cause  where 
one  can  be  found.  Malarial  cases  require  quinine  ;  rheumatic  cases  are 
benefited  by  rest  in  bed,  hot  applications,  counter-irritation,  friction,  and 
sometimes  by  anti-rheumatic  remedies.  Cases  which  have  lasted  a  month 
usually  require  some  orthopaedic  head-support,  and  those  which  have 
lasted  six  months  or  more  are  rarely  cured  without  a  surgical  operation. 
This  may  be  either  a  subcutaneous  tenotomy  or  myotomy  of  the  sterno- 
mastoid,  or  an  open  incision.  Whitman  gives  the  result  of  thirty-two  cases 
admitted  for  treatment  to  the  hospital  mentiohed,  as  follows  :  In  17  in 
which  the  deformity  had  lasted  less  than  six  months,  10  were  cured,  the 
average  duration  of  treatment  being  three  months;  4  were  improved,  and 
3  not  improved,  the  average  duration  of  treatment  in  these  cases  being 
eleven  months.  Of  15  cases  in  which  the  deformity  had  lasted  over  six 
months,  none  were  cured  and  only  6  improved,  after  an  average  of  about 
eight  months'  treatment.  In  the  foregoing  series  of  cases  the  treatment 
consisted  mainly  in  the  use  of  orthopa?dic  apparatus  ;  later  results  from 
incision  have  been  considerably  more  favourable.  But  these  figures  show 
how  serious  a  matter  is  an  old  case  of  torticollis,  and  emphasize  the  im- 
portance of  resorting  to  efficient  measures  early  in  the  disease. 

HYSTERIA. 

This  is  not  a  disease  of  childhood,  but  one  which  is  occasionally  seen 
in  early  life.  All  that  will  be  attempted  in  this  chapter  is  to  point  out  the 
most  common  manifestations  of  hysteria  when  it  occurs  in  young  children. 
After  puberty  it  is  essentially  thQ  same  as  in  adults.* 

Etiology. — Hysteria  is  very  rare  before  the  seventh  or  eighth  year,  and 
most  of  the  cases  seen  in  children  occur  after  the  tenth  year.  As  to  sex, 
there  is  no  such  predominance  of  females  as  in  later  life,  although  even  in 
childhood  they  are  more  frequently  affected  than  males.  Hereditary 
influences  play  an  important  part  in  the  production  of  this  disease.  It  is 
seen  in  children  who  inherit  a  nervous  constitution,  or  in  whose  parents 
nervous  diseases,  such  as  insanity,  or  hysteria,  or  alcoholism  have  been 
present.  Of  the  other  etiological  factors  the  most  important  are  a  dis- 
ordered nutrition,  frequently  with  anaemia  or  chlorosis,  and  overpressure 
in  schools.  Masturbation  or  phimosis  may  act  as  an  exciting  cause,  or, 
indeed,  anything  which  leads  to  an  exalted  nervous  irritability  and  depre- 
ciation of  the  general  health.     It  is  occasionally  associated  with  tuber- 

*  For  a  fuller  discussion  of  this  subject,  and  references  to  recent  literature,  see 

Mills,  in  Heating's  Cyclopiedia,  vol.  iv. 


686  DISEASES  OF   THE  NERVOUS  SYSTEM. 

culosis ;  it  may  follow  any  of  the  acute  infectious  diseases ;  or  it  may  be 
excited  by  injury,  fright,  or  imitation. 

Symptoms. — There  is  scarcely  any  disease  in  which  the  clinical  picture 
presented  is  so  varied  as  in  hysteria.  It  may  simulate  almost  any  form  of 
organic  disease  of  the  brain,  lungs,  digestive  organs,  bones,  or  joints.  The 
most  common  symptoms  may  be  grouped  under  four  general  heads.  These 
are,  however,  seen  in  almost  every  conceivable  combination. 

1.  Psychical  symptoms. — Where  these  predominate  there  may  be  seen 
periods  of  mental  depression  of  longer  or  shorter  duration,  a  change  in 
disposition,  an  indifference  to  surroundings,  a  capricious  humour,  or  a  nerv- 
ous condition  of  extreme  irritability  with  irregular  paroxysms  of  laugh- 
ter or  weeping  without  cause.  There  may  be  great  excitability  of  temper, 
and  fits  of  passion  almost  maniacal  in  their  severity.  There  may  be  vari- 
ous hallucinations.  Sleep  is  frequently  disturbed,  sometimes  by  attacks 
resembling  ordinary  night-terrors ;  sometimes  somnambulism  is  present. 
There  is  often  a  disposition  to  deception  about  the  most  trivial  matters, 
which  may  last  for  weeks.  There  is  a  tendency  to  imitate  the  symptoms 
of  various  diseases,  which  the  patients  may  have  witnessed  in  others  or 
about  which  they  have  read. 

2.  Sensory  symptoms. — These  are  the  most  frequent  manifestations  of 
hysteria  in  early  life.  There  is  often  general  or  local  hyperaesthesia, 
which  may  be  so  great  as  to  simulate  inflammation  of  the  various  internal 
organs.  Anaesthesia  is  much  less  common,  although  it  may  be  seen  in 
children  as  young  as  eight  or  nine.  Headache  is  an  occasional  symptom, 
and  is  sometimes  associated  with  great  tenderness  of  the  scalp.  There 
may  be  neuralgias  in  the  different  parts  of  the  body,  or  sharp  epigastric 
pain,  sometimes  accompanied  by  vomiting.  Sometimes  the  special  senses 
are  affected,  giving  rise  to  hysterical  blindness  or  deafness,  usually  of  short 
duration. 

3.  Joi7it  symptoms. — These  are  really  a  variety  of  sensory  disturbances. 
They  are  not  uncommon,  and  are  often  most  puzzling.  The  symptoms 
may  be  referable  to  the  spine,  or  to  any  of  the  large  joints,  particularly 
those  of  the  lower  extremity.  All  forms  of  organic  disease  of  these  joints 
may  be  simulated,  and  these  patients  are  often  treated  for  months  with 
orthopedic  apparatus,  with  the  belief  that  they  are  suffering  from  Pott's 
disease,  lateral  curvature  of  the  spine,  club-foot,  or  ostitis  of  the  hip,  knee, 
or  ankle.  Cases  of  this  sort  have  been  very  fully  described  by  Gibney,* 
and  by  Shaffer,  whose  articles  should  be  consulted  for  fuller  details.  They 
are  usually  seen  between  the  ages  of  ten  and  fourteen  years,  and  occur  in 
both  sexes.  There  may  be  lameness  referred  to  one  of  the  large  joints, 
curvature  of  the  spine,  or  torticollis.     The  symptoms  are  most  frequently 


*  Gibney.  Transactions  of  the  American  Neurological  Association,  1877.     Shaffer, 
Archives  of  Medicine,  New  York,  December,  1879,  February  and  April,  1880. 


HYSTERIA.  6gY 

referred  to  the  hip,  and  next  to  the  knee,  the  ankle,  or  the  spine.  The 
pain  is  often  acute.  It  is  increased  by  motion,  and  by  attempts  at  over- 
coming the  deformity,  if  any  is  present.  There  is  a  marked  hyperaesthesia 
of  the  whole  limb,  and  sometimes  of  the  body.  In  nearly  every  case  there 
is  marked  tenderness  of  the  spine  npon  pressm-e,  especially  in  the  dorsal 
region.  The  deformity  may  be  very  slight  from  spasm  of  the  flexors 
only,  or  it  may  be  severe,  and  followed  by  contracture,  so  that  the  thighs 
may  be  flexed  tightly  against  the  abdomen  with  the  heels  against  the 
buttocks.  Such  deformities  may  last  for  months.  There  may  be  con- 
siderable muscular  atrophy,  but  only  that  which  comes  from  disuse.  A 
special  difficulty  in  diagnosis  arises  from  the  circumstance  that  these 
symptoms  occasionally  follow  an  injury. 

Organic  disease  of  bones  and  joints  m:iy  usually  be  excluded  by  atten- 
tion to  the  following  points :  The  mode  of  onset  is  more  abrupt  than  is 
seen  in  bone  disease,  and  the  course  of  the  disease  is  quite  irregular.  The 
degree  of  deformity  is  greater  than  is  seen  in  bone  disease  of  the  same 
duration.  There  are  general  hyperesthesia  of  the  limb,  acute  tenderness  of 
the  spine  upon  pressure,  and  undue  sensitiveness  to  heat  or  cold.  The  de- 
formity varies  from  time  to  time,  being  always  more  marked  when  examina- 
tion is  attempted.  If  the  patients  are  closely  watched,  other  evidences  of 
hysteria  may  be  seen.  Under  complete  anaesthesia  the  contractures  may 
disappear  entirely.  There  is  no  enlargement  of  the  articular  ends  of  the 
bones,  no  swelling  of  the  soft  parts,  and  no  evidence  of  active  inflammation 
or  of  suppuration.  All  the  symptoms  except  the  deformity  are  subjective. 
Under  proper  treatment  there  is  in  most  cases  perfect  recovery,  often  in  a 
surprisingly  short  time. 

4.  Motor  and  convulsive  syynjitoms. — In  the  milder  forms  we  may 
see  many  varieties  of  tonic  or  clonic  spasm.  There  may  be  seen  local 
spasm  of  the  eyes,  face,  or  mouth,  spasm  of  the  muscles  of  the  neck  pro- 
ducing torticollis,  of  the  muscles  of  respiration  causing  dyspnoea,  which 
may  be  constant  or  paroxysmal.  There  may  be  hiccough,  or  spasm  of  the 
larynx  causing  hysterical  aphonia.  A  very  common  symptom  is  hysterical 
cough,  which  may  be  so  frequent  and  so  severe — even  accompanied  by 
haemoptysis — that  grave  disease  of  the  lungs  is  suspected  ;  the  chest, 
however,  is  free  from  the  physical  signs  of  disease.  There  may  be  fre- 
quent attacks  of  vomiting  with  eructations;  these  maybe  continued  some- 
times even  for  months,  and  in  rare  instances  blood  has  been  vomited. 
There  may  be  dysphagia  from  spasm  of  the  oesophagus,  or  regurgitation 
of  food  on  attempts  at  swallowing.  In  more  severe  cases  we  may  have  the 
symptoms  of  chorea  major  and  attacks  of  hystero-epilepsy.  The  latter  are 
rare  in  children  and  do  not  differ  essentially  from  such  attacks  in  older 
patients.  There  are  usually  prodromal  symptoms.  The  convulsive  move- 
ments are  exceedingly  varied  in  type.  There  are  painful  sensations  and 
sensitive  areas,  by  pressure  upon  which  hysterical  symptoms  may  be  in- 
45 


588  DISEASES  OP  THE  NERVOUS  SYSTEM. 

creased  or  even  convulsions  excited.  The  respiration  may  be  rapid  or 
irregular.  All  variations  in  tonic  and  clonic  spasm  may  be  seen.  Opis- 
thotonus is  frequent.  Cousciousuess  is  not  fully  lost,  but  is  disturbed,  and 
hallucinations  are  present.     The  temperature  is  normal. 

Hysterical  paralysis  is  not  common  in  children,  but  it  may  be  seen 
even  in  the  very  young.  Gillette  has  reported  the  case  of  a  child  eighteen 
months  old  who  exhibited  the  symptoms  of  hysterical  palsy  of  one  arm. 
Other  symptoms  occasionally  seen  in  hysteria,  are  persistent  anorexia,  poly- 
uria, sometimes  incontinence  of  urine,  disturbance  of  the  secretion  of 
saliva  or  perspiration,  and  very  rarely  hysterical  fever. 

The  general  condition  of  hysterical  patients  is  usually  below  the  nor- 
mal. They  are  poorly  nourished  and  anaemic ;  they  sleep  badly  ;  they  have 
capricious  appetites,  feeble  digestion,  and  faulty  assimilation. 

Diagnosis. — Hysteria  is  apt  to  be  overlooked  because  its  occurrence  in 
children  is  not  considered  as  often  as  it  should  be.  In  most  cases  the 
diagnosis  is  easy  if  hysteria  is  suspected.  A  combination  of  vague  discon- 
nected symptoms  is  usually  present  which  admits  of  no  other  explanation. 
Organic  disease  can  be  excluded  only  by  careful  and  repeated  examinations. 
It  is  to  be  borne  in  mind,  however,  that  hysteria  not  infrequently  compli- 
cates organic  or  constitutional  disease.  Much  importance  is  to  be  attached 
to  a  family  history  of  hysteria  or  of  other  neuroses.  From  poliomyelitis, 
hysterical  paralysis  is  differentiated  by  the  presence  of  faradic  contractility 
even  though  atrophy  exists.  Hysterical  convulsions  are  differentiated  from 
true  epilepsy  by  the  absence  of  any  elevation  of  temperature,  of  biting  of 
the  tongue,  evacuation  of  the  viscera,  of  a  violent  fall,  and  often  by  the 
rapid  disappearance  of  the  symptoms  under  appropriate  treatment. 

Prognosis. — This  is  better  than  in  adults,  especially  if  the  cases  are 
taken  in  hand  early,  before  the  disease  has  become  deeply  seated.  Very 
much  depends  upon  how  well  the  directions  for  treatment  can  be  carried 
out.  The  prognosis  is  less  favourable  where  the  hereditary  tendency  is 
strongly  marked.     In  many  cases  there  are  relapses  later  in  life. 

Treatment. — Prophylaxis  is  of  much  importance.  When  a  hereditary 
tendency  to  nervous  diseases  exists  in  a  family,  or  whenever  very  nervous 
children  are  placed  under  the  physician's  care,  every  means  should  be  taken 
toward  muscular  development,  keeping  the  nervous  system  in  the  back- 
ground. Snch  children  should  lead  an  out-of-door  life  as  much  as  possi- 
ble, preferably  in  the  country  ;  they  should  keep  early  hours,  have  regular 
exercise,  and  their  education  should  be  directed  with  moderation  and  judg- 
ment; special  attention  being  paid  to  regularity  of  work,  and  the  preven- 
tion of  overpressure  in  schools.  Theatres  and  exciting  books  should  be 
avoided.  All  stimulants,  including  tea  and  coffee,  should  be  absolutely 
forbidden.  The  diet  should  be  plain  and  nutritious.  It  is  highly  impor- 
tant that  such  children  should  be  removed  from  association  with  a  hysteri- 
cal mother,  when  this  is  possible. 


HEADACHES.  g89 

In  the  general  management  of  a  case  of  hysteria,  it  is  of  the  first  im- 
portance that  the  child  should  be  cared  for  by  a  person  of  firmness,  who 
can  exercise  proper  control.  Hysterical  children  are  always  managed 
more  easily  when  they  are  removed  from  their  homes  and  placed  under  the 
charge  of  a  good  trained-nurse.  Isolation  is  absolutely  essential  in  many 
cases.  The  general  health  should  be  carefully  looked  after,  and  arsenic, 
iron,  cod-liver  oil,  and  other  tonics  given  according  to  indications.  Horse- 
back exercise  and  other  out-of-door  sports  should  be  encouraged,  and  every 
means  taken  to  interest  the  child  in  something  which  requires  physical 
exercise.  In  cases  of  simulated  disease,  the  child  should  be  put  to  bed,  no 
books  or  toys  allowed,  and  no  efi'ort  made  toward  his  amusement.  No 
sympathy  should  be  exhibited,  but  the  child  treated  with  kindness  and 
firmness.  This  moral  treatment  is  quite  as  important  as  any  other  part 
of  the  therapeutics.  In  cases  with  hysterical  joint  symptoms  the  most 
valuable  thing  is  counter-irritation  to  the  spine,  preferably  by  the  Paque- 
lin  cautery.  Some  cases  are  benefitted  by  galvanism.  The  moral  effect 
of  hypodermics,  even  of  cold  water,  is  sometimes  striking.  Under  no  cir- 
cumstances should  mechanical  force  be  used  to  overcome  deformity.  Many 
cases  of  hysteria  improve  under  hydrotherapy ;  the  cold  douche,  the  cold 
pack,  or  the  shower  bath  may  be  used.  This  is  valuable  in  conjunction 
with  massage  and  the  "rest  treatment." 

In  attacks  of  hystero-epilepsy  the  cold  douche  may  be  used,  or  pressure 
made  upon  the  testicle  or  ovary.  In  severe  cases  ether  may  be  given.  In 
all  hysterical  cases  the  condition  of  the  bowels  should  receive  careful  atten- 
tion, as  these  patients  are  very  prone  to  obstinate  constipation. 

HEADACHES. 

Headaches  are  not  common  in  little  children  except  in  connection 
with  disease  of  the  brain  or  meninges ;  in  older  children  they  occur  from 
causes  similar  to  those  seen  in  adult  life.  The  most  frequent  headaches 
may  be  grouped  in  the  following  classes  : 

1.  Toxic  headaches. — Such  are  the  headaches  resulting  from  uraemia, 
from  carbonic  acid  in  poorly  ventilated  rooms,  and  from  malaria.  But 
the  largest  number  are  due  to  absorption  of  toxines  from  the  intestines, 
and  are  associated  with  chronic  indigestion  and  constipation. 

2.  Headaches  from  ancemia  and  malnutrition. — These  are  most  fre- 
quently seen  in  girls  from  ten  to  fourteen  years  old.  Some  are  intellec- 
tually bright,  and  have  been  crowded  in  their  school  work;  others  are  dull 
and  learn  only  with  difficulty,  and  in  consequence  worry  over  their  work 
until  their  health  becomes  undermined.  They  sleep  badly,  lose  appetite, 
and  often  become  choreic.  The  anaemia  may  be  either  the  cause  or  the 
result  of  these  symptoms.  The  urine  in  these  cases  often  contains  a  large 
excess  of  uric  acid. 


(590  DISEASES  OP   THE   NERVOUS  SYSTEM. 

3.  Headaches  of  nervous  origin. — These  may  occur  in  children  who 
are  highly  neurotic,  either  from  their  inheritance  or  surroundings,  and  in 
those  who  are  the  subjects  of  epilepsy  or  hysteria,  and  they  may  be  symp- 
tomatic of  organic  disease  of  the  brain,  such  as  tumour  or  tuberculous  or 
syphilitic  meningitis.  True  facial  neuralgia  is  rare  in  childhood  except 
from  carious  teeth ;  from  this  cause,  however,  it  is  not  infrequent. 

4.  Headaches  due  to  disease  of  some  of  the  organs  of  special  sense. — In 
connection  with  the  eyes  there  may  be  conjunctivitis,  keratitis,  iritis,  errors 
of  refraction,.or  strabismus ;  connected  with  the  nose  there  may  be  polypi, 
hypertrophic  rhinitis,  or  adenoid  vegetations  of  the  pharynx ;  connected 
with  the  ears  there  may  be  otitis  or  foreign  bodies  in  the  canal.  Each  one 
of  these  conditions  requires  special  treatment. 

5.  Headaches  due  to  inherited  gout  or  rheumatism. — These  are  not 
very  frequent,  but  they  may  be  severe,  and  may  at  times  simulate  the  onset 
of  meningitis.  They  are  often  accompanied  by  pains  in  the  joints,  mus- 
cles, or  nerve  trunks ;  they  may  be  associated  with  a  urine  which  is  highly 
acid  and  contains  deposits  of  oxalates  or  of  free  uric  acid. 

6.  Disturhances  of  the  genital  tract  are  rarely  a  cause  of  headaches  in 
children,  although  this  may  be  the  case  in  girls  about  the  time  of  puberty, 
especially  where  menstruation  is  delayed  or  difficult. 

Diagnosis. — The  diagnosis  of  headaches  includes  the  discovery  of  the 
cause,  and  this  is  often  difficult.  In  an  infant  or  a  young  child,  organic 
disease  of  the  nervous  system  should  always  be  suspected  as  a  cause  of  se- 
vere headaches.  In  older  children  the  important  things  to  be  considered, 
because  the  most  frequent,  are  digestive  disturbances,  nervous  exhaustion, 
malnutrition,  and  visual  disorders.  An  absolute  diagnosis  in  a  case  of 
persistent  headache  can  be  made  only  by  a  careful  physical  examination, 
not  omitting  a  study  of  the  urine ;  often  there  must  be  a  close  observation 
of  the  patient  for  some  time. 

Treatment. — The  only  successful  treatment  is  that  which  is  directed 
toward  a  removal  of  the  cause.  Each  one  of  the  different  groups  above 
mentioned  is  to  be  managed  differently,  according  to  the  principles  else- 
where laid  down  regarding  the  treatment  of  these  conditions.  For  the 
relief  of  the  symptom,  cold  to  the  head,  a  hot  foot-bath,  and  phenacetine 
in  moderate  doses  are  perhaps  the  most  certain  of  all  remedies. 

DISORDERS  OP   SPEECH. 

In  this  chapter  will  be  discussed  only  functional  speech  defects,* 
those  depending  upon  organic  conditions  being  considered  in  connection 
with  diseases  of  the  brain.  The  most  common  varieties  are  stuttering, 
stammering,  lisping,  alalia,  backwardness,  and  functional  aphasia.     All 

*  See  Wyllie,  Edinburgh  Medical  Journal,  October,  1891. 


DISORDERS  OF   SPEECH.  691 

forms  are  much  more  frequent  in  boys  than  in  girls,  the  proportion  being 
more  than  four  to  one. 

Stuttering. — This  is  the  most  common  form  of  speech  disturbance. 
Articulation  is  distinct  and  the  separate  sounds  are  properly  produced, 
but  there  is  a  difficulty  in  connecting  the  consonant  with  the  succeeding 
vowel ;  this  seems  like  an  obstacle  to  be  overcome.  Stuttering  is  occa- 
sionally seen  in  most  children.  It  is  more  frequent  in  the  third  and 
fourth  years,  before  speech  is  thoroughly  mastered.  At  this  age  it  is 
aggravated  or  produced  by  disturbances  of  nutrition,  but  is  usually  of 
temporary  duration,  lasting  for  a  few  weeks  or  months.  Only  recently  a 
little  boy  of  four  was  under  my  care,  who  became  very  anaemic,  slept 
poorly,  and  suffered  from  malnutrition  as  a  result  of  the  confinement  inci- 
dent to  a  home  in  the  city.  He  soon  began  to  stutter,  and  in  a  short 
time  it  became  painfully  marked.  After  a  few  weeks  in  the  country  he 
improved  very  much  in  his  general  condition,  gained  four  or  five  pounds 
in  weight,  and  his  stuttering  completely,  and  I  think  permanently,  disap- 
peared. Such  disturbances  as  this  are  analogous  to  chorea.  In  other  cases 
stuttering  follows  some  acute  illness,  and  under  such  conditions  also  it  is 
usually  of  short  duration. 

Most  children  who  become  habitual  stutterers  do  not  begin  until  they 
are  six  or  seven  years  old,  and  sometimes  even  later.  Stuttering  may  arise 
from  imitation,  and  probably  inheritance  is  an  occasional  factor.  It  is 
frequently  a  mark  of  degeneration. 

It  is  important  that  all  such  cases  receive  early  treatment  before 
the  habit  becomes  firmly  fixed.  The  prognosis  is  good  for  sponta- 
neous recovery  in  nearly  all  the  cases  seen  in  very  young  children, 
and  also  in  those  coming  on  after  acute  illness.  Other  cases  in  which 
the  condition  has  become  habitual,  should  have  the  benefit  of  syste- 
matic training  under  a  competent  teacher  in  breathing,  vocal,  and  speech 
gymnastics. 

Stammering. — This  term  is  sometimes  used  synonymously  with  stut- 
tering. Kussmaul  makes  the  distinction  between  them  that,  in  stammer- 
ing, individual  sounds  are  difficult  of  production,  while  in  stuttering  it  is 
syllabic  combinations.  Stammering  is  often  accompanied  by  some  defect 
in  the  organs  of  articulation — the  teeth,  lips,  tongue,  or  palate — which 
is  not  present  in  stuttering. 

The  treatment  consists  in  careful  training  and  in  the  correction  of 
whatever  abnormal  local  conditions  may  exist. 

Lisping. — In  this  there  is  imperfect  production  of  certain  sounds, 
owing  usually  to  a  faulty  position  of  the  organs  of  articulation.  The 
sounds  may  be  so  indistinct  that  they  can  not  be  understood.  In  this 
condition  also  there  may  be  defective  formation  of  some  of  the  organs  of 
articulation,  although  in  the  milder  forms  this  is  not  the  case.  The  treat- 
ment is  similar  to  that  of  stammering. 


692  DISEASES  OP  THE   NERVOUS  SYSTEM. 

Alalia. — This  consists  in  a  total  inability  to  articulate.  It  is  seen  in 
all  young  infants  during  their  earliest  attempts  at  talking.  In  older 
children  it  is  usually  associated  with  some  mental  defect. 

Backwardness. — Backwardness  is  carefully  to  be  distinguished  from  a 
late  development  of  speech  due  to  idiocy.  At  two  years  old  children  not 
deaf  are  almost  invariably  able  to  speak.  Speech  may  be  late  in  conse- 
quence of  prolonged  or  very  severe  illness,  and  where  it  has  been  acquired 
it  may  be  lost  from  similar  causes. 

Functional  Aphasia. — The  term  has  been  applied  to  a  temporary  loss 
of  speech  which  sometimes  occurs  in  chorea,  and  sometimes  from  severe 
fright  or  anything  else  which  has  produced  a  marked  nervous  im- 
pression. West  records  an  instance  in  a  girl  of  eight  years,  who  was 
suffering  from  an  attack  of  chorea  induced  by  fright.  Speech  first  be- 
came difficult  and  then  was  lost  altogether.  For  a  month  the  child  could 
say  only  "  Yes  "  and  "  No."  The  case  very  slowly  improved,  but  at  the  end 
of  nine  weeks  had  recovered  completely. 

Loss  of  speech  sometimes  follows  the  acute  infectious  diseases,  espe- 
cially typhoid  fever. 

In  all  disorders  of  speech,  the  functional  cases  are  to  be  distinguished 
from  those  which  depend  upon  deafness  and  mental  deficiency.  The 
frequency  with  which  these  disorders  are  due  to  disturbances  of  general 
nutrition,  and  to  local  causes  in  the  mouth  and  throat,  should  be  born^ 
in  mind,  and  these  conditions  should  receive  their  appropriate  treatment 
early,  before  the  habit  of  defective  speech  becomes  firmly  established. 
For  the  latter  class  of  unfortunates,  special  training  at  the  hands  of  a 
competent  teacher  should  be  advised,  preferably  in  an  institution. 

DISORDERS  OP  SLEEP.* 

Disturbed  Sleep,  Sleeplessness. — Disturbed  or  restless  sleep  is  much 
more  common  in  infancy  and  childhood  than  is  true  insomnia,  although 
the  causes  of  the  two  conditions  may  be  the  same. 

Etiology. — In  infancy  these  symptoms  are  most  frequently  due  to 
hunger  or  to  indigestion  resulting  from  overfeeding  or  improper  feeding. 
Very  often  disturbed  sleep  is  the  result  of  bad  habits,  such  as  rocking 
during  sleep  or  night-feeding.  Sometimes  it  arises  from  dentition,  or  the 
pain  of  colic  or  otitis ;  at  other  times  it  may  be  simply  the  expression  of  a 
condition  of  nervous  irritability,  the -result  of  inheritance  or  of  the  child's 
surroundings. 

In  later  childhood  the  first  thing  to  be  suspected  when  sleep  is  much 
disturbed  is  some  derangement  of  the  digestive  organs;  in  this  will  be 
found  the  explanation  of  fully  half  the  cases.     The  most  frequent  type, 

*  Por  the  characteristics  of  the  sleep  of  infancy,  and  the  average  amount  taken  at 
the  different  ages,  see  pages  5  and  6. 


DISORDERS  OF  SLEEP.  593 

where  the  symptom  is  of  long  duration,  is  chronic  intestinal  indigestion, 
often  associated  with  indicanuria,  a  condition  in  which  the  diagnosis  of 
the  mother  is  usually  worms.  Other  cases  are  due  to  obstructed  respira- 
tion from  adenoid  growths  of  the  pharynx  or  enlarged  tonsils,  sometimes 
to  nocturnal  attacks  of  asthma.  A  lack  of  fresh  air  in  the  sleeping  room, 
excessive  or  insuflBcient  bedclothing,  and  cold  feet,  are  other  frequent 
causes.  Disturbed  sleep  with  "  starting  pains "  is  one  of  the  earliest 
symptoms  of  hip-joint  disease.  In  the  nervous  exhaustion  resulting 
from  overpressure  in  schools,  and  in  malnutrition  and  anaemia,  dis- 
turbances of  sleep  are  well-nigh  constant.  They  are  also  seen  in  organic 
cardiac  disease  and  in  all  pulmonary  conditions  accompanied  by  dysp- 
noea or  cough.  Sleep  may  be  disturbed  in  consequence  of  bad  dreams 
which  have  their  origin  in  exciting  stories  heard  or  read  just  before  bed- 
time, or  in  too  violent  or  exciting  play.  To  discover  the  cause  in  almost 
any  case  it  is  necessary  to  investigate  carefully  the  whole  routine  of  the 
child's  life. 

Symjjtoms. — The  condition  may  be  one  of  real  insomnia  which  may 
last  for  weeks  or  months ;  or  the  sleep  may  be  simply  disturbed  and  rest- 
less, the  child  waking  many  times  during  the  night,  and  when  asleep  will 
not  lie  quietly,  but  constantly  changes  his  position.  Sometimes  children 
wake  suddenly  with  a  scream,  but  immediately  drop  off  to  sleep  again. 

Treatment. — The  essential  treatment  consists  in  the  discovery  and  re- 
moval of  the  cause  of  the  disturbance.  This  will  often  involve  a  radical 
change  in  the  manner  of  feeding,  in  the  hygiene  of  the  nursery,  and  in 
all  the  surroundings  of  the  child ;  but  in  this  way  only  should  these  cases 
be  managed.  Under  no  circumstances  should  the  phvsician  countenance 
the  use  of  drugs  to  promote  sleep  in  children,  except  in  the  case  of  severe 
acute  disease.  Soothing  syrups  and  all  nostrums  for  "  teething  "  should 
be  absolutely  forbidden.  Mothers  and  nurses  are  only  too  ready  to  fall 
into  the  habit  of  using  them,  because  the  injurious  effects  are  not  appre- 
ciated. When  the  cause  of  sleeplessness  is  found  and  removed  the  child 
will  sleep,  but  compulsory  sleep  obtained  under  other  conditions  is  always 
productive  of  more  harm  than  good.  If  food,  diet,  and  all  bad  habits 
have  been  corrected,  nervous  causes  must  be  investigated.  When  no  cause 
can  be  discovered  the  treatment  should  consist  in  putting  the  child  upon 
the  simplest  possible  diet,  and  in  attention  to  such  general  conditions  as 
anaemia,  malnutrition,  and  neurasthenia,  some  of  which  are  almost  certain 
to  be  present.  In  many  cases  a  warm  bath  at  bed-time  will  be  found  bene- 
ficial. A  quiet,  darkened  room,  plenty  of  fresh  air,  and  the  stopping  of 
both  eating  and  drinking  during  the  night,  are  essential  to  a  cure  in  most 
cases.  When  the  condition  accompanies  some  acute  disease,  the  drugs 
which  are  most  useful  are  codeia  and  trional.  A  child  of  two  years  may 
take  -^Q  of  a  grain  of  codeia  or  two  grains  of  trional  as  an  initial  dose,  to 
be  increased  if  necessary. 


694  DISEASES  OP  THE  NERVOUS  SYSTEM. 

Night  Terrors — Pavor  Nocturnus. — Two  classes  of  cases  have  been 
grouped  under  this  head,  both  having  this  in  common,  that  sleep  is  dis- 
turbed by  fright.  In  an  excellent  recent  article  upon  this  subject,*  Coutts 
calls  attention  to  the  necessity  of  sharply  distinguishing  between  them. 

The  condition  in  the  first  group  partakes  of  the  nature  of  nightmare. 
It  may  be  due  to  partial  asphyxia  from  adenoid  growths  of  the  pharynx, 
or  to  other  causes  mentioned  under  disturbed  sleep,  or  it  may  be  gastric  or 
intestinal  in  its  origin.  These  cases  are  quite  frequent.  Sleep  may  be 
disturbed  from  the  outset,  and  the  attack  may  be  merely  the  culmination 
of  such  disturbance.  The  child  wakes  in  a  state  of  fright  and  excitement, 
and  often  says  he  has  had  a  bad  dream.  His  mind  is  clear,  he  recognises 
those  about  him,  but  it  may  be  a  long  time  before  he  is  sufficiently  calm 
to  sleep  again.  The  attack  may  be  remembered  perfectly  the  next  day. 
Cases  like  this  are  to  be  managed  in  the  same  general  way  as  cases  of  dis- 
turbed sleep  above  mentioned. 

In  the  second  group  are  the  only  cases  to  which  the  term  "  night  ter- 
rors" should  really  be  applied.  These  are  relatively  rare,  but  the  condi- 
tion is  a  much  more  serious  one.  The  symptom  is  due  to  some  dis- 
turbance of  the  central  nervous  system.  According  to  Coutts,  it  occurs 
especially  in  those  of  neurotic  antecedents,  or  those  who  have  previously 
suffered  from  infantile  convulsions,  and  it  is  often  the  precursor  of  other 
nervous  attacks, — migraine,  hysteria,  epilepsy,  and  even  insanity.  The 
attack  usually  comes  suddenly  where  a  child  has  previously  been  sleep- 
ing quietly,  and  more  frequently  in  the  early  part  of  the  night  than  later. 
He  is  generally  found  sitting  upright  in  his  bed  in  a  bewilderment  of 
terror,  being  afraid  of  "  the  dog,"  or  "  the  bear,"  or  there  is  some  other 
vision  or  hallucination  which  has  produced  the  fright.  Often  this  is  asso- 
ciated with  something  of  a  red  colour.  The  child  does  not  recognise 
those  about  him,  does  not  know  where  he  is,  and  may  go  to  sleep  again 
without  coming  to  full  consciousness.  The  next  day  there  is  no  recollec- 
tion of  what  has  happened.  Usually  no  after-effects  are  seen,  but  some- 
times a  large  amount  of  pale  urine  is  passed.  The  attacks  may  be  re- 
peated at  intervals  of  a  few  months,  or  they  may  occur  every  few  nights ; 
but  whatever  the  peculiar  nature  of  the  vision,  it  is  likely  to  be  repeated 
in  nearly  the  same  form.  Such  attacks  have  something  in  common  with 
epileptic  seizures,  and  the  diagnosis  between  them  may  at  times  be  diffi- 
cult. They  are  always  to  be  regarded  seriously,  not  only  on  account  of 
what  they  are  in  themselves,  but  on  account  of  what  may  follow. 

Treatment. — All  mental  and  nervous  strain  should  be  most  carefully 
avoided,  and  where  the  attacks  are  frequent  the  bromides  should  be  given 
at  bedtime.  Some  person  should  sleep  in  the  same  room  with  the  child, 
or  in  an  adjoining  one  with  the  door  open. 

*  American  Journal  of  the  Medical  Sciences,  February.  1896. 


INJURIOUS  HABITS   OP   INFANCY   AND   CHILDHOOD.  695 

Excessive  Sleep. — It  is  rare  that  either  infants  or  children  sleep  an  un- 
natural amount  of  the  time  unless  one  of  two  causes  is  present — organic 
brain  disease  or  the  use  of  drugs.  The  latter  is  always  to  bo  suspected  if 
with  the  sleep  there  is  associated  obstinate  constipation.  Opium  in  the 
form  of  "  soothing  syrup  "  or  paregoric,  is  the  drug  which  has  usually  been 
given. 

INJURIOUS   HABITS   OP   INFANCY   AND   CHILDHOOD. 

On  account  of  the  close  connection  of  these  habits  with  disturbances 
of  the  nervous  system,  they  may  be  properly  considered  with  the  func- 
tional nervous  diseases.  Although  some  of  these  habits  may  not  be  of 
serious  importance,  yet  as  a  group  they  have  received  altogether  too  little 
attention  at  the  hands  of  the  physician. 

Sucking. — This  is  a  very  common  habit  in  infants,  and  during  the  first 
few  months  it  is  seen  to  some  degree  in  most  of  them.  If  they  are  care- 
fully watched  the  habit  is  easily  stopped  ;  otherwise  it  may  continue  in- 
definitely. Young  infants  ^^sually  suck  the  fingers  when  hungry,  and  this 
can  scarcely  be  considered  abnormal,  but  an  effort  should  always  be  made 
to  stop  it,  lest  the  habit  become  fixed.  Lindner  *  distinguishes  between 
simple  sucking  and  sucking  with  combinations.  In  the  former,  the  child 
sucks  some  part  of  the  body,  such  as  the  thumb,  fingers,  toes,  tongue,  lips, 
back  of  the  hand  or  arm,  or  it  may  be  some  foreign  substance,  such  as , 
part  of  the  clothing,  the  blanket,  a  rubber  nipple,  or  a  "  sugar-teat."  This 
is  the  most  common  form  that  is  seen.  In  the  second  variety  the  suck- 
ing is  accompanied  by  the  rubbing  of  some  other  parts,  which  seems  to 
afford  a  pleasurable  excitement ;  this  may  be  the  ear,  the  genitals,  or  any 
other  portion  of  the  body.  Sometimes  sucking  is  accompanied  by  some 
practice  which  produces  actual  pain,  such  as  pulling  of  the  hair  or  scratch- 
ing the  body.  Habits  of  sucking  often  persist  throughout  infancy,  and 
not  infrequently  throughout  childhood  ;  they  have  often  been  known  to 
continue  up  to  puberty.  The  longer  the  habit  has  lasted  the  more  diffi- 
cult is  it  to  break. 

The  results  of  sucking  may  be  serious.  Deformities  of  the  thumb  or 
finger,  of  the  lips  and  teeth,  and  even  of  the  jaws,  are  sometimes  pro- 
duced. I  know  a  lady,  now  in  advanced  life,  whose  thumbs  to  this  day 
show  a  deformity  resulting  from  the  habit  of  thumb-sucking  while  a  child. 
In  her  case  the  habit  was  not  broken  until  she  was  eight  or  nine  years 
old.  Probably  the  most  pernicious  result  of  sucking  is  its  tendency  to 
develop  the  habit  of  masturbation.  Habitual  sucking  of  one  hand  or 
finger  may  lead  to  spinal  curvature. 

Treatment. — In  the  management  of  these  cases  the  most  important 
thing  is  to  arrest  the  habit  early,  before  it  becomes  fixed.     Too  often  the 


*  Jahrbuch  fiir  Kinderheilkunde,  vol.  xiv,  p.  68. 


696  DISEASES  OF  THE   NERVOUS  SYSTEM. 

habit  of  thumb-sucking,  or  of  sucking  a  rubber  nipple,  is  encouraged  by 
mothers  and  nurses,  because  of  the  temporary  quiet  which  is  thereby 
produced;  even  physicians  are  sometimes  accessory  to  this  procedure. 
Under  no  circumstances  should  it  be  resorted  to  as  a  means  of  putting 
children  to  sleep  or  otherwise  quieting  the  nervous  system.  Nurses 
and  parents  should  be  put  on  their  guard.  With  infants,  the  only 
treatment  which  is  at  all  successful  is  such  mechanical  restraint  as  will 
make  sucking  an  impossibility.  It  is  of  no  use  to  cover  the  part  which 
is  sucked  with  bitter  solutions.  My  experience  has  been  that  children  are 
not  deterred  even  in  the  slightest  degree  by  such  procedures.  The  hands 
of  young  infants  may  be  covered  with  mittens,  or  with  the  long  sleeves  of 
a  night-gown  which  is  pinned  to  the  bed,  so  that  it  is  impossible  for  the 
child  to  get  the  part  to  the  mouth ;  or  pasteboard  splints  may  be  applied 
at  the  bend  of  the  elbow,  so  as  to  prevent  flexion  of  the  arms.  Children 
must  be  carefully  watched  at  all  times,  but  particularly  when  going  to 
sleep  and  when  they  first  wake,  since  these  are  the  times  when  sucking 
is  most  likely  to  be  indulged  in.  In  the  milder  cases  the  habit  is  often 
discontinued  spontaneously  when  infants  are  eighteen  months  or  two  years 
old  ;  but  when  it  has  been  indulged  until  a  child  is  four  or  five  years  old, 
it  is  broken  only  with  the  greatest  difficulty  and  after  prolonged  effort. 
Punishments  are  of  little  avail,  but  rewards  are  often  successful.  The 
child's  pride  must  be  stimulated.  Restraint  should  be  encouraged  by  every 
means  possible.  On  no  account  should  this  be  passed  over  as  a  trivial 
matter  either  by  the  parents  or  the  pliysician. 

Masturbation. — This  is  not  uncommon  even  in  infancy.  Many  cases 
have  been  observed  during  the  first  year,  and  some  as  early  as  the  seventh 
or  eighth  month.  In  the  Babies'  Hospital  within  the  last  three  years  at 
least  half  a  dozen  cases  have  been  under  observation  in  children  under 
two  years  old,  some  of  them  most  intractable  ones.  Masturbation  is  more 
frequent  after  the  eighth  or  ninth  year,  but  it  is  from  the  twelfth  to  the 
fifteenth  that  it  is  especially  seen.  At  this  age  it  is  much  more  often 
seen  in  males  than  in  females,  although  in  girls  it  is  particularly  hard  to 
control. 

The  symptoms  which  these  older  children  exhibit  who  practise  fre- 
quent masturbation,  are  usually  marked  and  quite  characteristic.  They 
are  pale  and  anaemic ;  they  have  dark  rings  under  the  eyes ;  they  sleep 
poorly,  are  easily  fatigued,  and  frequently  complain  of  headaches.  They 
become  quiet,  reticent,  and  easily  embarrassed ;  they  avoid  the  society  of 
other  children,  and  lose  all  animation  and  all  interest  in  out-of-door 
amusements.  They  are  absent-minded,  and  show  an  inability  to  concen- 
trate the  attention  upon  anything.  Gradually  they  may  become  more  and 
more  morbid,  and  in  extreme  cases  may  develop  melancholia,  mental  weak- 
ness, or  even  insanity.  In  other  cases,  attacks  of  convulsions  and  epilepsy 
may  follow.     I  had  recently  under  observation  a  boy  of  seven  years  who 


INJURIOUS  HABITS  OF   INFANCY  AND   CHILDHOOD.  697 

was  having  from  six  to  ten  epileptic  seizures  a  week,  in  whose  case  mas- 
turbation appeared  to  be  the  principal  cause.  I  do  not,  however,  think 
such  cases  are  frequent.  Sometimes  hysteria  and  chorea  are  traceable  to 
the  influence  of  masturbation,  this  result  being,  of  course,  more  likely  to 
follow  where  there  already  exists  a  predisposition  to  these  diseases.  In 
addition  to  these  effects  upon  the  nervous  system,  where  it  is  begun  at 
an  early  age,  masturbation  may  seriously  interfere  with  the  physical  de- 
velopment of  the  child.  The  local  symptoms  of  masturbation  in  the 
male,  are  redness  and  sometimes  slight  swelling  of  the  prepuce;  but  very 
often  there  is  simply  a  relaxed  condition  of  all  the  genital  organs.  In  the 
female  there  may  be  redness  and  swelling  of  the  vulva,  and  in  some  cases 
a  moderate  vaginitis. 

Among  the  local  causes  may  be  mentioned  anything  which  excites 
undue  irritation, — a  long  or  adherent  prepuce,  phimosis,  balanitis,  vagini- 
tis, any  skin  disease  which  causes  itching  of  the  part,  thread-worms,  and 
even  constipation.  Urine  which  is  rendered  irritating  on  account  of  ex- 
cessive acidity  or  the  presence  of  crystals  of  uric  acid,  is  a  not  infrequent 
cause.  Exercises  in  which  the  legs  are  rubbed  together  may  lead  to  it,  also 
posture  or  clothing  which  causes  friction  of  the  parts,  and  sometimes  warm 
feather-beds.  To  these  must  be  added  as  a  potent  cause,  the  habit  of  suck- 
ing. Masturbation  often  results  from  example  or  because  the  habit  has 
been  taught  by  other  children,  sometimes  by  nurses.  Where  it  develops  in 
a  young  child  without  local  cause,  it  should  not  be  forgotten  that  mas- 
turbation is  one  of  the  signs  of  degeneration,  often  an  early  one,  and  other 
stigmata  (page  758)  will  usually  be  found  if  they  are  looked  for. 

In  infants  and  very  young  children  masturbation  is  often  not  recog- 
nised. At  this  age  it  is  more  frequently  accomplished  by  thigh-friction, 
or  by  rubbing  the  genitals  against  a  chair  or  some  other  object,  than  by 
the  use  of  the  hands.  The  variety  of  ways  is  almost  endless.  During  the 
act  there  are  usually  noticed  flushing  of  the  face  and  some  rigidity  of  the 
muscles  of  the  trunk  and  lower  extremities,  which  are  followed  by  complete 
relaxation  and  often  by  perspiration. 

The  prognosis  depends  most  of  all  upon  how  firmly  rooted  the  habit 
has  become  before  it  is  recognised.  It  is  usually  a  simpler  matter  to  stop 
it  in  infants  and  in  young  children,  as  they  can  be  more  easily  controlled 
and  more  closely  watched  than  those  who  are  older.  The  outlook  is  much 
better  where  the  cause  is  a  local  one  capable  of  being  removed,  than 
where  no  such  cause  exists.  It  is  also  much  better  when  in  an  older  child 
it  has  been  acquired  by  imitation,  than  where  it  is  a  symptom  of  degen- 
eracy ;  in  fact,  the  last-mentioned  cases  are  rarely  if  ever  cured. 

Treatment. — The  most  important  thing  is  an  early  recognition  of  the 
condition.  The  physician  should  put  parents  and  nurses  on  their  guard, 
and  the  first  suspicions  should  be  reported  and  the  child  carefully  watched 
until  all  doubt  is  removed.     In  most  cases  seen  by   the  physician  the 


698  DISEASES  OF  THE  NERVOUS  SYSTEM. 

habit  is  not  difficult  to  arrest  at  the  outset,  but  it  becomes  extremely  so 
after  it  has  been  practised  for  years  before  it  is  discovered.  In  young 
infants  much  may  be  accomplished  by  mechanical  restraint.  The  kind 
of  restraint  which  is  necessary  will  depend  upon  the  manner  of  mastur- 
bating. If  by  the  hands,  these  must  be  tied  during  sleep,  so  that  the 
child  can  not  reach  the  genitals  ;  if  by  thigh-friction,  the  thighs  must 
be  separated  by  tying  one  to  either  side  of  the  crib.  In  inveterate  cases, 
a  double  side-splint,  such  as  is  used  in  fracture  of  the  femur,  may  be  ap- 
plied. In  children  that  are  over  three  years  old,  all  such  contrivances  are 
almost  invariably  unsuccessful.  It  is  of  the  utmost  importance  in  every 
case  to  have  the  child  under  the  close  surveillance  of  a  competent  and 
trustworthy  person.  He  should  be  especially  watched  just  after  being  put 
to  bed  and  immediately  after  waking.  Corporal  punishment  is  often  use- 
ful in  very  young  children,  but  of  little  or  no  benefit  in  those  who  are  over 
four  years  old.  In  fact,  in  such  it  may  do  positive  harm,  for  deception 
and  lying  are  soon  added  to  the  previous  vice.  The  mother  should  secure 
the  child's  confidence,  and  in  every  way  possible  seek  to  strengthen  his 
will  and  stimulate  his  self-control,  using  her  influence  to  help  him  break 
the  habit.  The  local  causes,  too,  must  be  examined  into  and  removed 
whenever  found.  Circumcision  should  be  done  if  phimosis  exists,  and 
even  where  it  is  not,  the  moral  effect  of  the  operation  is  sometimes  of 
very  great  benefit.  Care  should  be  taken  that  the  clothing  does  not 
irritate  the  parts.  The  child  should  be  removed  from  all  vicious  com- 
panions. In  some  cases  hypnotism  has  been  employed  with  excellent  re- 
sults. The  general  treatment  should  be  directed  to  the  child's  condition. 
Cold  bathing  should  be  practised,  iron  and  tonics  administered  where  they 
are  indicated  by  the  general  condition,  and  the  child  should  be  put  under 
as  healthful  local  surroundings  as  possible.  The  administration  of  drugs 
for  the  habit  itself  is  of  little  or  no  value. 

Nail-biting  and  Tongue-sucking  are  two  forms  of  habit  which  are  less 
frequent  and  less  important  than  those  already  mentioned.  The  former 
is  best  remedied  by  keeping  the  nails  cut  very  short ;  the  latter  seldom 
becomes  a  fixed  habit,  and  the  child  usually  ceases  it  of  his  own  accord  as 
he  grows  older. 


MALFORMATIONS. 


699 


CHAPTER   III. 
DISEASES   OF   THE  BRAIN  AND  MENINGES. 

MALFORMATIONS. 

The  malformations  of  the  brain  are  of  great  variety,  and  many  of 
them  are  solely  of  anatomical  interest,  as  the  conditions  are  incompatible 
with  life.  Only  the  most  frequent  and  the  best-known  types  will  be  men- 
tioned, and  those  which  are  of  interest  from  a  clinical  point  of  view.* 

Meningocele,  Encephalocele,  and  Hydrencephalocele.— These  three  con- 
ditions have  in  common  a  protrusion  of  some  part  of  the  cranial  contents 


Fig.  110.— Meuinfi'ocele. 


Fig.  111. — Encephalocele. 


through  an  opening  in  the  skull.  In 
meningocele  (Fig.  110)  there  is  i3rotru- 
sion  of  the  membranes  alone.  These 
form  a  sac,  Avhich  is  usually,  but  not 
invariably,  distended  by  fluid.  In  en- 
cephalocele (Fig.  Ill)  there  is  a  pro- 
trusion of  a  portion  of  the  brain  sub- 
stance ;  this  is  connected  with  the  rest 
of  the  brain  by  a  constricted  neck  or 
pedicle.  There  may  or  may  not  be 
fluid  present  in  the  tumour.  In  hy- 
drencephalocele (Fig.  112)  there  is  a 
protrusion  of  a  portion  of  the  brain  substance  which  contains  within  it 
a  cavity  filled  with  fluid,  this  cavity  communicating  with  the  distended 
lateral  ventricles. 


Fig.  112. — HyJi-(.'iicc'phalocele. 


*  For  other  forms  see  Sachs,  Nervous  Diseases  of  Children,  1895,  pp.  589-607. 


700 


DISEASES  OP  THE   NERVOUS  SYSTEM. 


In  all  these  conditions  there  is  a  tumour,  usually  pedunculated,  of  a 
round  or  pyriform  shape,  with  a  smooth  or  lobulated  surface.  The  ordi- 
nary size  is  that  of  a  mandarin  orange  ;  it  may  be  as  small  as  a  walnut,  or 
as  large  as  the  patient's  head.  It  is  generally  covered  by  the  scalp,  which 
is  often  denuded  of  hair;  but  it  may  be  covered  only  by  granulation- 
tissue,  or  it  may  show  a  central  cicatrix,  like  that  of  spina  bifida.  Its 
coverings  are  usually  thin  and  translucent.  Other  deformities,  such  as 
spina  bifida,  club-foot,  and  hare-lip,  are  frequently  present. 

All  these  conditions  are  rare,  but  the  most  frequent  and  most  serious 
one  is  hydrencephalocele,  this  being  usually  associated  with  hydrocephalus. 
The  next  in  frequency  is  encephalocele,  which  has  the  best  prognosis. 
This  is  frequently  termed  hernia  cerebri.  It  may  exist  without  very  serious 
alteration  in  the  cranial  contents.  If  fluid  is  present,  it  is  external  to 
the  brain.     Meningocele  is  the  rarest  form,  and   consists  simply  of  an 

accumulation  of  fluid  in  the  arach- 
noid cavity,  which  communicates  by  a 
small  opening  with  the  general  arach- 
noid cavity  of  the  brain. 

Of  one  hundred  and  five  cases  col- 
lected by  Schatz,  fifty-nine  occupied 
the  occipital  region  and  forty- six  were 
frontal.  The  aperture  through  which 
the  occipital  protrusion  takes  place  is 
usually  in  the  median  line.  It  may 
communicate  with  the  posterior  fon- 
tanel, with  the  foramen  magnum,  or 
with  the  cleft  of  a  spina  bifida.  The 
occipital  bone  may  be  divided  in  the 
median  line,  or  rarely  it  may  be  absent. 
In  the  naso-f rental  form  (Fig.  113)  the  tumour  is  usually  at  the  root 
of  the  nose,  a  little  to  one  side  of  the  median  line.  The  aperture  is  most 
frequently  between  the  cribriform  plate  of  the  ethmoid  and  the  frontal 
bones.  It  may  be  between  the  lateral  halves  of  the  frontal  bone,  causing  a 
median  tumour.  The  point  of  protrusion  may  also  be  the  lateral  region 
of  the  skull,  generally  about  the  lateral  fontanel,  or  along  the  line  of  the 
sutures;  it  may  project  into  the  mouth  or  the  pharynx.  These  anterior 
tumours  are  usually  small,  although  large  ones  containing  the  anterior 
lobes  of  the  brain,  have  been  seen. 

The  theory  of  the  origin  of  these  malformations  which  is  most  widely 
accepted  is  that  they  are  primarily  cases  of  intra-uteriue  hydrocephalus, 
and  as  the  cranial  cavity  has  gradually  been  closed  by  the  development 
of  the  bones,  a  certain  portion  of  the  brain  has  been  left  outside. 

Symptoms. — The  tumour  is  always  congenital,  although  after  birth 
it  frequently  increases  very  much  in  size.     A  typical  tumour  is  round 


Fig.  113. 


-Naso- frontal  meningocele  (after 
Deuime). 


MALFORMATIONS   OF   THE   BRAIN.  701 

and  elastic,  usually  giving  evidences  of  fluid  ;  it  pulsates  synchronously 
with  the  heart ;  during  screaming  or  forced  inspiration,  it  increases  in 
size ;  partial  and  in  some  cases  complete  reduction  is  possible,  but  this  is 
usually  followed  by  marked  cerebral  symptoms,  even  by  convulsions.  After 
partial  reduction,  an  opening  in  the  skull  may  often  be  made  out.  Micro- 
cephalus  may  be  present,  or  there  may  be  unequal  development  of  the  two 
sides  of  the  head. 

The  following  differential  points  given  by  Treves,  indicate  the  most 
characteristic  features  of  the  three  varieties  :  In  meningocele,  the  tumour 
is  at  first  small,  but  increases  ;  it  has  a  smooth  surface  ;  it  is  pedunculated  ; 
there  is  distinct  fluctuation,  perfect  translucency,  rarely  pulsation;  often 
it  is  completely  reducible ;  compression  of  the  tumour  causes  cerebral 
symptoms;  the  skull  is  normal.  In  encephalocele,  the  tumour  is  small 
and  smooth ;  it  is  rarely  pedunculated ;  fluctuation  is  absent ;  it  is  not 
translucent ;  there  is  distinct  pulsation ;  it  is  usually  reducible ;  pressure 
causes  cerebral  symptoms;  the  skull  is  normal.  In  hydrencephalocele, 
there  is  a  large  pendulous  tumour  with  an  irregular  or  lobulated  sur- 
face; it  is  pedunculated;  translucency  is  rarely  complete;  fluctuation  is 
distinct ;  it  is  irreducible  ;  pressure  rarely  causes  symptoms ;  microcepha- 
lus  and  other  deformities  are  often  associated. 

The  occipital  tumours  are  usually  more  serious  than  the  frontal  ones. 
The  majority  of  cases  die  in  the  course  of  the  first  few  weeks  of  life, 
death  resulting  from  meningitis,  convulsions,  or  rupture.  In  meningocele 
the  tumour  usually  grows  slowly,  and  ultimately  may  be  shut  off  from  the 
cranial  cavity  ;  but  gradual  thinning  of  the  membrane  may  take  place,  and 
spontaneous  or  accidental  rupture  occur.  In  encephalocele  the  tumour 
grows  slightly,  or  not  at  all.  Most  of  these  patients  exhibit  signs  of 
mental  impairment  or  other  evidences  of  organic  brain  disease. 

Treatment. — According  to  Treves,  operation  is  Justifiable  only  in  case 
of  impending  rupture.  The  conditions  present  are  essentially  the  same 
as  in  spina  bifida.  Meningocele  may  be  aspirated,  injected  with  iodine, 
or  with  Morton's  iodine  and  glycerin  solution  (page  765) ;  the  sac  may  be 
laid  open  and  a  plastic  operation  performed  for  the  closure  of  the  com- 
munication with  the  cranial  cavity ;  or  the  skin  may  be  divided,  and  a 
ligature  or  clamp  applied  to  shut  off  the  communication  with  the  brain. 
All  these  methods  have  been  at  times  successful,  but  cure  has  in  many  in- 
stances been  followed  by  the  development  of  chronic  hydrocephalus.  En- 
cephalocele is  to  be  treated  by  protection  and  compression.  Aspiration 
may  be  resorted  to  if  fluid  is  present.  In  hydrencephalocele  the  prognosis 
is  absolutely  bad  under  all  circumstances.  Schatz  *  gives  the  following 
statistics,  showing  the  results  with  and  without  operation,  all  varieties 
being  included  :  Of  twenty-four  occipital  tumours  not  operated  on,  tiiree 


*  Berlin,  klin.  Wochenschrift,  No.  28,  1885. 


702  DISEASES   OP  THE  NERVOUS  SYSTEM. 

recovered ;  of  thirty-five  operated  on  by  excision,  ligation,  or  injection, 
six  recovered.  Of  forty-six  frontal  tumours,  there  were  six  recoveries  in 
thirty-two  cases  without  operation,  and  two  recoveries  in  fourteen  cases 
with  operation. 

Microcephalus. — This  is  generally  regarded  as  due  to  premature  ossi- 
fication of  the  skull ;  but  this  theory  is  certainly  inadequate  to  explain 
all  the  cases.  In  many  children  suffering  from  marasmus,  the  sutures 
ossify  and  the  fontanels  close  much  earlier  than  in  healthy  infants  of 
the  same  age,  chiefly  because,  with  the  rest  of  the  body,  the  brain  also 
has  ceased  to  grow.  So  it  is  true  of  some  of  the  cases,  at  least,  of  micro- 
cephalus, that  the  early  ossification  of  the  skull  is  due  to  arrested  growth 
of  the  brain,  and  not  the  reverse.  The  reasons  for  the  developmental 
arrest  in  the  brain  are  for  the  most  part  unknown.  The  condition  usually 
dates  back  to  intra-uterine  life,  although  in  some  cases  it  appears  to  begin 
after  birth. 

It  is  well  known  that  there  is  not  an  invariable  relation  between  the 
size  of  the  head  and  the  size  of  the  brain,  although  generally  the  two  cor- 
respond. If  the  circumference  of  the  head  is  much  below  the  average  for 
the  age  (page  20),  and  relatively  much  less  than  the  measurements  of  the 
rest  of  the  body,  microcephalus  may  be  assumed  to  exist.  Sachs  calls 
attention  to  the  fact  that  the  circumference  of  the  head  may  be  nearly 
normal  and  yet  the  essential  conditions  of  microcephalus  exist,  owing  to 
imperfect  development  of  the  anterior  part  of  the  brain. 

The  symptoms  of  microcephalus  are  those  of  idiocy  and  cerebral 
paralysis,  existing  in  all  possible  combinations  and  wdth  variable  degrees 
of  severity. 

A  new  surgical  interest  in  these  cases  has  been  awakened  during  the 
last  few  years  by  the  operation  of  craniectomy.  The  purpose  of  this  oper- 
ation, which  was  devised  by  Lannelongue,  is  to  relieve  the  intracranial 
pressure  by  making  a  longitudinal  opening  in  the  skull,  on  one  or  both 
sides.  The  opening  made  is  usually  about  half  an  inch  wide  and  four 
or  five  inches  long.  It  is  one  or  two  inches  from  the  sagittal  suture,  to 
which  it  is  parallel.  For  the  time  being  the  cranial  capacity  is  increased, 
but  it  is  doubtful  if  even  this  is  permanent.  Jacobi*  gives  a  report  of 
thirty-three  cases  operated  upon  by  American  surgeons,  with  fourteen 
deaths  and  nineteen  recoveries.  At  the  time  of  report  the  condition  in 
the  cases  which  survived  the  operation  was  as  follows :  no  improvement 
in  seven  ;  slight,  in  seven  ;  "  some,"  in  one ;  much,  in  two  ;  no  history,  in 
one ;  uncertain,  in  one,  I  quite  agree  with  him  that  such  results  do  not 
justify  the  performance  of  this  operation. 

Congenital  Hydrocephalus.— These  cases  may  fairly  be  considered  as 
belonging  to  this  category,  although  they  have  been  discussed  elsewhere. 


*  New  York  Medical  Record,  May  19,  1894. 


PACHYMENINGITIS.  703 

Porencephalus  (literally,  a  hole  in  the  brain)  is  a  condition  in  which 
there  is  a  large  depression  in  some  part  of  the  brain,  but  with  surrounding 
parts  well  developed.  Such  depressions  may  involve  a  whole  lobe,  and 
they  may  be  deep  enough  to  reach  the  lateral  ventricles. 

Porencephalus  is  described  as  congenital  or  acquired.  In  the  congeni- 
tal form,  the  defect  is  usually  found  in  the  anterior  or  middle  part  of  the 
brain.  The  origin  of  these  conditions  is  still  a  disputed  question.  Thev 
are  probably  due  to  early  vascular  changes.  Children  sometimes  live 
several  years  with  very  large  defects,  the  symptoms  depending  upon  the 
seat  of  the  lesion.  The  acquired  form  of  porencephalus  is  usually  one  of 
the  late  results  of  meningeal  haemorrhage.  It  may  affect  one  or  both 
sides.  Such  cases  present  the  symptoms  of  spastic  paralysis — usually 
diplegia.     In  all  cases  with  large  brain  defects,  the  space  is  filled  with  fluid. 

PACHYMENINGITIS. 

Pachymeningitis,  or  inflammation  of  the  dura  mater,  occurs  both  as 
an  acute  and  a  chronic  disease. 

Acute  Pachymeningitis. — This  is  very  rare  in  children.  Only  pachy- 
meningitis externa  is  generally  included  under  this  term,  as  acute  pachy- 
meningitis interna  does  not  occur  alone,  but  usually  with  inflammation  of 
the  pia  mater  (leptomeningitis).  It  may  be  associated  with  disease  or 
injury  of  the  bones  of  the  skull,  but  is  most  frequently  seen  in  connection 
with  middle-ear  disease.  It  generally  begins  as  a  localized  process,  but 
the  inflammation  may  extend  to  the  inner  layer,  and  to  the  pia  mater;  or 
it  may  remain  circumscribed,  and  terminate  in  the  formation  of  an  abscess 
between  the  dura  mater  and  the  bone. 

The  symptoms  of  acute  pachymeningitis  are  distinctive  only  when  the 
process  is  localized.  They  are  then  usually  associated  with  middle-ear 
disease,  and  are  indistinguishable  from  those  of  cerebral  abscess.  The 
treatment  is  surgical. 

CJironic  Pachymeningitis. — This,  in  children,  almost  invariably  affects 
the  inner  layer  (pachymeningitis  interna) ;  it  is  also  known  as  pseuclo- 
membranoics  and  as  hcemorrhagic  pachymeningitis  or  licematoma  of  the 
dura  mater.  Its  causes  are  for  the  most  part  unknown.  It  is  not  very 
rare,  being  usually  discovered  at  autopsy  in  children,  chiefly  cachectic 
infants,  who  have  died  of  other  diseases.  In  the  Eeport  of  the  New  York 
Pathological  Society  for  1890  Northrup  records  six  such  cases.  I  have 
seen  five  similar  ones,  as  well  as  one  other  associated  with  chronic  hydro- 
cephalus. 

Two  classes  of  cases  are  to  be  distinguished, — those  with,  and  those 
without  extensive  hemorrhages.  In  the  latter  group  there  is  found  a  thin, 
translucent,  vascular  membrane  lining  the  inner  surface  of  the  dura.  It 
may  be  only  a  delicate  film  which  can  be  scraped  off ;  it  may  be  as  thick 
as  ordinary  blotting-paper,  or  even  twice  that  thickness.  The  membrane 
40 


Y04  DISEASES  OP   THE   NERVOUS  SYSTEM. 

is  often  tedematous ;  it  is  exceedingly  vascular,  and  the  vessels  have  very 
thin  walls.  There  are  usually  scattered,  punctate  haemorrhages,  and 
there  may  be  a  few  of  larger  size.  This  membrane  may  cover  the  whole 
inner  surface  of  the  dura,  but  in  most  cases  it  is  priucipally  over  the  con- 
vexity and  may  be  found  only  here  ;  it  is  apt  to  be  more  upon  one  side 
than  upon  the  other.  In  cases  of  long  standing  there  may  be  adhesions 
between  the  dura  and  the  pia.  When  large  haemorrhages  have  taken  place, 
quite  a  different  pathological  appearance  is  presented.  The  lesions  found 
in  a  case  upon  which  I  made  an  autopsy  in  the  New  York  Infant  Asylum, 
are  fairly  typical :  The  infant  was  six  months  old,  and  the  symptoms  had 
existed  for  six  days.  The  fontanel  was  bulging  to  a  marked  degree,  and 
the  sagittal  and  coronal  sutures  were  separated.  A  thin  recent  clot  from 
one  eighth  to  one  fourth  of  an  inch  in  thickness  covered  nearly  the  whole 
of  the  right  hemisphere  and  part  of  the  convexity  of  the  left.  The  entii'e 
dura  was  lined  both  at  its  convexity  and  base  by  a  pseudo-membrane  of 
grayish  color,  about  one  sixteenth  of  an  inch  in  thickness.  The  brain 
was  anaemic. 

In  cases  of  longer  standing  partial  organization  of  the  clot  may  be 
seen  ;  in  more  recent  ones  the  blood  is  partly  or  entirely  fluid.  I  once 
found  acute  leptomeningitis  with  a  purulent  exudation,  associated  with 
haemorrhagic  pachymeningitis.  In  cases  where  life  is  prolonged  for  years, 
there  may  be  partial  or  even  complete  absorption  of  the  clot,  followed  by 
the  formation  of  cysts,  considerable  inflammatory  thickening  of  the  pia 
with  deposits  of  blood  pigment,  and  finally  atrophy  and  sclerosis  of  the 
cortex.  The  source  of  the  hajmorrhage  may  be  the  rupture  of  a  single 
large  vessel,  but  more  frequently  the  blood  comes  from  many  small 
vessels. 

Symptoms. — These  are  due  to  the  haemorrhage,  and  not  to  the  inflam- 
matory process.  Until  haemorrhage  occurs  there  are  no  symptoms  by 
which  the  disease  can  be  recognised.  Thus  in  many  of  the  cases  in  which 
pachymeningitis  is  found  at  autopsy,  its  existence  is  not  suspected  dur- 
ing life.  The  occurrence  of  haemorrhage  is  sometimes  marked  by  vomit- 
ing or  convulsions,  and  usually  there  is  loss  of  consciousness.  It  may 
be  a  question  whether  the  convulsions  are  the  cause  or  the  result  of 
the  haemorrhage.  In  most  cases  they  seem  to  be  the  result.  They  are 
usually  general  and  repeated.  If  the  haemorrhage  occurs  slowly,  there 
may  be  stupor  without  convulsions  until  nearly  the  close  of  the  disease. 
In  the  fatal  cases  the  symptoms  generally  continue  from  two  days  to  a 
week.  There  are  dulness,  stupor,  and  finally  coma,  death  occuring  in  coma 
or  convulsions.  If  the  htemorrhage  is  diffuse — and  this  is  apt  to  be  the 
case — there  is  rigidity  of  all  the  extremities ;  if  it  is  of  one  side  only,  the 
rigidity  affects  only  one  >arm  and  \e^.  The  pupils  are  more  frequently 
contracted,  but  may  be  dilated  or  unequal.  There  is  diplegia,  hemi- 
plegia, or  monoplegia,  according  to  the  seat  and  extent  of  the  haemor- 


P.\CI1YMENINGITIS.  705 

rliage.  The  respiration  is  slow  and  irregular  and  may  be  of  the  Cheyne- 
Stokes  variety.  The  pulse  is  slow,  irregular,  and  sometimes  intermittent. 
The  temperature  is  at  first  normal,  but  rises  slowly  until  death  occurs, 
when  it  is  from  100°  to  103°  F.  Generally  the  cranial  nerves  are  not 
affected,  and  opisthotonus  is  absent.  The  knee-jerk  is  often  exagger- 
ated. In  cases  which  do  not  prove  fatal — these  being  chiefly  in  older 
children — we  have  a  similar  onset,  but  after  a  few  days  consciousness  is 
regained,  and  only  hemiplegia  or  monoplegia  remains.  The  course  of  the 
paralysis  is  that  seen  after  meningeal  hasmorrhage  due  to  other  causes. 
Wagner  has  reported  a  case  in  which  recurring  haemorrhages  took  place 
at  intervals  of  several  months,  the  autopsy  showing  distinct  evidences  of 
both  old  and  recent  lesions. 

Pachymeningitis,  I  believe,  plays  a  much  more  important  role  in  the 
production  of  meningeal  hsemorrhages  in  children  than  has  generally  been 
accorded  to  it.  From  the  frequency  with  which  this  lesion  is  found  as  a 
cause  of  sudden  meningeal  haemorrhages  which  are  fatal,  it  is  not  unlikely 
that  many  of  the  cases  which  recover  with  hemiplegia  or  monoplegia,  may 
be  due  to  the  same  cause. 

The  prognosis  depends  upon  the  age  of  the  patient  and  the  extent  of 
the  haemorrhage.  Extensive  hajmorrhages  are  usually  fatal  in  infancy, 
but  small  ones  are  seldom  so,  for  they  are  rarely  at  the  base.  The  prog- 
nosis of  the  paralysis  in  cases  not  terminating  fatally,  is  the  same  as  after 
meningeal  hemorrhage  due  to  other  causes,  wdth  perhaps  an  added  liabil- 
ity to  recurrent  attacks. 

Without  large  haemorrhages,  pachymeningitis  interna  can  not  be  diag- 
nosticated ;  and  it  is  impossible  to  differentiate  the  ha?niorrhagic  cases 
from  other  varieties  of  meningeal  haemorrhage.  It  is  important  to  make 
a  diagnosis  between  pachymeningitis  with  hsemorrhage,  and  acute  simple 
meningitis.  In  the  former  we  have  a  sudden  onset;  stupor  occurring 
early,  usually  on  the  first  day,  gradually  diminishing  in  cases  of  recovery, 
or  deepening  into  coma  in  fatal  cases ;  localized  or  general  paralysis,  also 
occurring  early ;  there  is  no  fever  in  the  beginning,  and  only  moderate 
fever  at  the  close.  In  acute  meningitis  we  usually  have  a  higher  tem- 
perature, especially  early  in  the  disease  ;  coma  develops  later,  and  rigidity 
of  the  extremities  is  less  pronounced.  In  certain  cases,  however,  where 
the  haemorrhage  occurs  in  the  course  of  some  other  disease,  a  differential 
diagnosis  may  be  impossible. 

Treatment. — The  treatment  of  pachymeningitis  haemorrhagica  is  symp- 
tomatic. The  indications  are,  to  relieve  cerebral  congestion  by  applying 
ice  to  the  head,  to  allay  irritative  symptoms  by  the  use  of  bromides,  and 
to  keep  the  patient  perfectly  quiet. 


706  DISEASES  OF  THE  NERVOUS  SYSTEM. 

ACUTE  MENINGITIS, 
Acute  iuflammation  of  the  pia  mater,  or  acute  leptomeningitis,  is  seen 
under  a  variety  of  circumstances  : 

1.  It  occurs  epidemically.  It  is  then  usually  associated  with  the  same 
process  in  the  cord,  and  is  known  as  cerehro- spinal  meningitis,  or  spotted 
fever,  being  regarded  by  many  as  a  general  infectious  disease  with  a  local 
lesion. 

2.  It  occurs  sporadically  as  a  primary  disease,  with  symptoms  and 
lesions  which  may  be  identical  with  those  seen  in  the  first  group  of  cases. 

3.  It  occurs  as  a  secondary  disease,  complicating  other  acute  infectious 
diseases  and  local  inflammations. 

Etiology. — Epidemic  meningitis  occurs  especially  in  winter  and  spring ; 
it  affects  children  of  all  ages,  but  males  more  often  than  females.  It  has 
been  attributed  to  overcrowding  and  to  bad  drainage.  Epidemics  are  in- 
frequent, usually  separated  by  quite  long  intervals,  and  the  number  of 
persons  attaciied  is  rarely  large.  In  New  York  and  in  many  other  large 
cities  cases  occur  almost  every  year ;  but  in  some  seasons  their  number  is 
much  greater  than  usual  and  the  disease  is  said  to  be  epidemic.  Out- 
breaks are  occasionally  seen  in  small  towns  or  in  remote  country  districts 
where  their  origin  is  hard  to  trace.     The  disease  is  not  contagious. 

It  is  now  well  established  that  epidemic  meningitis  is  caused  by  the 
dijjlococcus  intracellular  is  of  Weichselbaum.  This  is  present,  according 
to  Councilman,*  in  the  meningeal  exudate,  iu  the  diseased  tissues,  and  in 
cerebro-spinal  fluid  obtained  by  lumbar  puncture.  It  is  found  almost  in- 
variably within  the  cells,  chiefly  polynuclear  leucocytes,  where  it  exists  in 
pairs  or  tetrads.  It  is  decolourized  by  Gram's  method.  It  is  hard  to  cul- 
tivate, the  best  medium  being  Loeffler's  blood  serum.  The  mode  of  infec- 
tion is  as  yet  somewhat  uncertain,  but,  as  a  diplococcus  resembling  Weich- 
selbaum's  has  been  found  by  Councilman  and  others  high  up  in  the  nose 
of  affected  persons,  it  seems  probable  that  it  is  in  this  way  that  the  organ- 
ism frequently  reaches  the  brain. 

Sporadic  cases  9f  meningitis  may  occur  either  before  or  after  epi- 
demics, or  without  assignable  cause  where  there  has  been  no  epidemic. 
Many  cases  regarded  as  primary  are  secondary  to  otitis  which  has  been 
overlooked.  Some  of  the  sporadic  cases  are  due  to  the  diplococcus  intra- 
cellularis,  others  to  the  pneumococcus,  and  still  others  to  the  streptococcus 
or  staphylococcus.  In  twenty-five  cases  studied  by  Netter  the  pneumo- 
coccus was  present  in  eighteen,  and,  according  to  most  observers,  this  is 
the  organism  most  frequently  found.  However,  it  is  only  very  recently 
that  the  diplococcus  intracellularis  and  pneumococcus  have  been  gener- 
ally differentiated,  and  some  of  these  findings  may  need  revision. 


Johns  Hopkins  Hospital  Bulletin,  February,  1898. 


PLATE   XV. 


Acute  Meningitis,  complicating  Pleuro-Pneumonia. 

Child  twenty  months  old  ;  on  twenty-third  day  of  a  protracted  attack  of  pneumonia, 
vomir.ed  six  times,  and  the  temperature,  which"  had  been  nearly  normal  for  four  days, 
rose  to  103°  F.  On  the  following  day  general  convulsions,  which  were  repeated  fre- 
quently during  the  next  few  days;  temperature,  101°  to  104°  F. ;  death  in  convulsions 
on  twenty-eighth  day. 

Atitopsy. — Pleuro-pneumonia  of  left  side ;  lung  resolving.  Anterior  portion  of 
brain  enveloped  in  lymph  and  pus,  more  marked  at  the  convexity,  but  present  also 
over  the  base. 


ACUTE  MENINGITIS.  707 

Acute  secondary  meningitis  may  complicate  pneumonia,  influenza, 
scarlet  or  typhoid  fever,  malignant  endocarditis,  or  acute  nephritis.  It 
also  follows  cerebral  abscess,  erysipelas  of  the  scalp,  disease  or  injury  of 
the  skull,  otitis,  mastoid  abscess,  or  an  infectious  process  in  any  of  the 
other  cavities  adjacent  to  the  cranium, — ethmoid  sinus,  nose,  orbit,  etc. 
Infection  may  take  place  by  direct  extension  through  the  blood-vessels  or 
the  lymph  channels  of  the  neighbourhood,  or  the  primary  focus  may  be 
in  some  distant  part,  the  brain  being  reached  through  the  general  circu- 
lation. 

In  secondary  meningitis  the  nature  of  the  infection  varies  with  that  of 
the  primary  disease,  it  being  perhaps  most  frequently  the  streptococcus. 

Lesions. — In  epidemic  meningitis  death  may  take  place  so  early  that 
the  changes  found  at  autojisy  are  slight.  There  may  be  only  a  serous 
exudation  and  intense  hyperasmia,  this  being  much  less  marked  after 
death  than  doubtless  existed  during  life.  The  microscope,  however,  may 
show,  even  in  these  early  cases,  an  abundant  exudation  of  leucocytes  in  the 
pia  mater.  It  is  rare  to  find  much  pus  before  the  third  day,  but  after  this 
the  lesions  are  quite  uniform.  The  convolutions  appear  somewhat  flat- 
tened from  pressure  due  to  distention  of  the  ventricles.  The  inner  sur- 
face of  the  dura  is  usually  normal  or  only  congested.  There  may  be 
thrombi  in  any  of  the  cerebral  sinuses,  or  in  the  meningeal  veins  of  the 
convexity.  There  is  an  exudation  of  greenish-yellow  lymph,  which  is 
usually  abundant,  and  in  places  may  nearly  conceal  the  convolutions.  It 
is  generally  most  marked  over  the  anterior  half  of  the  brain  and  at  the 
base,  but  usually  it  is  very  extensive.  There  is  an  increase  in  the  quan- 
tity of  cerebro-spinal  fluid.  The  ventricles  are  moderately  distended  with 
serum  or  sero-pus,  and  their  walls  may  be  slightly  softened.  The  brain 
substance  of  the  cortex  may  be  reddened  or  may  appear  normal.  In  the 
meninges  of  the  cord,  lesions  similar  to  those  of  the  brain  are  usually  seen. 
The  exudation  is  principally  upon  the  posterior  surface,  and  may  extend 
throughout  the  entire  length  of  the  cord,  or  be  limited  to  its  upper  or 
to  its  lower  portion.  In  some  cases  the  cord  lesion  is  overlooked,  Ibecause 
the  whole  cord  is  not  examined. 

Microscopical  examination  shows  the  exudation  to  consist  of  fibrin 
and  pus  cells,  which  infiltrate  the  pia  mater  and  may  cover  its  surface. 
The  superficial  layers  of  the  cortex  in  the  inflamed  areas  often  show 
minute  haemorrhages  and  very  marked  cell-infiltration.  Minute  ab- 
scesses may  be  present.  Very  marked  degenerative  changes  can  usually 
be  demonstrated  in  the  nerve  cells  themselves.  The  cells  of  the  neu- 
roglia are  also  affected  ;  they  are  swollen  and  increased  in  number ; 
and  there  may  be  proliferation  of  the  connective  about  the  blood-ves- 
sels (Councilman).  Changes  in  the  cord  of  a  similar  nature  to  those 
just  described  may  be  found,  but  these  are  less  frequent  and  as  a  rule 
much  less  severe  than  in  the  brain.     Inflammatory  products  are  some- 


708  DISEASES  OP  THE  NERVOUS  SYSTEX 

times  present  in  the  central  canal  of  the  cord  and  in  the  walls  of  the 
lateral  ventricles  of  the  brain.  The  inflammatory  process  frequently  ex- 
tends along  the  cranial  nerves,  especially  the  optic  and  auditory,  and  this 
may  result  in  choroiditis  or  otitis;  from  the  cord  it  may  extend  along 
both  the  anterior  and  posterior  nerve  roots.  Descending  degeneration  is 
found  in  the  nerves  both  of  the  brain  and  cord. 

In  cases  that  survive  the  acute  stage  the  inflammatory  process  may 
continue  and  the  late  results  of  tliese  lesions  be  seen.  There  is  usually  a 
chronic  meningo-encephalitis.  It  leads  to  thickening  of  the  meninges, 
the  formation  of  organized  adhesions  between  them  and  the  brain,  and 
the  development  of  permanent  changes  in  the  cortex.  These  are  some- 
time diffuse,  as  in  a  case  of  my  own  where  death  occurred  six  months 
after  the  acute  attack;  the  pia  was  much  thickened  and  everywhere 
adherent  to  the  brain,  while  in  the  cortex  were  the  early  changes  of 
a  general  encephalitis.*  More  often,  however,  they  are  in  patches 
and  result  in  formation  of  areas  of  sclerosis,  especially  over  the  frontal 
and  temporo-sphenoidal  lobes,  with  which  there  are  almost  always  as- 
sociated marked  descending  degenerative  changes  in  the  cord.  Such 
lesions  are  of  course  permanent,  and  seriously  interfere  not  only  with  the 
functions,  but  also  with  the  growth  and  development  of  the  brain.  An 
infrequent  sequel  is  chronic  hydrocephalus. 

The  lesions  most  frequently  associated  with  epidemic  meningitis  are 
in  the  lung.  There  may  be  lobar  or  broncho-pneumonia,  and  in  the  cells 
of  the  exudation  may  be  found  the  same  organism  as  in  the  brain. 
Acute  degeneration  of  the  liver  and  kidneys  is  also  frequent.  The 
other  viscera  are  seldom  affected. 

In  cases  of  acute  meningitis  due  to  other  organisms  than  the  diplo- 
coccus  the  lesions  resemble  in  a  general  way  those  above  described  ;  how- 
ever, the  cord  is  less  frequently  and  usually  less  seriously  involved.  The 
most  extensive  fibrinous  exudation  is  seen  in  cases  due  to  the  pneumo- 
coccus,  where  it  is  even  greater  than  in  epidemic  form.  It  may  be  so 
abundant  as  almost  to  envelop  the  brain,  and  in  places  to  conceal  the  con- 
volutions (Plate  XV). 

When  meningitis  is  secondary  to  otitis  or  some  other  local  process  in 
the  neighbourhood,  it  often  begins  as  a  localized  inflammation,  afterward 
becoming  general ;  it  may  be  associated  with  thrombosis  of  the  lateral  sinus. 

*  The  clinical  features  of  this  case  were  also  interesting.  The  patient  was  a  bright 
little  girl  of  four  and  a  half  years,  who  had  in  May  a  typical  attack  of  meningitis  of 
moderate  severity.  She  made  a  very  slow  convalescence,  but  at  the  end  of  two  months 
recovery  was  perfect  in  everything  but  her  mental  condition.  She  remembered  noth- 
ing which  she  had  previously  learned  in  the  kindergarten,  where  she  had  been  an  ex- 
ceptionally bright  pupil.  Tier  mind  was  a  blank.  She  was  dull,  listless,  and  her  face 
had  a  vacant,  idiotic  expression.  The  special  senses  seemed  unaffected,  and  speech 
was  retained.     Slie  died  during  an  attack  of  convulsions  in  November. 


ACUTE  MENINGITIS.  709 

Symptoms. — Few  diseases  are  so  irregular  in  their  course,  or  present  so 
many  atypical  forms,  as  does  acute  meningitis. 

1.  The  common  furm. — Most  of  the  sporadic  a;id  epidemic  cases  are 
of  this  type.  The  acute  symptcfms  are  sometimes  preceded  by  a  prodro- 
mal stage  of  one  or  two  days,  characterized  by  general  weakness  and  in- 
definite malaise,  but  in  the  majority  this  is  wanting,  and  the  attack  begins 
suddenly  with  vomiting  or  convulsions,  headache,  and  high  fever.  The 
ijiitial  temperature  is  from  102°  to  105°  F.  There  are  present,  intense 
headache,  marked  prostration,  pain  in  the  back  of  the  neck  and  along  the 
spine,  general  hypereesthesia,  opisthotonus,  constipation,  retraction  of  the 
neck,  and  rigidity  of  the  cervical  muscles.  Later,  more  intense  nervous 
symptoms  develop.  There  is  delirium,  which  is  often  active,  to  which  are 
added  muscular  twitchings,  and  sometimes  convulsions  ;  or  there  may  be 
dulness,  apathy,  and  finally  complete  coma.  The  respiration  is  slow, 
sometimes  irregular.  The  temperature  is  elevated,  usually  between  101° 
and  104°  F.  There  are  seen  in  a  few  of  the  cases  fine  petechial  spots 
upon  the  face,  abdomen,  or  all  over  the  body.  The  pupils  are  irregular ; 
there  may  be  strabismus  or  nystagmus.  The  pulse  is  weak,  and  some- 
times slow,  sometimes  rapid. 

After  these  symptoms  have  lasted  from  two  to  ten  days,  the  patient 
may  become  completely  comatose,  with  general  relaxation  and  dilated 
pupils,  and  may  die  in  this  condition  or  in  convulsions.  In  other  cases 
he  passes  into  a  typhoid  condition,  and  death  occurs  from  exhaustion  or 
complications,  particularly  pneumonia.  The  usual  duration  of  these  at- 
tacks is  from  one  to  two  weeks.  In  cases  recovering  convalescence  is 
sometimes  quite  rapid ;  or  the  disease  may  pass  into  a  subacute  form, 
lasting  from  three  weeks  to  two  or  three  months,  improvement  being  slow 
and  interrupted  by  relapses. 

2.  Abortive  cases. — In  every  epidemic  there  are  seen  attacks  which 
begin  precisely  like  those  above  described,  but  where  the  symptoms  last 
only  two  or.  three  days  and  then  subside  rapidly,  the  case  going  on  to 
a  complete  and  permanent  recovery.  In  some  epidemics  the  number  of 
such  cases  is  quite  large. 

3.  Malignant  or  fulminating  cases. — These  also  occur  principally  in 
epidemics,  but  are  not  confined  to  them.  The  onset  in  this  type  is  very 
abrupt,  and  the  patient  may  be  overcome  by  the  poison  and  die  in  from 
twelve  to  thirty-six  hours.  These  cases  often  begin  with  convulsions 
and  very  high  temperature,  from  105°  to  106-5°  F.  There  is  very  great 
prostration  and  frequently  cyanosis.  There  may  be  opisthotonus  and 
general  hyperesthesia,  or  these  may  be  absent.  The  patient  may  pass  in 
a  few  hours  into  a  condition  of  collapse,  with  general  relaxation,  feeble, 
irregular  pulse,  and  cold  extremities,  followed  by  convulsions  and  death. 
If  life  is  prolonged,  there  may  follow  after  a  few  hours  a  period  of  re- 
action, in  which  irritative  symptoms  are  prominent, — headache,  photo- 


710  DISEASES  OF  THE  NERVOUS  SYSTEM. 

phobia,  contracted  pupils,  general  hypersesthesia,  and  active  delirium. 
The  eruption  may  appear  within  the  first  twenty-four  hours  after  the 
onset.  In  most  of  these  cases  a  positive  diagnosis  is  impossible,  except 
by  finding  the  diplococcus  in  the  fluid*  drawn  by  lumbar  puncture,  as 
the  general  toxic  symptoms  mask  the  local  evidences  of  cerebral  inflam- 
mation. 

4.  Acute  primary  meiiingitis  occurring  sporadically  does  not  differ 
in  any  essential  particulars  from  the  epidemic  form.  The  fulminating 
and  the  abortive  cases  are,  however,  less  frequent  than  when  the  disease  is 
epidemic. 

5.  Acute  secondary  meningitis  presents  quite  a  different  clinical  pic- 
ture, and  the  symptoms  are  greatly  modified  by  those  of  the  original  dis- 
ease. Generally  in  this  form  the  disease  runs  a  short  course  and  it  is 
almost  invariably  fatal.  The  diagnosis  is  difficult,  and  in  many  cases  the 
lesions  are  found  at  autopsy  where  no  marked  cerebral  symptons  have 
existed  during  life.  This  is  particularly  true  where  the  process  is  mainly 
at  the  convexity.  The  onset  is  generally  with  convulsions,  after  which 
there  may  develop  quite  rapidly  stupor  and  finally  coma,  with  dilated 
pupils,  slow  pulse,  and  irregular  respiration.  Convulsions  and  gradually 
deepening  stupor  may  be  the  only  symptoms  ;  or  there  may  be  opisthoto- 
nus, retracted  abdomen,  and  rigidity  of  the  extremities.  The  duration  of 
these  cases  is  quite  short,  being  rarely  more  than  three  or  four  days,  and 
often  but  one  or  two.     Death  usually  occurs  in  convulsions. 

The  nervous  symptoms. — Headache  is  a  frequent  symptom  of  menin- 
gitis and  is  often  severe;  it  is  more  likely  to  be  frontal  than  elsewhere, 
although  it  may  be  general  and  associated  with  vertigo.  There  may  also 
be  pains  in  the  back  of  the  neck,  along  the  spine,  or  in  the  muscles,  which 
may  be  so  intense  as  to  cause  the  patient  to  scream  out.  Pain  may  be 
present  only  in  the  early  stage,  or  continue  throughout  the  disease.  With 
this  there  may  be  tenderness  along  the  spine,  and  often  general  hyperaes- 
thesia,  which  may  be  so  acute  that  any  movement  causes  agonizing  cries. 
Delirium  is  frequent  in  the  severe  cases  after  the  first  day ;  it  may  be  wild 
and  active,  or  low  and  muttering.  After  delirium  there  follows  usually  a 
stage  of  apathy  which  may  develop  into  complete  coma ;  deep  coma,  how- 
ever, is  not  often  present  in  cases  that  recover.  Convulsions  mark  both 
the  onset  and  the  close  of  the  disease,  but  rarely  occur  during  its  progress. 
Tonic  spasm  of  the  various  muscles  gives  rise  to  deformities  which  may 
continue  through  the  attack.  The  rigidity  and  contraction  of  the  muscles 
of  the  neck  produces  cervical  or  general  opisthotonus ;  there  may  be  tonic 
flexion  or  extension  of  the  extremities,  especially  of  the  legs.  In  some 
epidemics  opisthotonus  is  seen  in  nearly  every  case,  in  others  it  is  infre- 
quent. In  most  of  the  protracted  cases  localized  paralysis  is  present  in 
the  course  of  the  disease  It  may  affect  one  side  of  the  body,  or  one 
extremity. 


ACUTE  MENINGITIS.  7II 

Special  sejises. — The  eyes  are  affected  in  almost  all  severe  attacks.  The 
pupils  in  the  early  stage  are  generally  contracted,  later  they  may  be  irreg- 
ular, and  toward  the  close  they  are  usually  widely  dilated.  External 
strabismus  is  by  far  the  most  frequent  form  of  ocular  paralysis.  The 
fundus  is  rarely  normal.  In  a  study  of  thirty-five  cases,  Randolph  (Balti- 
more) noted  the  following  changes :  The  fundus  was  the  seat  of  venous 
engorgement  and  tortuosity,  with  more  or  less  congestion  of  the  optic  disc 
in  nineteen  cases ;  there  was  optic  neuritis  in  six  cases ;  retinitis  with 
thrombosis  of  the  central  vein  in  one  case.  Of  the  seven  cases  in  which 
the  fundus  was  normal,  one  had  strabismus,  one  nystagmus,  and  one 
greatly  dilated  pupils.  Inflammation  of  the^conjunctiva  is  also  very  fre- 
quent. Deafness  is  common  during  the  acute  stage  of  the  disease,  and  is 
its  most  frequent  sequel.  It  may  be  due  to  the  cerebral  lesion,  to  otitis 
media,  or  to  otitis  interna. 

Speech  is  disturbed  in  most  of  the  protracted  cases.  Bulging  of  the 
fontanel  is  one  of  the  regular  symptoms  in  young  infants.  Marked  pros- 
tration is  always  present;  it  may  come  very  early,  and  may  be  followed 
by  collapse,  or  may  last  but  a  short  time  and  be  followed  by  a  period  of 
reaction. 

The  temperature  is  always  elevated,  being  especially  high  at  the  onset. 
In  the  fulminating  cases  there  may  be  hyperpyrexia — 106°  or  even  107°  F. 
The  usual  range  is  between  100°  and  104°  F.  In  cases  terminating  in 
recovery,  the  fever  usually  lasts  from  one  to  two  weeks  and  gradually  falls 
to  normal.  There  is  no  regular  or  typical  curve.  The  height  of  the  tem- 
perature may  bear  no  relation  to  the  severity  of  the  other  symptoms. 
It  may  be  low  throughout,  even  in  the  fatal  cases. 

The  respiration  is  slow  and  irregular  as  the  disease  progresses,  and  it 
may  be  of  the  typical  Cheyne-Stokes  variety.  Cyanosis  is  often  present 
in  cases  where  no  cause  for  it  can  be  found  in  the  heart  or  lungs ;  it  is  es- 
pecially frequent  in  the  fulminating  cases. 

The  pulse  in  the  early  stages  is  full  and  rapid  ;  later  it  becomes  slow, 
irregular,  and  feeble,  and  may  be  intermittent. 

The  examination  of  the  blood  made  by  Barker  and  Flexner  (Balti- 
more) showed  the  presence  of  marked  leucocytosis  in  every  fatal  case 
examined.  Epistaxis  is  not  uncommon  as  an  early,  and  sometimes  as  a 
late  symptom. 

Digestive  syste?n.—Vomitmg  is  frequent  at  the  onset  and  may  be  per- 
sistent. The  bowels  as  a  rule  are  constipated.  The  tongue  is  often 
coated  ;  sometimes  it  is  dry  and  glazed,  or  covered  with  sordes.  Deglu- 
tition is  sometimes  difficult  on  account  of  the  retraction  of  the  neck. 
The  spleen  is  usually  not  enlarged.  Jaundice  occurs  in  a  small  propor- 
tion of  the  cases. 

Erupitions. — In  the  majority  of  cases,  the  skin  presents  no  changes. 
In  others  there  is  herpes  of  the  lips,  face,  or  nose,  or  an  eruption  over  the 


712  DISEASES   OF  THE  NERVOUS  SYSTEM, 

face  or  body  consisting  of  fine  purpuric  spots,  and  sometimes  larger  ex- 
travasations. These  are  particularly  significant  when  seen  upon  the  face 
or  the  ears,  and  from  this  symptom  the  name  "  spotted  fever  "  has  arisen. 
In  some  cases  a  general  erythema  is  present.  Tiie  petechial  eruption  may 
be  seen  during  the  early  part  of  the  disease,  even  in  the  first  twenty-four 
hours.  Late  in  the  protracted  cases  there  may  be  fine  punctate  ha^mor- 
.rhages  over  the  abdomen,  as  in  any  exhausting  disease. 

The  large  joints,  particularly  the  knees,  are  sometimes  swollen,  tender, 
and  painful,  the  symptoms  resembling  those  of  acute  rheumatism.  Incon- 
tinence of  urine  and  faeces  may  occur  in  the  late  stages  of  the  disease,  asso- 
ciated with  low  delirium  and  other  typhoid  symptoms.  Retention  of  urine 
is  not  infrequent,  and  often  overlooked. 

Course,  Termination,  and  Prognosis. — The  duration  of  the  disease  in 
the  fatal  cases  is  usually  less  than  a  week.  In  epidemics  many  deaths 
occur  within  forty-eight  hours.  In  infants  also  the  course  is  very  short. 
Of  the  cases  which  terminate  in  recovery,  if  we  exclude  the  abortive  cases, 
the  majority  last  at  least  three  weeks,  and  very  many  run  a  protracted 
course.  After  three  or  four  weeks,  there  is  in  such  cases  a  gradual  subsi- 
dence of  the  fever  and  of  most  of  the  acute  nervous  symptoms;  but  the 
child  remains  emaciated,  very  weak,  with  occasional  attacks  of  headache, 
general  pains  or  hyperaesthesia,  and  often  with  some  localized  paralysis. 
This  may  slowly  disappear,  or  it  may  be  permanent.  In  the  majority  of 
cases  recovery  is  only  partial.  The  child  may  recover  perfectly  so  far  as  all 
the  physical  functions  are  concerned,  but  be  mentally  deficient.  But  more 
frequently  there  is  also  hemiplegia  or  monoplegia,  and  often  contractures, 
which  are  sometimes  temporary  but  are  apt  to  be  permanent.  Of  the 
special  senses,  hearing  is  most  liable  to  be  affected,  deafness  being  quite 
common  after  severe  attacks,  and  deaf-mutism  not  an  infrequent  result 
in  young  children.  Blindness  is  rare,  and  may  be  due  to  optic-nerve 
atrophy  or  rarely  to  the  cerebral  lesion.  Asa  late  result  epilepsy  may 
develop. 

The  mortality  of  epidemic  meningitis  varies  much  at  different  times, 
ranging  from  forty  to  eighty  per  cent.  It  is  now  pretty  well  established 
that  many  more  such  cases  recover  than  of  meningitis  due  to  other  bac- 
teria; infection  by  the  pneumococcus  is  usually,  and  that  by  the  strepto- 
coccus nearly  always,  fatal. 

Diagnosis. — The  diagnosis  of  acute  meningitis  i:)resents  unusual  diffi- 
culties in  young  children,  because  of  the  frequency  wdth  which  cerebral 
symptoms  are  seen  in  all  forms  of  acute  disease,  both  at  the  onset  and  late 
in  their  course.  In  infants  the  usual  mistake  made  is  to  diagnosticate 
meningitis  where  there  is  none,  rather  than  to  overlook  it  when  it  is 
present.  The  symptoms  most  to  be  relied  upon  for  diagnosis  are  con- 
tinued stupor  or  coma,  opisthotonus,  slow  pulse  and  irregular  respiration 
— especially  if  associated  with  high  fever — localized  paralysis,  muscular 


ACUTE   MENINGITIS.  ^13 

rigidity,  general  hyperesthesia,  and  a  retracted  abdomen.  Cases  where  the 
principal  lesion  is  at  the  convexity  are  particularly  obscure,  and  often  the 
diagnosis  is  not  made  during  life.  There  is  no  opisthotonus  or  cranial- 
nerve  symptoms,  and  irregularity  of  pulse  and  respiration  is  rare. 

At  the  onset,  meningitis  is  most  likely  to  be  confounded  with  pneu- 
monia, scarlet  fever,  and  influenza.  Pneumonia  is  recognised  by  the 
accelerated  respiration  and  the  physical  signs ;  scarlet  fever,  by  the  con- 
gestion of  the  throat  and  the  eruption ;  from  influenza  the  diagnosis  may 
be  almost  impossible  except  from  the  course  of  the  disease.  From  all  other 
diseases,  meningitis  is  differentiated  by  the  continuance  and  the  severity  of 
the  nervous  symptoms,  rather  than  by  the  presence  or  absence  of  single  or 
special  symptoms. 

Quincke's  procedure  of  lumbar  puncture  *  is  of  much  value,  first  iu 
distinguishing  meningitis  from  other  diseases  with  cerebral  symptoms,  and 
secondly  in  determining  the  form  of  meningitis  which  is  present.  Menin- 
gitis is  indicated  by  cloudiness  in  the  fluid  drawn,  sometimes  marked  and 
sometimes  scarcely  recognisable,  by  an  increase  in  the  amount  of  fibrin 
present  so  that  spontaneous  coagulation  may  occur,  and  by  the  presence 
of  leucocytes  which  frequently  form  a  heavy  deposit  in  twenty-four  hours. 
The  different  forms  of  meningitis  are  distinguished  by  the  discovery  of  the 
form  of  bacteria  present.  Councilman  found  the  diplococcus  in  thirtv-eight 
of  fifty-five  cases  of  epidemic  meningitis  examined ;  positive  results  being 
obtained  in  nearly  all  cases  at  the  most  active  period  of  the  disease.  In 
other  varieties  of  meningitis,  the  pneumococcus,  streptococcus,  or  tubercle 
bacillus  may  be  found,  or  mixed  forms.  The  number  of  bacteria  present ' 
may  be  few  or  many,  but  their  discovery  in  the  cerebro- spinal  fluid  may  be 
regarded  as  definitely  establishing  the  nature  of  the  infection,  a  point 
which  can  not  be  settled  in  any  other  way  during  life. 

The  most  striking  points  which  contrast  simple  and  tuberculous  men- 
ingitis are  that  in  the  former  the  onset  is  usually  abrupt ;  the  temperature 
is  high  ;  the  disease  develops  rapidly ;  and  in  forty-eight  hours — sometimes 
in  twenty-four — nearly  all  the  severe  nervous  symptoms  may  be  present ; 
pain  in  the  spine  and  general  hyperaesthesia  are  quite  frequent.  Usually 
the  patient  is  a  child  Avho  has  been  in  perfect  health  up  to  the  beginning 
of  the  disease  ;  or  there  is  present  some  local  cause,  such  as  middle-ear 

*  Puncture  is  usually  made  between  the  third  and  fourth  lumbar  vertebrae  a  little 
to  one  side  of  the  median  line.  The  smallest  exploring  needle  may  be  used,  and  for 
convenience  it  may  be  attached  to  a  syringe  as  a  handle,  as  it  is  not  necessary  to  aspi- 
rate. The  canal  is  reached  at  a  variable  depth,  usually  about  one  inch  from  the  skin. 
The  body  should  be  flexed  during  the  operation  so  as  to  separate  the  vertebra?,  and 
unless  the  patient  is  comatose  an  anjvsthetic  is  advisable.  All  observers  agree  that 
with  a  clean  needle  lumbar  puncture  is  harmless.  SeeJacoby.  New  York  MedicalJour- 
luil,  December  28,  I8O0.  and  .January  4,  1896;  Caille,  New  York  Medical  Journal,  June 
13,  181)0;  and  Wentworlh,  Transactions  of  the  American  Pa-diatric  Societv,  1896. 


714  DISEASES  OF   THE   NERVOUS  SYSTEM. 

disease,  or  traumatism  ;  or  an  epidemic  may  be  prevailing.  In  tuberculous 
meningitis,  the  onset  is  usually  insidious;  the  temperature,  low  ;  the  pros- 
tration not  marked  for  the  first  few  days ;  the  evolution  of  the  nervous 
symptoms  is  often  slow  and  irregular,  and  the  child  may  be  sick  a  week 
before  he  appears  to  'be  seriously  ill ;  pain  in  the  spine  and  general  hyper- 
esthesia are  rare.  The  child  is  usually  one  who  has  a  history  of  heredi- 
tary tuberculosis;  or  who  has  been  previously  delicate,  or  who  has  suffered 
already  from  some  other  form  of  tuberculosis,  in  the  lungs,  bones,  or 
lymph  nodes.  In  cases  of  sporadic  meningitis  which  are  apparently  pri- 
mary, the  tuberculous  is  much  more  frequent  than  the  simple  form — in 
my  experience  fully  three  to  one. 

Treatment. — The  treatment  of  acute  meningitis  is  quite  unsatisfactory, 
and  it  is  very  doubtful  whether  the  result  is  greatly  modified  by  any  spe- 
cial plan  of  treatment ;  it  seems  to  depend  upon  the  age  of  the  patient, 
and  the  nature  and  severity  of  the  attack,  rather  than  upon  its  manage- 
ment. The  treatment  directed  toward  the  inflammation  consists  in  the 
constant  use  of  an  ice-cap  to  the  head,  and  at  times  an  ice-bag  along  the 
spine.  Counter-irritation  may  be  maintained  by  painting  the  nape  of 
the  neck  and  the  spine  daily  with  a  strong  tincture  of  iodine,  or  by  blis- 
ters, but  best  of  all  by  the  Paquelin  cautery.  The  bowels  should  be  kept 
freely  open  by  calomel  or  saline  cathartics.  Internally,  ergot  and  iodide 
of  potassium  should  be  given  in  as  full  doses  as  will  be  tolerated  by  the 
stomach. 

Of  the  symptoms  which  call  for  special  treatment,  the  most  prominent 
'one  is  pain,  which  when  severe  requires  morphine,  even  in  large  doses. 
It  is  often  best  to  give  it  hypodermically.  For  other  nervous  symptoms — 
delirium,  sleeplessness,  etc. — iAie  bromides  and  chloral,  sulfonal,  or  trional 
may  be  given,  or  warm  sponge  baths.  Stimulants  are  required  in  most  of 
the  cases  at  some  time  in  the  course  of  the  disease.  They  are  indicated 
by  weak,  rapid,  and  irregular  pulse.  Alcohol  and  digitalis  should  be 
used,  but  not  strychnine.  The  difficulties  in  feeding  these  patients  are 
sometimes  great,  but  they  can  often  be  overcome  by  the  use  of  gavage 
(page  62),  which  may  be  advantageously  employed  as  a  routine  practice  in 
the  most  severe  cases.  The  physician  should  be  on  the  watch  for  bed- 
sores, and  endeavour  to  prevent  them  by  cleanliness,  frequently  changing 
the  patient's  position,  etc.  The  bladder  also  must  not  be  forgotten,  as 
retention  of  urine  is  not  uncommon  and  may  require  the  use  of  the 
catheter. 

For  the  residual  paralysis,  massage,  warm  baths,  and  friction  should  be 
employed,  but  electricity  only  when  all  symptoms  of  central  irritatioh 
have  subsided.  The  prolonged  use  of  iodide  of  potassium,  especially  in 
combination  with  mercury,  seems  to  have  considerable  influence  in  pro- 
moting absorption  of  the  inflammatory  products  in  cases  where  there  is  a 
persistence  of  symptoms  for  two  or  three  months. 


TUBERCULOUS  MENINGITIS.  715 


TUBERCULOUS  MENINGITIS. 


Synonyms :  Acute  hydrocephalus ;  basilar  meningitis ;  water  on  the  brain. 

Tuberculous  meningitis  is  a  tuberculous  inflammation  of  the  pia  mater 
of  the  brain,  sometimes  involving  also  that  of  the  cord.  It  is  doubtful  if 
it  ever  occurs  as  the  only  tuberculous  lesion  of  the  body.  It  is  quite 
frequently  seen,  and  is  more  uniformly  fatal  than  any  other  disease  of 
early  life.  In  infancy  it  is  usually  associated  with  general  or  pulmonary 
tuberculosis ;  in  older  children  with  tuberculosis  of  the  bones,  joints,  or 
lymph  nodes.  Of  my  own  cases,  twenty-five  per  cent  of  all  deaths  from 
tuberculosis  in  children,  were  due  to  meningitis. 

Lesions. — The  lesion  consists  in  the  production  of  miliary  tubercles, 
with  which  are  frequently  found  tuberculous  nodules  of  variable  size,  and 
in  almost  every  case  there  are  also  the  products  of  ordinary  inflamma- 
tion of  the  pia  mater — lymph  and  pus — together  with  an  accumulation  of 
fluid  in  the  lateral  ventricles  of  the  brain.  Frequently  there  are  tubercles 
in  the  pia  mater  of  the  upper  portion  of  the  cord.  The  miliary  tu- 
bercles appear  as  small  gray  or  white  granules,  situated  along  the  vessels 
of  the  pia  mater.  AVhen  few  in  number  they  are  usually  only  at  the  base, 
especially  along  the  Sylvian  fissures  and  in  the  interpeduncular  space. 
When  numerous  they  are  most  abundant  at  the  base,  but  are  also  seen 
scattered  over  the  convexity  in  small  groups.  In  about  half  of  my  au- 
topsies they  have  been  limited  to  the  base,  and  in  no  case  were  they  seen 
exclusively  at  the  convexity.  Tubercles  are  often  found  in  the  choroid  coat 
of  the  eye.  The  amount  of  lymph  and  pus  present  is  rarely  great,  and 
never  equal  to  that  seen  in  simple  acute  meningitis.  It  is  often  a 
matter  of  surprise  at  autopsy  to  find  the  lesions  so  few,  after  very  marked 
symptoms.  The  inflammatory  products  are  most  abundant  at  the  base. 
In  addition  to  the  patches  of  greenish-yellow  lymph,  there  are  adhesions 
between  the  lobes  of  the  brain  and  thickening  of  the  pia.  In  cases  which 
have  lasted  for  several  weeks,  the  pia  mater  in  places  is  often  very  much 
thickened,  owing  to  cell  infiltration  and  the  production  of  new  connective 
tissue,  and  it  is  studded  with  miliary  tubercles,  sometimes  with  small  yel- 
low tuberculous  nodules ;  frequently  there  is  arteritis,  which  is  sometimes 
obliterating. 

In  the  most  acute  cases  the  brain  substance  immediately  beneath  the 
jiia  is  intensely  congested,  slightly  softened,  and  shows  under  the  micro- 
scope a  superficial  encephalitis.  The  lateral  ventricles  are  usually  dis- 
tended with  clear  serum,  sometimes  with  serum  containing  flocculi  of 
lymph  or  pus ;  the  amount  present  varies  from  one  to  four  ounces  in  each 
ventricle,  being  always  greater  in  the  subacute  cases.  The  walls  of  the 
ventricles  may  be  softened.  The  distention  of  the  ventricles  leads  to 
flattening  of  the  convolutions  from  pressure  against  the  skull,  to  bulging 


716 


DISEASES  OP   THE   NERVOUS   SYSTEM. 


of  the  fontanel,  and  sometimes  to  separation  of  the  sutures,  if  they  are  not 
completely  ossified. 

Tuberculous  nodules  varying  in  size  from  a  small  pea  to  a  walnut  are 
frequently  seen  associated  with  meningitis  in  older  children,  but  not  so 
often  in  infants.  These  nodules  may  be  connected  with  the  meninges,  or 
they  may  be  situated  within  the  brain  substance,  usually  in  the  cerebel- 
lum. The  larger  ones  are  classed  as  brain  tumours.  Inflammatory  prod- 
ucts are  rarely  found  in  the  spinal  canal. 

Although  it  is  not  infrequent  to  see  meningitis  without  symptoms  of 
tuberculosis  elsewhere,  I  have  never  failed  at  autopsy  to  find  other  tuber- 
culous lesions  in  the  body.  In  my  own  exi^erience  the  following  are  those 
most  often  met  with,  given  in  the  order  of  frequency: 

(1)  In  infants,  associated  with  general  or  pulmonary  tuberculosis;  (2) 
in  children  from  three  to  twelve  years  of  age,  with  tuberculosis  of  the 
vertebrae,  hip,  knee,  or  ankle;  (3)  at  any  age,  with  tuberculosis  involving 
only  the  tracheal,  bronchial,  or  cervical  lymph  nodes ;  (4)  much  less  fre- 
quently with  the  pulmonary  tuberculosis  of  older  children.  Meningitis 
has  been  reported  when  it  was  secondary  to  tuberculosis  of  the  skin  or 
mucous  membranes.     I  have  not,  however,  met  wath  such  cases. 

Etiology. — Tuberculous  meningitis  is  produced  only  by  the  transpor- 
tation of  the  tubercle  bacilli  to  the  brain.  They  may  find  their  way  by 
the  blood-vessels  or  lymphatics. 

The  following  table  shows  the  age  at  which  the  disease  is  most  fre- 
quently observed : 


Age. 

Personal  cases. 

Oxley.* 

Total. 

Under  one  year 

14 

9 

24 

15 

5 

3 
16 
20 
18 

0 

17 

One  to  two  years 

25 

Two  to  five  years 

50 

Five  to  nine  years 

33 

Nine  to  sixteen  years 

5 

Totals 

67 

63 

130 

In  this  series,  males  were  a  little  more  frequently  affected  than  fe- 
males. In  two  or  three  instances  traumatism  was  apparently  an  exciting 
cause.  Tuberculous  meningitis  is  occasionally  seen  in  young  children  who 
were  previously  healthy,  whose  family  history  is  free  from  tuberculosis, 
and  where  no  exposure  can  be  traced.  It  is  probable  that  in  all  such  cases 
there  has  been  latent  tuberculosis  somewhere  in  the  body,  and  that  the 
exposure  was  long  antecedent  to  the  symptoms.  In  the  majority,  how- 
ever, this  is  not  the  case.  There  is  usually  a  history  of  hereditary  tuber- 
culosis or  of  exposure  to  infection  ;  or  there  have  been  previous  evidences 
of  tuberculosis  in  the  lungs,  bones,  or  lymph  nodes. 


*  Liverpool,  Medico-Chirurgical  Journal,  July,  1885. 


TUBERCULOUS  MENINGITIS.  7IY 

Symptoms. — In  forty-three  of  sixty-three  cases  the  onset  was  gradual ; 
but  in  a  considerable  number  of  those  classed  as  sudden,  careful  inquiry 
elicited  a  history  of  previous  indisposition.  The  most  frequent  earlv 
symptoms  are  disinclination  to  play,  or  drowsiness;  sometimes  there  is 
constant  fretfulness  or  irritability.  Often  a  distinct  change  in  disposition 
is  seen.  In  a  case  recently  under  observation  this  was  most  striking : 
from  being  devoted  to  her  mother,  a  little  girl  could  not  endure  her  presence 
in  the  room.  There  is  loss  of  appetite,  and  usually  constipation.  Sleep 
is  restless  and  disturbed  ;  there  may  be  grinding  of  the  teeth.  Older 
children  often  complain  of  headache.  At  all  ages  a  suggestive  symptom 
is  frequent  attacks  of  vomiting  without  apparent  cause.  In  addition  to 
these  there  may  be  a  slight  but  continuous  elevation  of  temperature.  In- 
definite symptoms  may  last  for  four  or  five  days,  or  they  may  be  spread 
over  two  or  three  weeks  without  perhaps  being  sufficiently  severe  to  attract 
much  notice.  Finally,  unmistakable  evidence  of  brain  disease  develops, 
and  then  it  is  recollected  that  symptoms  like  the  above  had  existed  for 
some  time.  These  early  disturbances  are  often  ascribed  to  dentition,  to 
worms,  or  to  indigestion ;  and  sometimes  they  are  regarded  simply  as 
the  result  of  the  constipation. 

In  the  midst  of  such  indefinite  symptoms  there  may  come  an  attack  of 
convulsions,  and,  in  the  course  of  a  few  hours,  deep  stupor.  The  early 
symptoms  of  the  active  stage  are  indicative  of  cerebral  irritation.  There  is 
headache,  often  located  in  the  frontal  region,  and  occasionally  photophobia ; 
sometimes  there  is  sudden  screaming  out  at  night  without  waking.  The 
skin  is  usually  somewhat  hyperaesthetic  ;  the  reflexes  are  apt  to  be  exagger- 
ated ;  the  muscles  of  the  neck  may  be  rigid  and  the  head  is  drawn  back,  or 
there  may  be  rigidity  of  one  or  more  of  the  extremities.  The  pupils  are 
normal  or  contracted  ;  there  may  be  nystagmus.  The  child  is  fretful, 
wishes  to  be  left  alone,  and  cries  if  disturbed  ;  but  otherwise  is  apt  to  be  un- 
naturally drowsy.  Such  symptoms  may  continue  for  a  day  or  two,  or  even 
for  a  week.  If  prolonged,  they  are  likely  to  alternate  with  periods  of  more 
marked  apathy  and  dulness.  During  this  stage  there  is  occasional  vomit- 
ing, and  the  bowels  are  obstinately  constipated.  The  pulse  is  usually 
somewhat  accelerated,  but  may  be  slow  and  occasionally  is  irregular.  The 
respiration  is  of  normal  frequency,  but  a  careful  observation  during  sleep 
or  perfect  quiet  will  often  show  a  slight  irregularity  which  is  very  signifi- 
cant. This  becomes  more  marked  as  the  disease  progresses.  The  tem- 
perature is  invariably  elevated,  but  never  very  much  so,  generally  being 
from  99°  F.  to  101°  F.  "When  a  high  temperature  is  ceen,  it  is  usually 
due  to  tuberculosis  elsewhere  than  in  the  brain. 

During  the  intermediate  or  second  stage,  the  irritative  symptoms  sub- 
side, and  stupor  becomes  deeper  and  more  continuous.  If  undisturbed, 
the  child  may  sleep  a  great  part  of  the  time,  but  can  be  roused,  and  then 
appears  quite  rational.     Later  the  stupor  becomes  so  profound  that  the 


718  DISEASES  OP  THE  NERVOUS  SYSTEM. 

child  can  not  be  roused  at  all ;  or,  again,  this  condition  may  alternate  with 
periods  of  complete  lucidity.  Active  delirium  is  rare.  The  pupils  respond 
slowly  to  light  or  not  at  all ;  they  may  be  unequal ;  occasionally  there  is 
seen  strabismus,  ptosis,  or  paralysis  of  the  face.  More  often  there  is  hemi-. 
plegia,  or  paralysis  of  one  arm  or  leg.  Such  paralyses  are  often  transient, 
disappearing  after  a  day  or  two.  Automatic  movements  of  the  extremi- 
ties, particularly  of  the  arms,  are  frequent.  Muscular  twitchings  may  be 
noticed.  Opisthotonus  is  marked  and  well-nigh  constant.  In  infants 
the  fontanel  is  tense  and  bulging ;  the  abdomen  is  retracted,  giving  the 
typical  "  boat-belly."  On  drawing  the  finger-nail  along  the  skin  of  the 
abdomen,  there  appears,  after  a  few  seconds,  a  distinct  red  streak  one  or 
two  inches  wide,  which  remains  for  three  or  four  minutes.  This  is  the 
tache  cerebrale,  and  while  not  pathognomonic,  it  is  almost  always  present. 
Other  vaso-motor  disturbances  may  be  seen.  The  reflexes  are  variable ; 
in  the  early  part  of  the  disease  they  are  usually  increased,  later  they  are 
diminished  or  abolished.  The  pulse  now  becomes  slow  and  irregular, 
often  intermittent.  Tlie  respiration  assumes  the  characteristic  type,  which 
consists  in  the  movements  becoming  deeper  and  deeper  until  there  is 
a  long  sigh,  then  a  complete  arrest  of  respiration  for  several  seconds,  after 

which  the  movements  begin  again, 
at  first  shallow,  but  gradually  in- 
creasing in  depth  until  the  sigh 

Fig.  114.— Tracing  of  respiration  in  tuberculous       jg    repeated.       The    accompanying 
meningitis.  .  /Vi- 

tracing  illustrates  the  type  (rig. 
114).  An  examination  with  the  ophthalmoscope  usually  shows  the  pres- 
ence of  choked  discs. 

The  duration  of  this  stage  is  from  three  to  ten  days.  The  progress 
is  irregular,  and  subject  to  great  variations,  especially  as  regards  the 
mental  symptoms.  Sometimes  a  child  will  be  seen  in  quite  deep  stupor, 
and  on  the  following  day  will  be  sitting  up  in  bed  playing  with  its  toys. 
Such  a  course  is  to  be  expected,  and  the  physician  should  never  raise 
any  false  hopes  of  recovery  because  of  these  periods  of  temporary  improve- 
ment. 

In  the  third  stage  there  is  complete  coma.  The  child  can  not  be 
roused  at  all.  The  pupils  are  widely  dilated,  and  do  not  respond  to  light. 
There  is  general  muscular  relaxation.  There  may  be  retention  of  the 
urine.  Deglutition  is  difficult,  sometimes  almost  impossible.  The  boat- 
belly  and  opisthotonus  are  still  marked.  The  respiration  is  more  rapid, 
but  still  irregular.  There  are  sordes  on  the  lips  and  teeth,  emaciation, 
and  anaemia.  Toward  the  end  the  temperature  rises  rapidly  to  104°  F., 
sometimes  to  106°  or  107°  F.  (Fig.  115).  The  pulse  becomes  very  rapid 
and  feeble,  often  160  to  180  a  minute.  Death  usually  takes  place  from 
exhaustion  in  deep  coma ;  or  convulsions  develop  and  continue  from  twelve 
to  twenty-four  hours  until  death.     The  duration  of  the  stage  of  coma  is 


TUBERCULOUS   MENINGITIS. 


719 


from  two  days  to  a  week.  Often  the  patient  will  live  for  four  or  five  days 
in  a  condition  of  prostration  so  extreme  that  death  is  hourly  expected. 
A  rapidly  rising  temperature  or  the  occurrence  of  convulsions  indicates 


DAY 

1            2 

3 

4 

5 

6 

7 

3 

9 

10 

11 

12 

13 

14 

15 

18 

17 

DATE 

OCT. 

10 

11 

12 

13 

1* 

15 

IS 

17 

18 

19 

so 

21 

22 

23 

24 

25 

26 

I 

I 
< 

H 
< 

1- 

106° 
105° 
104° 

103° 
102° 
101° 
100° 
99° 

M.e. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 
/ 

/ 

J 

y 

/ 

V 

h 

\, 

N 

r-^ 

^ 

-4 

A 

1 

\ 

^ 

l^ 

\N 

A/ 

A 

ht 

^ 

A 

K 

y 

/ 

\j 

J 

V 

v 

V 

v\/ 

fV 

L 

^^ 

J 

v 

V 

V 

Pig.  115. — Fairly  typical  temperature  curve  iu  tuberculous  meningitis ;  boy,  twenty  months 
old  ;  death  on  seventeenth  day. 

•approaching  death.     Of  fifty-seven  cases,  fifty  died  iu  coma,  seven  in  con- 
vulsions. 

The  entire  duration  of  the  disease  from  the  beginning  of  definite 
^symptoms,  in  sixty-five  of  my  own  cases,  was  as  follows : 

One  week,  or  less 17 

One  to  two  weeks  . . .'. 15 

Two  to  three  weeks 17 

Three  to  four  weeks 14 

Five  weeks 2 

65 

Variations  in  the  conrse  of  the  disease. — There  are  few  diseases  which 
present  a  greater  variety  of  symptom^  than  tuberculous  meningitis.  Typical 
■cases  like  those  above  described  are  seen  most  frequently  in  children  over 
two  years  old,  in  whom  the  cerebral  symptoms  predominate  over  those  of 
general  tuberculosis.  In  infancy,  especially  when  the  disease  follows 
acute  tuberculous  pneumonia,  the  duration  of  the  cerebral  symptoms  may 
be  only  three  or  fotir  days.  The  stages  then  are  not  marked.  The  onset 
is  usually  with  convulsions,  and  in  less  than  twenty-four  hours  there  may 
be  marked  stupor,  and  all  the  symptoms  belonging  to  the  third  stage  of 
the  disease. 

In  some  cases  the  course  is  much  longer  than  that  described,  the 
symptoms  lasting  from  four  to  eight  weeks.  In  character  they  are  much 
the  same  as  those  in  the  typical  cases,  except  that  the  irritative  symptoms 
are  less  marked,  and  there  is  less  fever.  If  the  child  is  young,  there  is 
great  bulging  of  the  fontanel,  or  even  an  increase  in  the  size  of  the  head. 
47 


Y20  DISEASES   OP   THE   NERVOUS  SYSTEM. 

In  older  children  the  symptoms  are  chiefly  those  of  a  general  pressure 
upon  the  cortex.  These  are  due  to  the  great  accumulation  of  fluid  in  the 
lateral  ventricles.  The  symptoms  of  general  compression  are  persistent 
drowsiness,  but  rarely  deep  coma,  rigidity  of  all  the  extremities,  and  some- 
times paralysis.  The  pupils  are  usually  contracted,  but  there  are  no 
symptoms  which  are  distinctly  focal.  Opisthotonus  is  nearly  always 
marked  in  these  cases. 

Diagnosis. — There  are  no  diagnostic  symptoms  in  the  first  stage.  If 
the  patient  has  previously  suffered  from  local  or  general  tuberculosis,  and 
symptoms  develop  which  are  enumerated  as  prodromal,  meningitis  may 
be  suspected  with  a  strong  degree  of  probability.  If  the  child  has  pre- 
viously given  no  evidence  of  tuberculosis,  a  diagnosis  is  impossible.  The 
indefinite  symptoms  tliat  belong  to  the  early  stage  of  the  disease  are  fre- 
quent in  young  children  suffering  from  chronic  indigestion  associated 
with  constipation.  In  nine  out  of  every  ten  cases,  such  will  be  the  ex- 
planation of  the  indisposition  rather  than  incipient  meningitis.  Dis- 
turbances of  nutrition,  classed  as  cyclic  vomiting  (page  287),  may  present 
many  of  the  symptoms  of  meningitis.  I  have  seen  two  cases  in  which  a 
differential  diagnosis  was  impossible  for  two  or  three  days. 

The  most  frequent  symptoms  of  tuberculous  meningitis  enumerated  in 
the  order  of  their  occurrence  in  fifty-eight  cases,  were  as  follows  :  obsti- 
nate constipation,  persistent  drowsiness,  irregular  respiration,  vomiting 
without  apparent  cause,  irregular  pulse,  convulsions,  opisthotonus,  and 
fever  which  was  usually  slight.  Equally  important  for  diagnosis,  and  es- 
pecially significant  when  associated  with  the  above,  are  strabismus,  facial 
paralysis,  and  loss  of  the  pupillary  reflexes. 

The  discovery  of  tubercle  bacilli  in  the  fluid  drawn  by  lumbar  puncture 
(page  713)  is  conclusive.  However,  this  does  not  add  greatly  to  our  means 
of  diagnosis,  as  the  bacilli  are  never  numerous  and  always  difficult  to 
find,  and  in  a  number  of  undoubted  cases  they  can  not  be  found  at  all. 
Without  finding  bacilli  we  may  be  quite  certain,  from  the  other  conditions 
present,  that  meningitis  exists,  but  we  can  not  with  any  certainty  separate 
the  simple  from  the  tuberculous  cases.  The  symptoms  which  distinguish 
these  from  each  other  have  already  been  considered  (page  713). 

The  cerebral  symptoms  of  ileo- colitis  and  other  diarrhceal  diseases, 
sometimes  closely  resemble  those  of  tuberculous  meningitis  ;  but  whenever 
in  a  young  child  there  is  another  disease  present  which  may  furnish  an 
explanation  for  the  cerebral  symptoms,  the  diagnosis  of  meningitis  should 
be  made  with  great  caution.  The  development  of  meningitis  in  the  course 
of  an  ordinary  attack  of  pneumonia  may  simulate  very  closely  pulmonary 
tuberculosis  with  tuberculous  meningitis.  A  diagnosis  may  be  impossible 
during  life.  In  doubtful  cases  the  probabilities  are  greatly  in  favour  of 
tuberculosis,  since  it  is  so  much  more  common. 

Prognosis. — It  is  still  a  matter  of  disj)ute  whether  tuberculous  menin- 


CHRONIC   BASILAR  MENINGITIS  IN  INFANTS.  721 

gitis  ever  ends  in  recovery.  Such  a  result  is  certainly  so  rare  as  not  to  be 
expected.  I  have  never  seen  it.  In  certain  cases  simple  meningitis 
may  so  closely  simulate  the  tuberculous  variety  that  a  differential  diag- 
nosis can  not  be  made,  and  it  is  possible  that  the  cases  of  alleged  recov- 
ery were  simple  and  not  tuberculous.  Gibney  has  reported  a  case  of  men- 
ingitis occurring  in  a  boy  with  double  hip-joint  disease,  which  certainly, 
so  far  as  symptoms  went,  should  be  classed  as  tuberculous,  and  yet  re- 
covery took  place.  The  child  died  several  months  later,  of  amyloid  dis- 
ease. I  was  present  at  the  autopsy,  and  there  was  found  no  trace  of  cere- 
bral tuberculosis.  On  theoretical  grounds  there  seems  to  be  no  reason 
why  recovery  may  not  sometimes  follow  from  meningitis  as  well  as  from 
other  forms  of  local  tuberculosis,  but  as  a  matter  of  clinical  observation 
such  a  result  is  extremely  doubtful. 

Treatment. — From  what  has  been  said  regarding  prognosis,  it  follows 
that  if  the  diagnosis  is  correct  the  case  is  practically  hopeless,  no  matter 
what  treatment  is  employed ;  but  as  a  positive  diagnosis  is  not  always 
possible,  all  cases  should  be  treated  like  those  of  simple  meningitis. 

CHRONIC   BASILAR  MENINGITIS  IN  INFANTS. 

Basilar  meningitis  is  generally  tuberculous.  Not  very  infrequently  there 
is,  however,  seen  in  infants  a  chronic  form  of  basilar  meningitis  which  is 
not  tuberculous.  Attention  was  first  called  to  these  cases  by  Gee  and  Bar- 
low, who  in  1878  published,  under  the  title  of  "  Cervical  Opisthotonus  in 
Infants,"  six  cases  of  simple  basilar  meningitis  in  which  the  diagnosis  was 
confirmed  by  autopsy.  Since  that  time  a  number  of  other  cases  have  been 
reported  by  various  writers.  I  have  followed  two  such  cases  to  the  post- 
mortem table,  one  of  which  was  undoubtedly  syphilitic.  I  have  seen 
others  of  a  similar  nature  which  have  recovered,  one  of  these  also  being  in 
a  syphilitic  infant.  Not  all  these  cases  are  syphilitic,  but  the  etiology  of 
the  other  cases  is  unknown. 

Lesions. — This  process  is  usually  limited  to  the  base  of  the  brain. 
The  pia  mater  is  thickened  about  the  interpeduncular  space,  also  over  the 
medulla,  pons,  and  cerebellum.  These  different  parts  may  be  adherent  to 
each  other,  or  to  the  inner  surface  of  the  dura.  The  cranial  nerves  may 
be  compressed.  The  openings  in  the  fourth  ventricle  are  usually  obliter- 
ated, and  there  results  a  distention  of  the  lateral  ventricles  with  clear 
serum,  sometimes  in  sufficient  amount  to  be  regarded  as  hydrocephalus. 
Barely,  pus  may  be  found  in  the  ventricles.  The  lesions  thus  are  very 
much  like  those  seen  in  the  protracted  cases  of  tuberculous  meningitis, 
minus  the  tubercles. 

Symptoms. — These  in  all  cases  are  quite  uniform.  The  two  most 
prominent  symptoms  are  cervical  opisthotonus  and  moderate  hydroceph- 
alus. The  opisthotonus  is  constant  and  may  be  quite  extreme.  In  one  of 
my  cases  the  cervical  spine  for  weeks  formed  nearly  a  right  angle  with  the 


722 


DISEASES  OP   THE  NERVOUS  SYSTEM. 


body.  The  accompanying  illustration  (Fig.  116)  is  from  a  photograph  of 
this  patient.  From  time  to  time  the  opisthotonus  varies  in  intensity,  but 
it  never  entirely  disappears.  The  degree  of  hydrocephalus  is  generally 
not  extreme.  It  causes  the  usual  symptoms  of  enlargement  of  the  head, 
separation  of  the  sutures,  and  bulging  of  the  fontanel.  Mental  dulness  or 
apathy  is  less  liable  to  be  present  when  the  disease  begins  in  early  infancy, 
and  the  cranial  bones  yield  more  readily  to  the  increased  pressure,  than 
when  it  comes  so  late  that  the  sutures  are  firmly  ossified.  In  addition  to 
these  two  cardinal  symptoms,  there  are  often  seen  nystagmus,  occasional 
attacks  of  vomiting  without  apparent  cause,  and  convulsions  more  or  less 


Fig.  116. — Chronic  basilar  meningitis;  a  patient  in  the  Babies' Hospital  (diagnosis 
coniirmed  by  autopsy). 


severe.  There  may  be  tonic  rigidity  of  the  extremities,  with  exaggeration 
of  the  reflexes.  Febrile  symptoms,  as  a  rule,  are  wanting.  The  course  is 
essentially  chronic.  The  duration  varies  usually  from  one  to  four  months ; 
exceptionally  it  may  last  a  year.  Patients  may  die  from  convulsions  or 
from  the  effects  of  the  hydrocephalus,  but  more  frequently  waste  and  die 
from  marasmus.  The  prognosis  is  bad,  except  in  the  cases  which  are  due 
to  syphilis,  where  recovery  may  take  place.  How  large  a  proportion  of 
the  cases  are  syphilitic  has  not  yet  been  determined. 

Diagnosis. — The  disease  is  to  be  distinguished  from  tuberculous  menin- 
gitis, and  from  the  opisthotonus  of  reflex  origin,  which  is  occasionally  seen 
in  infants  suffering  from  marasmus.  It  differs  from  tuberculous  menin- 
gitis in  its  more  protracted  course,  in  the  absence  of  fever,  paralysis,  and 
the  evidences  of  tuberculosis  elsewhere  in  the  body,  and  also  in  the  greater 
prominence  of  the  opisthotonus  and  hydrocephalus.  The  opisthotonus 
which  is  seen  in  cases  of  marasmus  is  never  so  extreme  or  so  continuous, 


THROMBOSIS   OF  THE   SINUSES  OP  THE   DURA   MATER.        723 

and  is  not   accompanied  by  any  enlargement  of    tlie  head,  or  by  other 
cerebral  symptoms. 

Treatment. — This  consists  in  the  administration  of  potassium  iodide. 
Although  this  has  little  or  no  influence  upon  cases  not  syphilitic,  it  may 
cure  those  which  are  syphilitic.  As  it  is  impossible  to  distinguish  be- 
tween syphilitic  and  non-syphilitic  cases,  every  child  should  have  the 
benefit  of  a  thorough  trial  of  this  drug  in  full  doses.  At  least  fifteen 
grains  daily  should  be  given  for  several  weeks  to  an  infant  six  months  old, 
and  still  larger  doses  if  the  stomach  will  tolerate  it. 

THROMBOSIS  OF   THE  SINUSES  OF   THE   DURA  MATER. 

This  is  not  very  frequent.  It  may  depend  upon  certain  general  condi- 
tions, when  it  is  usually  classed  as  cachectic  or  marantic  thrombosis ;  it 
may  be  associated  with  local  pathological  processes,  when  it  is  known  as 
inflammatory  or  septic  thrombosis. 

Cachectic  Thrombosis. — This  is  seen  in  infants  and  young  children, 
but  is  very  rare  after  the  age  of  flve  years.  It  occurs  in  the  course  of 
various  diseases,  the  most  frequent  being  pneumonia,  pertussis,  diphtheria, 
nephritis,  tuberculosis,  and  the  acute  intestinal  diseases.  In  connection 
with  the  last-mentioned  group,  altogether  too  much  has  been  made  of  it, 
as  it  is  really  rare,  and  in  only  a  very  few  cases  does  it  explain  the  cerebral 
symptoms  present.  This  statement  is  made  from  personal  observations 
upon  over  two  hundred  autopsies  upon  cases  of  acute  intestinal  disease. 
The  actual  cause  of  the  thrombosis  is  the  altered  condition  of  the  blood 
and  the  feeble  circulation,  as  the  walls  of  the  sinuses  are  normal. 

The  most  frequent  seat  of  cachectic  thrombosis  is  the  superior  longi- 
tudinal sinus.  At  autopsy  one  must  be  careful  not  to  confound  the  soft, 
partly-decolorized,  non-adherent  thrombi  of  post-mortem  origin,  with  those 
of  ante-mortem  formation.  The  latter  are  firm,  and  when  of  long  stand- 
ing may  be  very  hard  and  even  show  a  laminated  structure.  They  usually 
fill  the  sinus  completely,  and  are  adherent.  The  thrombus  extends  from 
the  sinuses  to  the  veins  emptying  into  it,  which  stand  out  like  dark  worms 
upon  the  surface  of  the  brain.  The  brain  itself  may  be  deeply  congested, 
or  it  may  be  covered  with  a  diffuse  ha3morrhage,  but  more  frequently  the 
brain  and  the  membranes  are  simply  oedematous. 

The  symjjtoms  of  cachectic  thrombosis  are  few  and  uncertain,  and 
in  a  large  number  of  cases  the  disease  is  latent.  Very  rarely  is  a  posi- 
tive diagnosis  possible  during  life.  When  the  thrombosis  occurs  just 
before  death,  its  symptoms  are  so  mingled  with  those  of  the  original 
disease  that  they  can  not  be  separated.  In  some  cases  there  may  be 
localized  or  general  convulsions,  or  paralysis,  loss  of  consciousness,  and 
strabismus. 

The  prognosis  is  bad,  cases  generally  proving  fatal  in  the  course  of  a 
few  days.     The  diagnosis  is  so  uncertain  and  obscure  that  the  treatment 


724  DISEASES   OF  THE   NERVOUS  SYSTEM. 

must  be  symptomatic,  and  directed  toward  the  general  rather  than  the 
local  condition. 

Inflammatory  Thrombosis — Septic  Thrombosis — Smus-Phlebitis. — This 
condition  is  most  frequent  in  children  in  connection  with  acute  meningitis. 
It  may  exist  either  with  the  simple  or  the  tuberculous  variety.  It  also  fol- 
lows otitis — especially  old  and  neglected  cases — usually  with  necrosis  of  the 
petrous  bone,  but  sometimes  without  it.  It  is  much  less  frequently  asso- 
ciated with  disease  of  the  ear  in  children  than  in  adults.  It  may  arise 
from  traumatism,  necrosis  of  the  cranial  bones,  or  from  septic  processes 
involving  any  of  the  cavities  or  any  of  the  structures  adjacent  to  the  brain, 
such  as  the  scalp,  orbit,  nasal  fossa,  mouth,  or  pharynx.  Infection  from 
the  mouth  or  pharynx  is  most  frequent  in  children  in  connection  M^ith 
scarlet  fever  or  diphtheria  ;  while  usually  secondary  to  otitis  it  may  occur 
without  it,  the  infection  being  carried  by  the  blood-vessels.  Infection 
from  the  nose  may  have  its  origin  in  ulceration  from  syphilis  or  tubercu- 
losis.    In  the  orbit,  the  source  may  be  malignant  disease. 

The  seat  of  the  thrombosis  will  depend  upon  the  original  disease.  If 
this  affects  the  cranial  bones  or  the  scalp,  it  will  be  the  longitudinal  sinus ; 
if  the  ear,  the  lateral  sinus  ;  if  the  base  of  the  skull,  the  orbit,  the  mouth, 
the  jaw,  or  the  nose  is  affected,  it  will  be  the  cavernous  sinus.  When 
thrombosis  occurs  with  meningitis  the  lesions  are  much  the  same  as  in 
the  cachectic  form,  with  the  exception  that  there  are  sometimes  slight 
changes  in  the  walls  of  the  sinuses.  If  the  patient  has  suffered  from  a 
local  septic  process,  there  may  be  puriform  softening  of  the  clot,  and  gen- 
eral pyaemia,  with  the  development  of  secondary  abscesses  in  the  brain, 
in  the  lungs,  and  in  other  organs.  With  such  cases  there  may  be  asso- 
ciated a  general  or  localized  meningitis. 

Symptoms. — The  symptoms  of  septic  thrombosis  are  more  decided  than 
those  of  the  cachectic  form.  When  occurring  in  the  course  of  meningitis, 
it  usually  adds  no  new  symptoms  to  those  of  the  original  disease.  In  the 
pyaemic  form  the  symptoms  are  more  characteristic,  particularly  when 
associated  with  otitis.  There  are  recurring  chills  with  very  high  and 
widely-fluctuating  temperature.  There  is  headache,  and  often  localized 
tenderness  of  the  scalp ;  the  other  symptoms  which  are  present  are  usually 
the  same  as  those  of  meningitis.  If  metastasis  occurs,  there  may  be  evi- 
dences of  abscesses  of  the  brain  or  in  other  organs,  and  sometimes  there 
are  signs  of  suppuration  in  the  jugular  vein. 

The  local  symptoms  of  the  thrombosis  differ  somewhat  according  to 
the  sinus  affected  :  if  its  seat  is  the  superior  longitudinal  sinus,  there  may 
be  cyanosis  of  the  face,  dilatation  of  the  temporal  and  frontal  veins,  and 
sometimes  epistaxis ;  if  the  lateral  sinus  is  involved,  the  process  may  ex- 
tend to  the  jugular  vein,  which  may  be  felt  in  the  neck  as  a  hard  cord, 
and  there  may  be  dilatation  of  the  veins  of  the  mastoid  region,  and  even 
localized  oedema ;  when  the  cavernous  sinus  is  affected,  there  may  be  pro- 


CEREBRAL  ABSCESS.  725 

trusion  of  the  eyeball  of  the  affected  side,  oedema  of  the  lid,  and  with  the 
ophthalmoscope  the  retinal  veins  appear  enlarged  and  tortuous,  sometimes 
being  the  seat  of  thrombosis.  The  process  may  affect  either  one  or  both 
sides.  The  course  of  septic  thrombosis  is  rather  irregular,  varying  from  a 
few  days  to  three  weeks.  In  fatal  cases  death  takes  place  from  menin- 
gitis, cerebral  abscess,  or  pyaemia.  The  prognosis  is  very  grave,  unless  the 
disease  is  so  situated  that  it  is  accessible  to  surgical  operation. 

Treatment. — The  only  successful  treatment  is  surgical.  Operation 
is  easiest  in  thrombosis  of  the  lateral  sinus,  being  much  more  difficult 
if  involving  the  superior  longitudinal  sinus.  So  many  cases  are  now  on 
record  of  successful  operation  upon  septic  thrombosis  of  the  lateral  sinus, 
that  it  should  always  be  urged  when  the  diagnosis  is  clear.  Recurring 
chills  and  high,  fluctuating  temperature,  associated  with  disease  of  the  ear, 
either  with  or  without  symptoms  of  meningitis,  are  sufficiently  character- 
istic to  justify  operative  interference. 

CEREBRAL  ABSCESS. 

Cerebral  abscess  is  quite  rare  in  children,  decidedly  more  so  than  is 
cerebral  tumour.  In  Gowers'  collection  of  223  cases,  only  24  were  under 
ten  years  of  age.  In  infants,  abscess  is  one  of  the  least  frequent  diseases 
of  the  brain,  and  up  to  five  years  it  is  exceedingly  rare. 

Etiology. — By  far  the  most  frequent  cause  in  children  is  otitis.  This 
is  the  origin  of  the  great  majority  of  the  cases.  Abscess  rarely  compli- 
cates acute  otitis,  but  is  seen  with  the  chronic  form.  Exactly  how  otitis 
causes  cerebral  abscess  it  is  not  always  easy  to  determine.  Toynbee  was 
the  first  to  call  attention  to  the  fact  that  cerebellar  abscess  was  most 
frequent  with  disease  of  the  mastoid  cells,  and  cerebral  abscess  with  otitis 
media.  Usually  there  is  caries  of  the  petrous  bone,  but  there  may  be 
none.  The  infection  may  extend  through  the  small  veins  traversing  this 
bone,  or  along  the  lateral  sinuses  to  the  cerebellum.  Abscess  is  often 
attributed  to  the  retention  of  pus  in  the  ear,  but  it  may  occur  when  the 
discharge  is  free. 

Traumatism  is  the  second  important  etiological  factor.  Abscess  may 
be  associated  with  fracture  of  the  skull,  or  follow  simple  concussion.  The 
abscess  is  generally  in  the  neighbourhood  of  the  injury,  but  occasionally 
is  produced  by  contre  cowp.  In  one  instance,  reported  by  Wagner,  thrush 
was  believed  to  be  the  cause  of  cerebral  abscess,  the  same  fungus  that 
existed  in  the  mouth  being  found  in  the  brain,  which  in  this  case  was 
studded  with  small  abscesses.  Abscess  may  be  the  result  of  infectious 
emboli,  associated  with  general  pyemia,  though  this  is  rare  in  early  life ; 
and  finally  it  may  occur  without  any  assignable  cause. 

Lesions. — The  most  frequent  seat  of  the  abscess  is,  first,  the  temporo- 
sphenoidal  lobe ;  secondly,  the  cerebellum ;  thirdly,  the  frontal  lobes. 
Other  locations  are  very  rare.     Abscesses  are  usually  single.     In  size  they 


726  DISEASES  OF  THE   NERVOUS  SYSTEM. 

vary  from  that  of  a  small  cherry  to  an  orange.  One  case  was  observed,  by 
Meyer,  in  which  an  abscess  occupied  one  entire  hemisphere.  The  con- 
tents are  usually  thick  greenish-yellow  pus,  which  may  be  very  fetid. 
When  abscesses  have  lasted  for  some  time  they  are  usually  surrounded 
by  dense  pyogenic  membrane,  and  may  become  encysted.  The  patho- 
logical process  may  be  slow,  and  often  is  apj)arently  stationary  for  a  long 
period.  Abscesses  may  rupture  into  the  ventricles,  less  frequently  upon 
the  surface  of  the  brain,  causing  meningitis,  or  the  pus  may  even  escape- 
externally  through  the  auditory  meatus,  as  in  Lallemand's  case. 

Symptoms. — These  are  general  and  local.  The  general  symptoms  are 
much  the  more  important  for  diagnosis,  and  often  are  the  only  ones  present. 
The  local  symptoms  are  those  of  a  tumour.  The  clinical  history  of  a  case 
of  abscess  of  the  brain  may  be  divided  into  three  stages :  First,  the  period 
of  onset,  or  early  acute  inflammatory  symptoms,  fever,  etc.,  which  attend 
the  formation  of  pus.  Secondly,  the  latent  period,  or  period  of  remission,, 
in  which  very  few  symptoms  are  present.  In  many  acute  cases  this  stage 
is  wanting  altogether ;  in  the  chronic  cases  it  may  last  for  months,  or  even 
years.  Thirdly,  the  final  period,  with  recurrence  of  active  cerebral  symp- 
toms, followed  by  death  in  a  few  days. 

The  onset  may  be  accompanied  by  symptoms  so  slight  as  almost  to- 
escape  notice.  In  most  cases,  however,  headache  and  fever  are  present. 
The  headache  is  usually  severe,  and  often  localized  upon  the  affected  side ;. 
in  cerebellar  abscess  it  may  be  occipital.  The  fever  is  moderate  in  inten- 
sity, and  continuous.  In  addition  there  may  be  vertigo,  vomiting,  gen- 
eral convulsions,  and  cessation  of  the  aural  discharge,  if  one  has  been 
present.  The  duration  of  this  stage  is  variable ;  it  may  be  only  a  few 
days,  or  several  weeks.  It  is  shorter  in  traumatic  cases,  and  in  those  which 
are  due  to  pyaemia. 

The  latent  stage,  or  period  of  remission  of  symptoms  may  be  quite 
short — only  a  few  days'  duration — and  it  is  often  absent.  During  this- 
period  the  temperature  may  fall  quite  to  the  normal,  and  the  headache 
disappear,  or  be  only  occasional  and  slight.  However,  if  any  focal  symp- 
toms have  been  present  they  remain  unchanged. 

The  symptoms  of  the  terminal  stage  are  due  to  a  rapid  extension  of 
the  inflammatory  process,  with  oedema  and  softening  about  the  abscess,, 
sometimes  to  rupture  into  the  ventricle,  and  sometimes  to  meningitis. 
The  fever  now  returns,  and  may  be  high.  There  is  headache,  often 
very  intense  and  continuous ;  there  may  be  delirium  and  convulsions,  and 
the  gradual  development  of  coma.  In  addition  there  may  be  vomiting, 
paralysis,  opisthotonus,  retracted  abdomen,  and  the  other  symptoms  of 
meningitis.  Occasionally  all  the  earlier  symptoms  may  be  latent,  and  the 
terminal  symptoms  may  be  the  only  ones  present.  In  infants,  the  fontanel 
is  usually  large  and  bulging ;  convulsions  are  rather  more  frequent  than 
in  older  children. 


CEREBRAL  ABSCESS.  *         Y27 

The  local  symptoms  of  abscess  are  rather  indefinite,  owing  to  its  usual 
situation.  Abscesses  of  considerable  size  may  exist  in  the  temporo-sphe- 
noidal  lobe,  in  the  central  part  of  the  frontal  lobe,  or  in  the  cerebellum, 
without  any  definite  local  symptoms.  If  the  abscess  is  near  the  motor  area, 
there  are  the  usual  symptoms  of  disease  in  this  location,  spasm,  or  paraly- 
sis of  the  face,  arm,  or  leg.  A  cortical  or  sub-cortical  abscess  is  likely  to 
cause  convulsions.  Cerebellar  abscess  may  give  rise  to  occipital  headache, 
frequent  vomiting,  and  when  the  abscess  is  large  enough  to  press  upon 
the  middle  lobe,  there  may  be  inco-ordination  of  the  muscles  of  the 
extremities.  Optic  neuritis  may  be  present,  but  other  symptoms  relating 
to  the  cranial  nerves  are  rare.  Localized  tenderness  over  the  scalp,  when 
persistent,  is  a  symptom  of  importance,  and  may  serve  to  locate  the  ab- 
scess, if  it  is  superficial. 

Diagnosis. — Of  the  general  symptoms,  the  most  important  for  diagnosis 
are  fever,  headache,  delirium,  and  terminal  coma.  These  become  particu- 
larly significant  when  following  otitis  or  traumatism.  The  differential 
diagnosis  of  abscess  is  to  be  made  principally  from  tumour  and  meningitis, 
and  from  these  conditions  more  by  the  history  and  general  course  of  the 
disease  than  by  any  special  symptoms.  The  diagnosis  of  abscess  from 
tumour  is  considered  in  connection  with  the  latter  disease.  It  is  more 
difficult  to  distinguish  between  meningitis  and  abscess,  since  the  two  pro- 
cesses are  often  associated.  With  meningitis  convulsions  are  more  com- 
mon, but  they  are  rarely  localized  ;  rigidity  and  the  inflammatory  symp- 
toms are  more  intense ;  the  course  is  usually  more  rapid  and  more  regular, 
being  rarely  interrupted,  as  is  the  course  of  abscess.  From  the  cerebral 
symptoms  occurring  with  otitis  it  is  extremely  difficult  to  distinguish 
abscess,  for,  according  to  Gowers,  optic  neuritis  may  be  present  in  the 
former  as  well  as  in  the  latter  condition.  The  more  intense  and  pro- 
longed are  the  cerebral  symptoms  and  the  more  marked  the  neuritis,  the 
greater  are  the  probabilities  of  abscess. 

Prognosis. — The  prognosis  in  cerebral  abscess  is  always  grave,  unless 
accessible  to  surgical  operation.  The  progress  may  be  slow,  or  rapid,  but 
it  is  inevitably  from  bad  to  worse,  and  sooner  or  later  the  disease,  if  not 
interfered  with,  proves  fatal. 

Treatment. — The  medical  treatment  of  abscess  in  its  active  stage  is 
that  of  any  acute  intracranial  inflammation, — ice  to  the  head,  absolute 
quiet,  free  catharsis,  and  full  doses  of  the  bromides  or  antipyrine  or  mor- 
phine, if  pain  is  intense.  The  absolutely  hopeless  condition  of  these  cases 
when  left  to  themselves,  and  the  recent  brilliant  results  from  surgical 
operations,  should  lead  the  physician  to  urge  operation  in  every  case.* 

*  For  a  discussion  of  the  surgical  aspects  of  this  question,  see  "  Brain  Surgery,"  by 
M.  Allen  Starr,  M.  D.,  and  "Pyogenic  Infectious  Diseases  of  the  Brain  and  Cord,"  by 
William  McEwen,  M.  D. 


728  DISEASES   OF   THE   NERVOUS   SYSTEM. 

CEREBRAL   TUMOUR. 

Very  little  has  been  added  to  our  knowledge  of  cerebral  tumour  in 
children  since  the  exhaustive  monograph  of  Starr,  which  appeared  in 
Keating's  Cyclopsedia  in  1890.  It  is  to  this  article  that  I  am  indebted 
for  most  of  the  facts  in  this  chapter. 

Varieties  and  Location, — Tumour  of  the  brain  is  not  very  infrequent, 
and  may  be  seen  even  in  infancy.  From  this  time  up  to  puberty  there  is 
no  period  of  special  susceptibility.  In  two  hundred  and  sixty-nine  of  the 
cases  in  Starr's  collection,  in  which  the  nature  of  the  tumour  was  stated, 
the  following  were  the  varieties  : 

Tubercle 152  cases. 

Glioma 37 

Sarcoma 34 

Glio-sarcoina 5 

Cyst 30 

Carcinoma 10 

Gumma 1 

2C9 

Tuberculous  tumours  are  more  often  multiple  than  are  other  varieties. 
Their  most  frequent  seat  is  the  cerebellum ;  next  to  this  the  pons  and 
crura  cerebri.  They  are  rarely  cortical  or  central.  Glioma  is  most  often 
found  in  the  cerebellum  or  in  the  pons,  and  next  in  the  cortex;  but  it  is 
rarely  central.  Sarcoma  is  most  frequently  in  the  cerebellum  ;  next  to 
this,  in  the  order  of  frequency,  in  the  pons,  the  basal  ganglia,  and  the  cor- 
tex. Cystic  tumours  are  either  central  or  cerebellar.  Taking  the  cases 
as  a  whole,  the  most  frequent  seat  of  tumour  in  children  is,  first  the  cere- 
bellum, second  the  pons,  third  the  centrum  ovale. 

Tuberculous  tumours  are  occasionally  seen  in  infancy,  but  they  occur 
most  frequently  between  the  ages  of  five  and  twelve  years.  They  are 
usually  secondary  to  tuberculosis  elsewhere,  especially  in  the  lungs  and  in 
the  bronchial  lymph  nodes.  They  most  frequently  start  from  the  mem- 
branes, rarely  being  centrally  situated,  and  extend  inward,  infiltrating 
the  superficial  portion  of  the  cerebellum  or  cerebrum.  There  is  almost 
invariably  localized  meningitis  at  the  site  of  the  tumour;  there  maybe 
adhesions  between  the  dura  and  pia  mater,  and  the  disease  may  extend  to 
the  cranial  bones.  In  size,  these  tumours  vary  from  a  small  pea  to  a 
child's  fist.  They  may  be  softened  and  broken  down  at  the  centre,  or 
cheesy  throughout.  They  are  the  result  of  a  localized  tuberculous  in- 
flammation, which  does  not  differ  essentially  from  that  seen  in  other 
parts  of  the  body. 

Glioma  is  not  infrequent  in  infancy.  It  is  probably  connected  in 
every  case  with  the  ependyma  of  the  ventricle.  It  repeats  the  structure 
of  the  neuroglia,  being  composed  of  connective  tissue  and  branching  cells. 


CEREBRAL   TUMOUR.  729 

Sarcoma  may  be  of  the  spindle-celled  or  the  mixed  variety.  It  grows 
much  more  rapidly  than  glioma.  The  two  varieties  are  not  infrequently 
combined  in  the  same  tumour — glio-sarcoma.  . 

Cystic  tumours  are  sometimes  sarcomatous  in  origin,  the  wall  of  the 
cyst  containing  sarcoma  cells,  and  they  may  also  be  parasitic,  from  the 
growth  of  the  echinococcus.    They  may  be  found  in  any  part  of  the  brain. 

The  other  varieties  of  sarcoma,  gumma  and  vascular  tumours,  are 
exceedingly  rare  until  after  puberty. 

As  the  tumour  grows,  secondary  lesions  are  produced  in  most  of  the 
cases.  These  are  the  result  of  pressure  upon  arteries,  causing  localized 
anaemia,  or  even  cerebral  softening ;  or  upon  veins,  producing  congestion 
and  oedema.  When  affecting  the  middle  lobe  of  the  cerebellum,  pressure 
npon  the  venae  Galeni  may  lead  to  effusion  into  the  ventricles.  Localized 
meningitis  over  tumours  superficially  situated  is  the  rule,  and  this  may  be 
the  cause  of  some  of  the  symptoms.  Earely,  cerebral  haemorrhage  may  be 
associated. 

Etiology. — The  causes  of  cerebral  tumours  are  for  the  most  part  un- 
known. In  a  few  instances  there  is  a  history  of  definite  traumatism. 
Sarcoma  or  carcinoma  may  be  secondary,  and  tuberculous  tumours  are 
probably  always  so. 

Symptoms. — These  may  be  divided  into  two  groups  :  first,  the  general 
symptoms  which  are  common  to  tumours  of  all  varieties,  and  are  inde- 
pendent of  location ;  secondly,  the  local  symptoms  depending  upon  the 
situation  of  the  growth. 

General  symptoms. — One  of  the  most  frequent  is  headache.  Though 
it  varies  much  in  its  severity,  character,  and  position,  it  is  rarely  absent. 
It  is  apt  to  be  severe,  and  may  continue  for  a  long  period,  or  it  may  be 
intermittent.  The  location  of  the  pain  has  no  definite  relation  to  the 
situation  of  the  tumour.  It  may  be  accompanied  by  sensations  of  tightness 
compression,  or  tension  in  the  head.  It  may  be  associated  with  localized 
tenderness  of  the  scalp  ;  when  this  is  constant  it  is  a  valuable  symptom 
for  diagnosis,  as  it  often  occurs  with  tumours  superficially  located. 

General  convulsions  often  occur  in  the  early  stage,  but  separated  by 
quite  long  intervals ;  they  become  more  frequent  and  more  severe  as  the 
disease  progresses.  All  degrees  of  severity  are  seen,  from  slight  twitchings 
and  temporary  loss  of  consciousness,  to  typical  epileptiform  seizures.  They 
are  most  common  when  the  growth  is  rapid  and  when  complicating  men- 
ingitis is  present.  Attacks  of  localized  spasm  may  for  a  considerable  time 
precede  general  convulsions ;  and  in  a  single  attack  there  may  be  first 
localized  and  then  general  convulsions. 

Mental  symptoms  are  generally  present  in  great  variety  and  complexity. 
There  may  be  only  fretfulness  and  irritability,  or  a  marked  change  in  dis- 
position. These  symptoms  are  so  frequent  from  other  causes  in  children 
that  they  excite   no   apprehension,  unless   to  them  are   added  dulness, 


730  DISEASES  OP  THE  NERVOUS  SYSTEM. 

apathy,  and  somnolence.  Later  in  the  disease  there  may  be  attacks  of 
hypochondriasis,  or  of  melancliolia ;  there  may  be  periods  of  wild,  almost 
maniacal  excitement ;  and,  finally,  the  mental  impairment  may  approach 
a  condition  of  imbecility. 

Optic  neuritis  and  optic-nerve  atrophy  are  very  frequent,  occurring, 
according  to  Starr,  in  eighty  per  cent  of  the  cases.  This  is  only  recog- 
nised by  the  ophthalmoscope,  as  there  may  be  no  disturbance  of  vision. 
The  optic  neuritis  is  generally  double,  appears  earlier,  and  is  more  con- 
stant in  basal  tumours  than  in  those  at  the  convexity,  or  those  centrally 
located. 

Vomiting  is  very  frequent,  but  diagnostic  only  when  it  occurs  sud- 
denly without  assignable  cause,  and  without  nausea  or  other  symptoms 
of  indigestion.  It  is  especially  significant  when  frequently  rej^eated,  and 
of  more  importance  in  older  children  than  in  infants. 

Vertigo  is  often  associated  with  vomiting.  At  first  it  is  occasional  and 
seen  upon  changing  position,  but  later  it  may  be  quite  constant,  espe- 
cially with  tumours  in  the  posterior  fossa. 

Disturbances  of  sleep  are  frequent.  There  is  usually  insomnia,  but 
sleep  may  be  broken  by  hallucinations,  accompanied  by  attacks  of  scream- 
ing ;  rarely  is  there  persistent  drowsiness  until  toward  the  end  of  the  dis- 
ease. 

Local  symptoms. — These  depend  upon  the  situation  of  the  tumour, 
but  not  at  all  upon  its  anatomical  character.  Local  symptoms  may  be 
wanting  entirely,  and  they  may  vary  much  in  different  cases  even  with 
tumours  in  the  same  situation.  They  'are  modified  by  the  size  and  by 
the  rapidity  of  growth,  and  by  the  existence  of  local  meningitis. 

In  tumours  of  the  cortex,  the  meninges  are  likely  to  be  involved,  espe- 
cially with  tuberculous  and  gliomatous  growths.  The  pathological  process 
may  extend  from  within  outward  or  from  without  inward.  The  most 
frequent  general  symptoms  in  such  cases  are  headache,  circumscribed  ten- 
derness of  the  scalp,  convulsions,  and  mental  symptoms.  Optic  neuritis^ 
vomiting,  and  vertigo  are  not  so  common.  Tumours  situated  in  the  fron- 
tal lobe,  as  a  rule,  present  few  symptoms  and  may  be  entirely  latent. 
Irritation  of  the  frontal  lobe  may  extend  to  the  motor  area  and  cause 
convulsions  either  local  or  general ;  but  not  often  is  there  paralysis.  Tu- 
mours of  the  left  side  (of  the  right  side  in  left-handed  persons)  in  the 
third  frontal  convolution  may  cause  motor  aphasia. 

Tumours  in  the  motor  convolutions  along  the  fissure  of  Rolando  pro- 
duce the  most  definite  and  uniform  local  symptoms.  When  situated  at 
the  upper  portion  the  leg  is  affected,  at  the  middle  portion,  the  arm, 
and  at  the  lower,  the  face.  Irritative  symptoms,  such  as  rigidity  or  clonic 
spasm,  commonly  precede  for  some  time  the  paralysis  which  results  from 
pressure  or  destruction.  These  attacks  of  localized  convulsions  may  begin 
in  the  face,  arm,  or  leg  ;    but  they  usually  extend  more  or  less  rapidly 


CEREBRAL  TUMOUR.  Y31 

until  all  three  are  involved.  There  is  no  loss  of  consciousness,  but  there 
may  follow  a  slight  transient  paralysis.  Such  attacks  are  known  as  "  Jack- 
sonian  epilepsy,"  and  form  one  of  the  most  diagnostic  symptoms  of  cere- 
bral tumour.  Localized  spasm  may  be  associated  with  anaesthesia  or 
other  disturbances  of  sensation.  The  paralysis  generally  first  affects  one 
extremity — the  arm  or  leg,  according  to  the  location  of  the  tumour — and 
afterward  it  may  involve  the  entire  side,  including  the  face. 

If  the  tumour  is  centrally  located,  or  at  the  base,  hemiplegia  may  be  an 
early  symptom  from  pressure  on  the  motor  tract.  With  cortical  paralysis 
there  may  be  associated  ataxia  and  anaesthesia. 

Tumours  of  the  parietal  lobe  may  give  no  local  symptoms.  At  times 
there  are  disturbances  of  muscular  sense,  tactile  sensibility,  or  sensations 
of  pain  and  temperature.  If  the  inferior  parietal  lobule  of  the  left  side 
is  affected,  there  may  be  word-blindness,  or  inability  to  understand  writ- 
ten language. 

Tumours  of  the  occipital  lobe  produce,  as  the  only  constant  local  symj)- 
tom,  hemianopsia.  This  is  usually  bilateral,  affecting  the  same  side  of 
both  eyes,  being  on  the  side  opposite  to  that  of  the  lesion — i.  e.,  a  tumour 
on  the  right  side  causes  blindness  in  the  left  half  of  both  eyes,  so  that 
the  i^atieat  sees  nothing  to  the  left  of  a  line  directly  in  front  of  him. 
Instead  of  hemianopsia,  there  may  be  only  irritation  and  various  disturb- 
ances of  sight. 

Tumours  of  the  temporo-sphenoidal  lobe  may  be  latent,  or,  if  on  the 
left  side,  may  cause  w^ord-deafness — i.  e.,  inability  to  understand  the  sig- 
nificance of  spoken  language. 

Tumours  in  the  island  of  Reil  when  situated  upon  the  left  side  (right 
side  in  left-handed  persons)  may  cause  motor  aphasia  or  disturbances  of 
speech.  If  they  are  large  they  may  produce  symptoms  by  pressure  upon 
the  motor  tract, — hemiplegia  or  monoplegia. 

Tumours  of  the  basal  ganglia  cause  marked  general  symptoms,  but 
none  of  a  definitely  local  character.  The  important  symptoms  relate  to  the 
various  tracts  or  bundles  of  fibres  which  pass  from  the  cortex  through  the 
internal  capsule.  These  include  the  motor  and  the  various  sensory  tracts, 
the  olfactory,  auditory,  visual,  and  speech  tracts.  Any  of  these  may  be 
pressed  upon,  and  the  nature  of  the  symptoms  will  depend  upon  the  size 
of  the  tumour  and  the  extent  of  the  pressure.  If  only  the  anterior  j^art 
of  the  capsule  is  affected  there  may  be  no  symptoms  ;  if  the  middle 
fibres,  hemiplegia  and  disturbances  of  articulation ;  if  the  posterior  fibres, 
hemiana^sthesia.  All  these  may  be  associated,  and  any  of  them  may  be 
complete  or  partial.  Tumours  in  this  situation  are  apt  to  implicate  the 
cranial  nerves.  Optic  neuritis  is  quite  constant,  and  appears  early.  Lo- 
calized or  general  convulsions  are  rare. 

The  peculiar  symptoms  pointing  to  tumours  of  the  crura  cerebri  are 
nystagmus,  strabismus,  and  loss  of  pupillary  reflex,  sometimes  with  general 


Y32  DISEASES  OF  THE   NERVOUS  SYSTEM. 

muscular  inco-ordinatiou,  and  a  staggering  gait.  There  is  usually  tliird- 
nerye  paralysis  on  the  side  of  the  tumour,  and  on  the  side  opposite  to  the 
hemiplegia  with  which  it  is  often  associated.  This  variety  of  crossed 
paralysis  is  quite  diagnostic.  The  symptoms  of  third-nerve  paralysis  are 
external  strabismus,  dilatation  of  the  pupil,  and  ptosis.  In  these  cases 
optic  neuritis  appears  early.  There  may  be  a  complicating  hydrocephalus. 
While  hemiplegia  is  commonly  present  with  large  tumours,  it  may  be  ab- 
sent with  small  ones,  or  may  appear  later  than  paralysis  of  the  third  nerve. 

Tumours  of  the  pons  are  quite  common.  The  diagnostic  symptoms 
consist  in  crossed  paralysis,  the  cranial-nerve  symptoms  being  on  the  side 
of  the  tumour,  and  the  general  motor  and  sensory  symptoms  on  the  oppo- 
site side.  When  the  seat  is  the  upper  half  of  the  pons,  the  third  and  fifth 
nerves  are  apt  to  be  implicated,  giving  rise  to  ptosis,  dilatation  of  the 
pupils,  external  strabismus,  trophic  disturbances  such  as  ulceration  of  the 
cornea,  and  neuralgic  pain  in  the  face.  Tumours  in  the  lower  half  of  the 
pons  involve  the  sixth,  seventh,  and  eighth  nerves,  causing  internal  strabis- 
mus, contracted  pupils,  facial  paralysis,  sometimes  deafness,  and  auditory 
vertigo.  Other  symptoms  associated  with  tumours  of  the  pons  are  head- 
ache, vomiting,  and  optic  neuritis ;  convulsions  being  rare. 

Tumours  of  the  medulla  are  recognised  by  the  involvement  of  the 
glossopharyngeal,  pneumogastric,  spinal  accessory,  and  hypoglossal  nerves. 
There  are  difficulty  of  deglutition,  irregular  respiration,  irregular  pulse, 
and  vaso-motor  disturbances,  such  as  flushing  of  the  face  and  perspiration. 
There  may  bo  projectile  vomiting,  polyuria  or  glycosuria,  opisthotonus, 
difficulty  in  articulation  or  in  sucking,  and  in  protrusion  of  the  tongue. 
When  large,  tliese  tumours  may  produce  symptoms  of  pressure  upon  the 
motor  or  sensory  tracts, — paralysis,  partial  anaesthesia,  with  rigidity  and 
exaggerated  reflexes. 

Tumours  of  the  cerebellum  are  especially  important,  this  being  the  most 
frequent  location  in  childhood.  When  only  one  hemisphere  is  affected 
there  may  be  no  local  symptoms.  Tumours  involving  the  middle  lobe,  or 
those  large  enough  to  produce  pressure  upon  the  middle  lobe,  give  rise  to 
vertigo  and  cerebellar  ataxia.  Vertigo  is  especially  frequent ;  it  may 
occur  with  headache.  Cerebellar  ataxia  is  different  from  the  ataxia  due 
to  a  spinal-cord  lesion,  and  strikingly  resembles  that  of  intoxication. 
It  may  increase  until  the  patient  is  unable  to  walk,  although  there  is 
no  loss  of  muscular  power.  Vomiting  is  a  frequent  symptom,  as  are  also 
optic  neuritis,  and  headache  which  is  usually  occipital.  When  there  is 
secondary  hydrocephalus,  as  is  not  uncommon,  mental  symptoms  are 
present,  and  there  may  be  enlargement  of  the  head.  Opisthotonus  is 
occasionally  seen,  but  general  convulsions  are  rare. 

Diagnosis. — The  size  of  the  tumour  is  to  be  determined  mainly  by  the 
general  symptoms,  special  attention  being  given  to  the  order  of  their 
development.     A  diagnosis  as  to  the  nature  of  the  tumour  is  really  not  of 


CEREBRAL  TUMOUR.  Y33 

much  importance ;  but  some  information  upon  this  point  may  be  gained 
from  the  consideration  of  its  etiology,  the  rapidity  of  its  growth,  and  the 
age  of  the  patient.  Cerebral  tumour  may  be  confounded  with  abscess,  tuber- 
culous meningitis,  chronic  basilar  meningitis,  and  chronic  hydrocephalus. 
The  symptoms  distinguishing  tumour  from  abscess  are  the  following  :  Tu- 
mour may  occur  at  any  age  ;  without  definite  etiology,  excepting  when 
tuberculous ;  the  progress  is  steady,  but  generally  slow,  new  symptoms  be- 
ing continually  added  ;  headache  is  more  constant  and  more  severe ;  optic 
iieuritis  more  frequent ;  cranial  nerves  more  often  involved  ;  mental  dis- 
turbances more  marked ;  focal  symptoms  are  often  definite ;  fever  is  absent ; 
duration,  six  months  to  two  years.  As  compared  with  the  above,  abscess 
is  not  so  frequent,  being  especially  rare  in  infancy ;  there  is  a  definite  his- 
tory of  traumatism  or  ear  disease ;  progress  more  irregular ;  symptoms 
often  intermittent ;  headache  less  severe ;  mental  symptoms  less  marked ; 
optic  neuritis  and  involvement  of  the  cranial  nerves  less  frequent ;  focal 
symptoms  usually  indefinite ;  localized  tenderness  over  the  scalp  more 
constant ;  fever  present  except  in  the  latent  period ;  the  most  frequent 
complication  is  acute  meningitis. 

Cases  of  tuberculous  meningitis  which  may  be  confounded  with  tumour 
are  those  of  slow  course  sometimes  seen  in  older  children.  The  diffi- 
culty in  diagnosis  is  increased  by  the  frequent  association  of  tuberculous 
tumours  with  tuberculous  meningitis.  The  main  points  of  difference  are 
that  in  tumour  the  symptoms  are  more  localized  and  the  course  gen- 
erally much  slower.  Almost  every  individual  symptom,  however,  may  be 
present  in  the  two  conditions. 

Chronic  basilar  meningitis  may  produce  symptoms  almost  identical 
with  those  of  tumour  in  the  posterior  fossa.  It  is,  however,  confined  to 
infancy,  and  is  frequently  syphilitic.  Hydrocephalus  and  opisthotonus 
are  much  more  marked  than  are  usually  seen  with  tumour. 

Chronic  hydrocephalus  may  resemble  tumour ;  this  occurs  so  frequently 
as  a  lesion  secondary  to  tumour  that  the  question  often  arises  whether  there 
is  only  hydrocephalus,  or  there  is  in  addition  a  tumour.  Primary  hydro- 
cephalus is  usually  congenital,  and  the  symptoms  appear  during  the  first 
year.  It  commonly  attains  to  a  greater  degree  than  is  seen  in  secondary 
hydrocephalus  ;  but  the  symptoms  in  the  two  forms  may  be  identical. 

Prognosis. — The  prognosis  in  cerebral  tumour  is  absolutely  bad ;  ex- 
cept in  syphilitic  cases,  which  are  among  the  rarest  forms  seen  in  child- 
hood, there  is  no  prospect  of  recovery,  and  but  little  of  improvement. 
The  symptoms  usually  progress  steadily  from  bad  to  worse,  and  more 
rapidly  in  children  than  in  adults.  Death  occurs  from  exhaustion,  coma, 
convulsions,  or  from  respiratory  failure,  sometimes  suddenly  from  un- 
known causes. 

Treatment. — If  there  is  any  reason  to  suspect  syphilis,  the  iodide  of 
potassium  should  be  given  in  large  doses  and  continued  for  a  long  period ; 


734  DISEASES  OF   THE  NERVOUS  SYSTEM. 

the  effect  of  this  drug  even  in  tumours  not  syphilitic  is  sometimes  bene- 
ficial. Starr  refers  to  a  case  in  which  symptoms  of  six  months'  duration, 
including  optic  neuritis,  entirely  disappeared  under  the  use  of  mercury 
and  the  iodide.  The  tumour  was  supposed  to  be  gumma,  but  an  autopsy 
obtained  six  months  later  showed  it  to  be  a  sarcomatous  cyst.  For  a 
discussion  upon  the  surgical  aspect  of  the  treatment  of  brain  tumours,  the 
reader  is  referred  to  Starr's  work  on  Brain  Surgery. 

HYDROCEPHALUS. 

Hydrocephalus  or  "  water  on  the  brain,"  consists  in  an  accumulation  of 
serum  in  the  cranial  cavity.  This  may  be  between  the  dura  mater  and 
the  pia  (external  hydrocephalus)  or  in  the  ventricles  of  the  brain  {internal 
hydrocephalus).  The  former  is  secondary  and  is  quite  rare,  while  the  lat- 
ter is  not  uncommon.     Hydrocephalus  may  be  acute  or  chronic. 

Acute  Hydrocephalus  is  secondary  to  basilar  meningitis,  which  is  usu- 
ally of  tuberculous  origin.  The  terms  tuberculous  meningitis  and  acute 
hydrocephalus  are  sometimes  used  synonymously.  A  moderate  distention 
of  the  ventricles  is  frequent  in  all  varieties  of  acute  meningitis.  The 
amount  of  fluid  in  acute  hydrocephalus  is  not  great,  there  being  rarely 
more  than  three  or  four  ounces  present. 

Chronic  External  Hydrocephalus  is  extremely  rare,  and  is  probably 
always  a  secondary  lesion.  It  is  found  with  certain  congenital  malforma- 
tions and  with  atrophy  of  the  brain,  and  it  may  follow  meningeal  haemor- 
rhage or  pachymeningitis.  On  incising  the  dura  mater  a  few  ounces,  or 
sometimes  even  a  pint,  of  serum  may  escape.  The  convolutions  are  some- 
what flattened,  and  may  be  greatly  atrophied.  Other  lesions  are  found 
either  in  the  brain  or  in  the  dura  mater.  There  may  be  some  degree 
of  internal  hydrocephalus  associated.  External  hydrocephalus  may  cause 
enlargement  of  the  head  and  separation  of  the  sutures,  and  in  fact  most 
of  the  symptoms  of  the  internal  variety;  but  usually  it  is  not  severe 
onough  to  give  rise  to  any  decided  symptoms.  It  is  so  rare  that  it  need 
not  be  considered  at  length. 

CHRONIC   INTERNAL   HYDROCEPHALUS. 

This  is  the  important  variety,  and  when  no  qualifying  term  is  men- 
tioned this  is  the  form  of  hydrocephalus  Avhich  is  always  understood. 

Etiology. — This  occurs  both  as  a  primary  and  a  secondary  condition. 
When  secondary  it  is  usually  associated  with  tumours  of  the  base  of  the 
brain  or  with  chronic  basilar  meningitis,  either  simple  or  tuberculous.  It 
is  in  these  cases  a  mechanical  condition  caused  by  pressure  which  oblit- 
■erates  the  openings  from  the  lateral  ventricles  into  the  fourth  ventricle, 
or  the  foramen  of  Magendie. 

The  causes  of  primary  hydrocephalus  are  as  yet  very  little  understood. 
In  a  large  proportion  of  the  cases  the   disease  is  congenital,  generally 


CHROMIC   INTERNAL   HYI)ROCP]PII ALUS.  735 

beginning  in  the  latter  months  of  intra-nterine  life.  Some  of  these  cases 
are  clearly  syphilitic.  D'Astros  *  has  collected  nine  cases  and  added 
three  others,  in  which  hydrocephalus  was  associated  with  lesions  un- 
doubtedly syphilitic.  When  due  to  syphilis,  the  disease  may  at  the  same 
time  be  congenital.  Kiekets  and  hydrocephalus  are  occasionally  associ- 
ated, but  so  infrequently  as  to  make  a  definite  etiological  connection  be- 
tween them  very  doubtful.  The  rachitic  head  has  been  so  often  mistaken 
for  hydrocephalus  that  an  erroneous  notion  has  arisen  as  to  the  frequent 
association  of  these  two  diseases.  This  point  will  be  referred  to  more 
fully  under  diagnosis.  Chronic  hydrocephalus  is  often  attributed  to 
tuberculosis,  but  here  again  the  connection  is  a  very  doubtful  one. 
Heredity  is  a  factor  of  some  importance ;  numerous  instances  are  on 
record  where  two  children  in  the  same  family  have  been  affected.  Hydro- 
cephalus not  infrequently  develojis  after  successful  operations  upon  spina 
bifida  or  encephalocele. 

Lesions. — The  difference  between  the  primary  and  secondary  cases  is 
chiefiy  one  of  degree.  The  amount  of  fluid  in  secondary  cases  is  rarely 
more  than  three  or  four  ounces.  In  jjrimary  cases  it  is  usually  from  half 
a  pint  to  one  pint,  but  it  may  be  very  great.  In  one  of  my  own  cases 
thei'e  was  removed  from  the  head  of  a  child,  who  died  at  four  months,  five 
})ints  of  fluid.  Larger  quantities  tban  this  have  been  reported,  but  not  at 
so  early  an  age.  In  composition  this  resembles  the  cerebro-spinal  fluid. 
An  examination  in  one  of  my  cases  showed  it  to  be  a  clear,  translucent 
fluid,  slightly  alkaline  in  reaction,  specific  gravity  1005,  containing  sodium 
and  potassium  chlorides,  alkaline  ])hosphates,  and  a  trace  of  albumin.  In 
some  specimens  sugar  is  found.  In  cases  of  inflammatory  origin  the 
amount  of  albumin  is  generally  larger,  and  the  fluid  may  be  slightly  tur- 
bid. The  effusion  may  become  purulent  from  accidental  infection  re- 
sulting from  operation,  from  rupture,  or,  as  in  one  of  my  cases,  from  in- 
fection through  the  sac  of  a  spina  bifida  with  which  it  Avas  complicated, 
the  process  extending  to  tlie  brain  through  the  central  canal  of  the  cord. 

The  changes  in  the  brain  result  from  the  gradual  accumulation  of 
fluid  in  the  ventricles.  The  septum  lucidum  is  usually  broken  down, 
aTid  all  the  avenues  of  communication  between  the  ventricular  cavities 
are  greatly  enlarged.  The  co7itinuous  distention  results  in  a  gradual 
thinning  of  the  brain  substance  which  forms  the  ventricular  walls ;  often 
these  are  found  only  one  fourth  of  an  inch  in  thickness,  or  even  less 
than  this,  the  cortex  being  a  mere  shell  (Fig.  117).  In  one  of  my 
autopsies  the  ependyma  of  the  ventricle  and  the  pia  mater  were  in 
places  actually  in  contact,  all  of  the  brain  tissue  having  been  absorbed ; 
the  brain  resembled  a  large  double  cyst.  In  a  case  of  Peterson's,  with 
the  exception    of  a  small    portion    of  one    temporo-sphenoidal    lobe,  all 

*  Revue  Mensuelle  des  Maladies  de  I'Enfance.  ix,  481,  543. 
48 


'36 


DISEASES   OF  THE  NERVOUS  SYSTEM. 


of  both  hemispheres  liad  disappeared,  the  cerebeUuiu  and  basal  ganglia 
alone  being  intact.  The  brain  is  always  ansemic,  and  the  gray  and  white 
substance  may  bo  indistinguishable.  The  changes  are  largely  mechanical, 
the  microscope  showing,  in  my  case  just  referred  to,  only  granular  matter 
and  round  nuclei  evidently  from  broken-down  nerve  cells.  In  less  severe 
cases  the  changes  may  be  slight.  It  is,  however,  always  surprising  to  see 
the  amount  of  compression  which  the  cortex  will  tolerate  without  inter- 
ference with  its  functions,  provided  the  pressure  comes  gradually.  The 
ependyma  mav  be  normal,  but  it  is  usually  somewhat  thickened  and  pale, 
sometimes  granular,  and  may  be  infiltrated  with  new  cells.  When  infection 
takes  place  an  acute  ependymitis  may  be  set  up.     Chronic  inflammation 

of  the  ejjendyma  is  thought 
■f^  _>     fw---  to  be  the  essential  lesion  in 

many  of  the  primary  cases, 
whether  of  simple  or  syphi- 
litic origin. 

The  bones  of  the  skull  are 
markedly  affected ;  tlie  su- 
tures at  the  vault  are  widely 
separated,  and  sometimes 
even  those  at  the  base.  After 
the  removal  of  the  fluid  the 
head  collapses,  giving  an  ap- 
pearance which  has  been  well 
likened  to  a  bag  of  bones. 
It  should  not  be  forgotten, 
however,  that  hydrocephalus 
may  coexist  with  premature 
ossification,  in  which  case  the 
head  may  be  small.  In  the 
cases  which  recover,  the  wide 
gaps  in  the  skull  may  be  closed  by  the  development  of  wormian  bones  ;  but 
ossification  is  often  not  complete  until  the  fifth  or  sixth  year. 

The  most  frequent  lesion  associated  with  congenital  hydrocephalus  is 
spina  bifida,  in  which  cases  there  may  also  be  a  patency  of  the  central 
canal  of  the  spinal  cord  ;  more  rarely  meningocele  or  encephalocele  are  met 
with.  Sometimes  there  are  deforinities  in  other  parts  of  the  body,  such  as 
club-foot  or  hare-lip. 

Symptoms. — Hydrocephalus  may  exist  with  a  small  head.  In  this 
condition  there  is  usually  premature  ossification  of  the  cranial  bones. 
Four  such  cases  have  come  under  my  notice,  one  child  having  lived  to 
be  fourteen  mouths  old.  These  children  are  usually  idiotic,  and  die  at  an 
early  age,  often  from  convulsions.  In  such  cases  other  malformations  of 
the  brain  are  frequently  associated. 


Fig.  117. —  WrtKal  tniiisverse  tsection  of  a  brain  in  eon- 
genital  liydroeepluilus,  from  a  child  who  died  at  the 
age  of  three  weeks.  A,  distended  lateral  ventricle  ; 
Ji,  its  descending  horn. 


CHRONIC   INTERNAL  HYDROCEPHALUS. 


737 


Hydrocephalus,  with  the  exceptions  mentioned,  is  recognised  by  the 
increased  size  of  the  head.  In  order  to  estimate  the  amount  of  enlarge- 
ment, it  must  be  remembered  that  at  birth  the  circumference  of  the 
normal  head  is  about  14  inches,  and  at  one  year  from  18  to  19  inches. 
The  degree  of  enlargement  in  hydrocephalus  may  be  very  great.  In  one 
of  my  cases,  the  head  at  four  months  measured  24:|  inches.  In  another  at 
ten  and  a  half  months,  "-iGf  inches  (Fig.  118).     8teiner  has  reported  a  re- 


FiG.  118. — Chronic  h\  droeephalus  of  a  severe  type  ;  head  of  a  globular  shajie ;  child,  teo 
and  a  half  months  old. 


markable  case  in  which  the  head  at  eight  months  measured  o"2f  inches. 
When  the  enlargement  of  the  head  is  not  great  the  diagnosis  is  not  so 
easy.  H3'drocephalic  enlargement  is  commonly  symmetrical  and  in  all 
directions.  The  head  is  sometimes  globular  in  outline  (Fig.  118)  and 
sometimes  pyramidal  (Fig.  119).  The  forehead  is  exceedingly  high  and 
projecting,  and  there  is  a  prominence  at  the  root  of  the  nose  seen  in  no 
other  form  of  enlargement.  The  sutures  may  be  separated  from  half  an 
inch  to  two  or  three  inches ;  the  fontanel  is  very  large,  tense,  and  bulging; 


738 


DISEASES  OF   THE   NERVOUS  SYSTEM. 


the  veins  of  the  scalp  are  enlarged  and  prominent.  In  marked  cases 
fluctuation  may  be  readily  obtained,  and  the  head  may  even  be  distinctly 
translucent. 

In  the  acquired  form  all  these  symptoms  are  less  marked,  and  if  ossi- 
fication of  the  skull  has  taken  place  it  is  often  impossible  to  discover 
any  increase  in  size.  The  rate  of  growth  of  the  head  varies  much  in  dif- 
ferent cases,  and  it  is  the  surest  measure  of  the  progress  of  the  case.  The 
increase  in  circumference  is  usually  from  one  to  three  inches  a  month. 

The  primary  cases  are  for  the  most  part  of  congenital  origin,  and  the 
child  may  die  in  utero.    At  other  times  the  process  may  have  advanced  so 


Fig.  119. 


-Chronic  hydrocephalus  of  average  severity ;  head  of  pyramidal  sliajie  :  showing  char- 
acteristic expression  of  the  eyes. 


far  before  birth  that  puncture  of  the  head  is  necessary  before  delivery  is 
possible.  In  perhaps  the  majority  of  cases  no  symptoms  are  observed  at 
birth,  or  the  head  is  only  slightly  larger  than  normal.  Usually  nothing 
is  noticed  until  the  child  is  two  or  three  months  old,  when  it  is  discov- 
ered that  the  head  is  increasing  in  size  at  an  abnormal  rate;  If  the 
progress  is  rapid,  other  symptoms  are  soon  evident :  the  infant  can  not 
hold  up  its  head  ;  it  is  lethargic,  and  all  its  perceptions  are  dulled,  sight 
and  hearing  included  ;  there  may  be  a  general  flaccid  condition  of  all  the 


CHRONIC    INTERNAL    PI YDROCEPH ALUS.  739 

muscles  of  the  extremities  due  to  a  sliglit  general  paresis,  but  more  often 
there  is  rigidity,  which  is  usually  most  marked  in  the  legs,  but  sometimes 
in  the  arms;  the  hands  are  often  clenched,  with  the  thumbs  adducted ; 
the  reflexes  are  exaggerated ;  the  pupils  are  generally  contracted  and 
equal,  though  tliey  may  be  dilated  ;  nystagmus  and  convergent  strabismus 
are  often  present.  Convulsions  may  occur  from  time  to  time,  or  may  be 
deferred  until  near  the  close  of  the  disease.  As  the  head  enlarges  the 
body  usually  wastes,  and  the  disproportion  between  the  two  may  seem 
greater  than  it  really  is. 

Such  congenital  cases  rarely  see  the  end  of  the  first  year,  and  are  often 
fatal  during  the  first  six  months.  The  causes  of  death  are  marasmus,  con- 
vulsions, and  intercurrent  disease,  rarely  rupture  of  the  head. 

In  the  cases  which  develop  more  slowly,  the  symptoms  are  quite  differ- 
ent. The  head  may  not  attain  at  eighteen  months  the  size  reached  in  the 
other  cases  at  the  third  or  fourth  month.  The  surprising  thing  about  many 
of  these  cases  is  that  the  distinctly  cerebral  symptoms  are  so  few.  Where 
the  pressure  develops  gradually,  the  brain  seems  able  to  tolerate  an  almost 
indefinite  amount  of  it.  The  more  readily  the  bones  of  the  skull  yield  to 
pressure  the  fewer  are  the  nervous  symptoms;  hence,  other  things  being 
equal,  they  are  less  marked  where  the  disease  begins  before  the  sutures 
are  firmly  ossified  than  in  the  later  cases.  A  comparatively  small  amount 
of  effusion  may  cause  very  marked  symptoms  in  a  child  two  or  three  years 
old,  while  a  much  larger  amount  in  an  infant  of  a  year,  may  produce  much 
less  disturbance.  It  is  for  this  reason  that  secondary  hydrocephalus 
causes  such  striking  symptoms,  although  the  accumulation  of  fluid  is 
small. 

Whether  the  progress  of  these  cases  is  slow  or  rapid,  the  development  of 
the  children  is  greatly  retarded.  Many  are  not  able  to  support  the  head 
nntil  two  or  three  years  old  ;  frequently  they  do  not  walk  until  five  or  six 
years  old.  The  special  senses  are  generally  not  noticeably  affected,  but  in- 
telligence in  most  cases  is  interfered  with, — in  some  only  slightly,  in  others 
very  markedly,  while  some  are  idiotic.  Contractions  of  the  extremities 
are  occasionally  seen,  but  usually  more  of  the  hands  than  the  legs.  Sen- 
sation is  not  often  affected.  The  course  is  a  very  chronic  one.  From 
time  to  time  there  are  exacerbations  of  the  symptoms,  and  even  inter- 
current meningitis  may  be  excited. 

Prognosis. — Recovery  is  rare.  It  is  quite  exceptional  that  a  hydro- 
cephalic child  reaches  the  age  of  seven  years.  In  some  cases  the  process 
goes  on  up  to  a  certain  age  and  then  ceases  spontaneously,  and  the  child 
may  go  through  life  with  a  head  very  much  larger  than  normal,  usually 
with  a  mental  condition  somewhat  impaired.  Retrogression  of  the  symp- 
toms is,  however,  never  to  be  looked  for. 

Diagnosis. — The  most  important  symptom  is  the  enlargement  of  the 
head,  and  this  can  only  be  arrived  at  by  careful  measurement  and  com- 


740  Dl&EASES  OP  THE  NERVOUS  SYSTEM. 

parison  with  the  normal  size.  The  rapidity  of  growth  is  quite  as  impor- 
tant for  diagnosis  as  the  fact  of  enlargement.  If  the  head  grows  more 
than  an  inch  a  month  there  can  be  little  doubt.  H^^drocephalus  without 
enlargement  of  the  head  can  not  be  diagnosticated.  The  enlargement 
most  frequently  confounded  with  hydrocephalus  is  that  which  occurs  in 
rickets.  In  the  latter  disease  it  is  almost  invariably  irregular ;  there  are 
prominences  over  the  two  frontal  eminences  and  over  the  parietal  bones, 
often  with  furrows  between  them ;  the  size  of  the  head  is  chiefly  due  to 
thickening  of  the  bones  of  the  skull ;  the  marked  prominence  of  the  fore- 
head is  not  seen,  and  the  increase  in  bi-parietal  diameter  is  not  jaresent ; 
furtliermore,  there  are  other  signs  of  rickets. 

Treatment. — Almost  every  sort  of  local  treatment  has  been  adopted  for 
hydrocephalus,  including  incision,  aspiration,  cranial  puncture  with  the 
trocar,  lumbar  puncture,  blisters,  strapping,  and  counter-irritation.  Up 
to  the  present  time  there  does  not  exist  sufficient  evidence  to  show  that 
any  one  of  these  means  is  curative.  If  aspiration  is  done,  the  fluid  reac- 
cumulates  very  quickly,  while  incision  or  cranial  puncture  is  almost  cer- 
tain to  be  followed  by  meningitis.  If  there  is  any  reasonable  suspicion  of 
syphilis,  mercurial  inunctions  to  the  head  should  be  employed,  and  even 
in  other  cases  a  few  favourable  results  have  been  reported.  Convulsions 
and  other  functional  symptoms  are  to  be  treated  upon  general  principles, 
as  they  arise.  At  the  present  time  I  believe  it  is  better  to  refrain  from 
all  operative  measures  unless  rupture  seems  likely  to  occur. 


INFANTILE  CEREBRAL   PARALYSIS. 

Synonyms :  Spastic  diplegia,  paraplegia,  or  hemiplegia. 

Under  the  term  cerebral  paralysis  are  included  several  groups  of  cases 
with  causes  quite  dissimilar,  but  having  certain  definite  clinical  features 
in  common.  While  the  symptomatology  is  quite  clear,  there  are  many 
questions  relating  to  the  pathology  that  are  not  yet  fully  settled,  although 
much  has  been  added  to  our  knowledge  within  the  last  few  years.  Paraly- 
sis depending  upon  cerebral  tumour,  abscess,  or  hydrocephalus  is  not  in- 
cluded in  this  chapter. 

The  cases  of  cerebral  paralysis  may  be  divided  into  three  groups, 
according  as  the  paralysis  depends  upon  conditions  existing  prior  to 
birth,  upon  those  connected  with  birth,  or  upon  those  of  subsequent 
development. 

I.  Paralysis  of  Intra-Uterine  Origin. — This  is  the  least  frequent  con- 
dition. In  such  cases  there  is  some  congenital  defect  in  the  brain,  due 
sometimes  to  arrested  development,  at  others  to  such  intra-uterine  lesions 
as  haemorrhage  or  thrombosis.  There  may  be  porencephalus,  or  cysts  ex- 
tending deeply  into  tlie  substance  of  the  brain,  sometimes  communicating 


INFANTILE   CEREBRAL   PARALYSIS.  Y41 

with  the  veutricles.  The  origin  of  tliis  condition  is  for  tlie  most  part  un- 
known. In  rare  cases  the  paralysis  is  due  to  cortical  agenesis,*  a  condition 
in  which  the  brain  may  seem  normal  to  the  naked  eye,  but  the  microscope 
shows  a  complete  arrest  in  the  development  of  the  cells  of  the  cortex,  usu- 
ally affecting  both  liemispheres.  In  still  other  cases  there  are  found  gross 
defects  in  development  in  the  motor  centres  of  the  cortex.  Such  a  lesion 
is  shown  in  Fig.  124,  page  751.  Cases  in  which  there  is  conclusive  evi- 
dence of  intra-uterine  hsemorrhage  are  very  rare. 

Symptoms. — In  most  of  the  paralyses  due  to  intra-uterine  lesions,  loss 
of  power  is  only  one  of  the  symptoms,  and  usually  not  the  most  promi- 
nent. It  is  rare  that  there  is  not  some  mental  impairment,  and  usually 
idiocy  is  present.  The  type  of  paralysis  is  nearly  always  diplegic  or  para- 
plegic. Where  this  is  due  to  arrested  cortical  development,  a  general  flac- 
cidity  of  the  muscles  may  be  seen  instead  of  the  rigidity  so  characteristic 
of  the  other  forms  of  cerebral  paralysis. 

II.  Birth-Paralysis. — Cerebral  birth-paralysis  is  due  in  nearly  all  cases 
to  meningeal  hsemorrhage.  The  primary  lesions  and  the  early  symptoms 
have  already  been  described  (page  105)  in  connection  with  the  Diseases  of 
the  Newly  Born.  The  secondary  lesions  present  considerable  variety. 
There  may  be  found  (1)  meningo-encephalitis,  (2)  atrophy  and  sclerosis 
of  the  cortex,  (3)  cysts  upon  the  surface,  (4)  secondary  degenerations  in 
the  spinal  cord. 

1.  Meningo-encephalitis. — This  lesion  is  often  quite  diffuse.  There 
is  thickening  of  the  pia  mater,  and  it  is  usually  adherent  to  the  brain 
substance.  The  cortex  is  involved  to  a  variable  degree,  depending  some- 
what upon  the  time  which  elapses  between  the  initial  lesion  and  the  au- 
topsy. The  following  were  the  microscopical  changes  found  by  Sachs  \  in 
the  brain  of  a  child  in  my  wards  at  the  Babies'  Hospital,  who  died  at  the 
age  of  one  year  of  measles :  The  lesions  were  found  everywhere  in  the 
cortex.  The  pia  was  universally  adherent,  and  showed  general  cellular 
infiltration ;  its  blood-vessels  showed  marked  cellular  proliferation,  and 
the  veins  in  the  sub-pial  space  were  dilated  and  filled  with  blood.  In  the 
pia  dipping  in  between  the  convolutions  similar  changes  were  present.  In 
the  cortex  few  if  any  normal  pyramidal  cells  were  found,  but  in  the  outer 
layers  were  an  enormous  number  of  small  glia  cells.  Many  of  the 
blood-vessels  showed  a  cell-proliferation  of  their  walls.     There  was  also 


*  For  fuller  description,  see  Sachs's  Nervous  Diseases  of  Children,  1895,  p.  601. 

f  The  clinical  features  of  this  case  are  quite  as  interesting  as  the  pathological  find- 
ings. The  child  was  a  first-born,  delivered  after  a  dry  labour  of  forty-eight  hours. 
It  was  asphyxiated,  and  from  the  first  days  of  its  life  it  had  attacks  of  convulsions, 
usually  repeated  many  times  a  day.  During  one  of  these  convulsions  the  photograph 
from  which  Fig.  122  was  made,  was  taken  by  Dr.  Peterson.  The  child  had  the  symp- 
toms of  typical  spastic  paraplegia — the  arms  being,  however,  slightly  involved — retarded 
mental  development,  and  convergent  strabismus. 


742 


DISEASES  OP   THE   NERVOUS  SYSTEM. 


a  degeneration  in   the  pyramidal  tracts  of  the  anterior  columns  of  the 
cord. 

2.  Atrophy  and  sclerosis. — These  changes  vary  much  in  extent  and 
degree.  There  may  be  only  a  circumscribed  area  in  which  the  convolu- 
tions are  small,  firmer  than  usual,  and  covered  with  an  adherent  pia,  or 
there  may  be  an  atrophy  so  extensive  as  to  involve  a  large  part  of  one  hemi- 
sphere (Figs.  130  and  121),  or  sometimes  of  both  hemispheres.  Usually 
the  lesion  is  somewhat  diffuse  over  the  convexity  of  both  sides,  and  much 
more  frequently  of  the  anterior  than  of  the  posterior  half  of  the  brain. 


Fig.  liO. — £xtC'ii?ivf  atrophy  and  sclerosis  oftlie  riorht  hemisphere,  from  an  infaut  seven  and  a 
half  months  old;  prol)ably  the  result  of  a  meningeal  hijemorrhage  at  birth  (lateral  view). 

Ilidory. — Twelve  hours  after  birth  wjis  seized  with  general  convulsions,  which  continued 
for  tliree  days.  No  other  symptoms  noticed  till  one  month  before  death,  when  weakness  of  left 
arm  was  observed.    Never  lield  head  erect.    Was  plump  and  well  nourished ;  died  from  erysipelas. 

Autopsy. — Pia  not  adherent;  a  large  cyst  uocupied  the  region  of  the  occipital  and  posterior 
part  of  the  parietal  lobes,  showing  in  its  lloor  discolouration  and  ])igmentation,  evidently  from 
an  old  hicmorrhage.     Kight  optic  nerve,  tract,  and  crus  much  smaller  than  the  left. 


Where  a  depression  of  the  brain  exists  the  space  is  filled  with  cerebro- 
spinal fluid,  and  in  many  cases  there  is  a  deformity  of  the  skull. 

3.  Cysts  upon  the  surface  may  occur  alone  or  in  connection  with  the 
lesions  just  mentioned.  These  are  usually  small,  about  the  size  of  a  wal- 
nut, but  they  may  cover  a  large  part  of  a  hemisphere.  Such  large  cysts 
are  sometimes  classed  as  cases  of  external  hydrocephalus. 

4.  Secondary  degenerations  of  the  internal  capsule  and  the  lateral  col- 
umns of  the  cord  are  found  in  most  of  the  cases  associated  with  extensive 
atrophy  and  sclerosis,  and  in  many  of  those  in  which  only  meningo- 
encephalitis is  present. 

Symjitoms. — The  type  of  paralysis  will  of  course  depend  upon  the 
extent  and  position  of  the  original  lesion.  A  diffuse  lesion  is  followed  by 
diplegia ;  one  not  quite  so  extensive  by  paraplegia ;  one  affecting  one  side 
only  by  hemiplegia,  or  even  monoplegia,  though  this  is  very  rare.     The 


INFANTILE   CEREBRAL   PARALYSIS. 


743 


relative  frequency  of  the  different  forms  will  vary  according  to  the  age-at 
which  the  patients  come  under  observation.  Thus  in  the  statistics  of 
Sachs  and  Peterson,*  there  were  twenty-seven  cases  of  diplegia  or  para- 
plegia, and  twenty-two  of  hemiplegia.  These  cases  were  drawn  from 
miscellaneous  sources,  chiefly  from  a  general  neurological  clinic.  Ac- 
cording to  my  own  observations,  which  have  been  chiefly  upon  infants, 


FiG.  121.— Atroi)hy  of  right  heniitipliere ;  same  case  us  Fig.  li'n:  su} 


uiiericir  view. 


the  cases  of  diplegia  and  paraplegia  have  outnumbered  those  of  hemi- 
plegia more  than  four  to  one.  My  belief  is  that  the  great  majority  of 
the  congenital  cases,  or  those  due  to  haemorrhage  occurring  at  birth,  are 
diplegias  or  paraplegias,  and  that  very  many  of  them  succumb  during  the 
first  two  years,  and  never  come  under  the  observation  of  the  neurologist; 
however,  the  cases  of  hemiplegia,  because  of  the  less  serious  lesion,  live  much 
longer,  and  hence  are  more  likely  to  be  seen  by  the  specialist.     Diplegia 


*  Journal  of  Nervous  and  Mental  Disease,  May,  1890. 


744  DISEASES   OP  THE   NERVOUS  SYSTEM. 

and  paraplegia  will  therefore  be  considered  as  the  characteristic  types  of 
cerebral  birth-palsy,  as  the  cases  of  hemiplegia  do  not  differ  from  those 
due  to  later  causes — i.  e.,  the  acquired  form. 

In  the  most  severe  cases  that  survive  the  symptoms  of  the  early 
days  of  life  (page  107)  there  remains  some  rigidity  of  the  exti'emities, 
chiefly  of  the  legs,  which  is  constant  or  intermittent,  slight  or  well  marked. 
There  is  often  spasm  of  the  muscles  of  the  neck  and  trunk,  giving  rise  to 
opisthotonus.  In  many  cases  there  are  frequent  attacks  of  convulsions 
(Fig.  122).  The  general  physical  development  of  the  child  is  often  inter- 
fered with,  so  that  it  remains  small  and  delicate,  and  perhaps  dies  of  some 
acute  disease  in  early  infancy,  never  having  been  able  to  sit  erect,  or  even 
support  its  head.     In  other  cases  the  general  nutrition  is  not  affected, 


Fi(i.  122. — ('uuvulsi<ius  ill  8putst'R-  jiaraiil<.')4'i;i;  from  a  pliotognipli  by  Dr.  Frederick  Peterson 
durin<!:  an  attack.     (History  on  page  743.) 

and  the  infants  may  be  plump  and  well  nourished.  Such  children  may 
live  indefinitely.  There  is  always  some  degree  of  mental  impairment ;  it 
may  be  so  slight  as  not  to  be  noticeable  until  the  child  is  old  enough  to 
talk,  and  sometimes  not  until  the  age  of  four  or  five  years ;  or  the  child 
may  be  idiotic.  Speech  is  not  only  delayed,  but  is  very  imperfect.  Hear- 
ing is  frequently  affected,  but  sight  rarely.  Often  these  children  are  not 
able  to  walk  alone  until  they  are  four  or  five  years  old,  and  then  with  a 
peculiar  cross-legged  gait,  owing  to  spasm  of  the  adductors  of  the  thighs. 
Tills  may  be  so  great  as  to  entirely  pjevent  walking,  and  while  sitting  or 
lying  the  thighs  may  cross  each  other.  All  the  reflexes  are  greatly  exag- 
gerated. In  one  child  under  my  observation  the  pharyngeal  reflex  was  so 
much  increased  that  swallowing  of  solid  food  was  impossible,  owing  to 
spasm  of  the  muscles.     Alcoholic  stimulants  and  medicines  that  were  at 


INFANTILE   CEREBRAL    PARALYSIS.  745 

all  pungeut  were  taken  only  with  the  greatest  difficulty.  In  some  of  the 
worst  cases  walking  is  impossible,  owing  to  the  shortened  tendons  and 
the  contractures  which  have  occurred  in  the  muscles.  The  arms  are  in 
nearly  all  cases  much  less  affected  than  the  legs,  and  in  about  half  the 
number,  according  to  the  observations  of  Sachs,  they  are  not  involved  at 
all.     The  condition  is  not  incompatible  with  long  life. 

In  the  mild  cases  it  not  infrequently  happens  that  the  early  symp- 
toms are  so  slight  as  to  be  overlooked,  and  nothing  excites  suspicion  until 
the  infant  is  six  or  eight  months  old.  There  is  then  discovered  an  unmis- 
takable muscular  weakness,  as  the  child  can  not  sit  up,  or  even  hold  up  the 
head  when  the  trunk  is  supported.  In  most  of  the  cases  there  is  observed 
before  this  time  a  tendency  to  stiffen  the  body  and  to  throw  it  backward, 
owing  to  spasm  of  the  cervical  or  spinal  muscles.  This  may  be  slight,  or 
it  may  be  very  marked.  The  muscular  weakness  is  not  infrequently  mis- 
taken for  rickets,  and  is  sometimes  regarded  as  simple  backwardness.  A 
closer  examination  usually  discloses  the  presence  of  some  rigidity  of  the 
extremities,  particularly  of  the  legs,  and  exaggeration  of  the  knee-jerk. 
As  the  child  grows  older  the  other  symptoms  of  late  or  imperfect  develop- 
ment become  more  and  more  evident. 

There  are  changes  in  the  shape  of  the  skull,  this  being  usually  smaller 
than  normal  in  all  its  diameters,  or  there  may  be  asymmetry.  There  is 
an  arrest  of  development  in  the  paralyzed  limbs.  These  are  both  smaller 
and  shorter  than  normal.  There  is  marked  muscular  atrophy.  In  many 
cases  abnormal  movements  are  seen,  which  may  be  of  an  irregular  choreic 
type,  or  they  may  be  athetoid.  According  to  various  statistics,  ejiilepsy 
develops  in  from  33  to  50  per  cent  of  all  the  patients  affected. 

III.  Acute  Acquired  Paralysis. — This  is  usually  of  the  hemiplegic 
type,  although  diplegia  and  paraplegia  may  in  rare  instances  be  met  with. 
This  group  includes  cases  developing  at  any  time  after  birth,  but  the  great 
majority  of  those  seen  in  childhood,  begin  before  the  fifth  year. 

Etiology. — The  etiology  of  many  of  these  cases  is  very  obscure.  The 
paralysis  sometimes  follows  traumatism.  It  is  occasionally  seen  in  the 
course  of  scarlet  fever,  measles,  diphtheria,  variola,  and  pneumonia. 
Much  more  frequently  than  with  any  of  these  diseases  it  occurs  during 
pertussis,  being  usually  the  outcome  of  a  severe  paroxysm.  Aside  from 
the  traumatic  cases  and  those  occurring  with  pertussis  (and  these  include 
but  a  small  proportion),  the  real  cause  is  for  the  most  part  unknown. 
The  frequency  with  which  these  cases  are  ushered  in  with  convulsions  has 
led  many  to  assign  this  as  the  cause  of  the  paralysis.  It  is  more  jirobable 
that  the  convulsions  are  the  result  than  the  cause  of  the  lesion  producing 
the  paralysis. 

Lesions. — The  lesions  of  acute  cerebral  palsy  may  be  grouped  under 
three  heads:  (1)  those  of  the  blood-vessels;  (3)  those  of  the  membranes; 
(3)  those  of  the  brain  substance. 


746  DISEASES   OF   THE   NERVOUS  SYSTEM. 

1.  Lesions  of  the  blood-vessels. — There  may  be  either  haemorrhage,  em- 
bolism, or  thrombosis.  Ha?morrhage  is  by  far  the  most  important.  It  is 
usually  meningeal,  very  rarely  cerebral.  It  occurs  more  frequently  at  the 
convexity  than  at  the  base,  and  is  often  quite  diffuse.  Meningeal  hsemor- 
rhage  may  result  from  pachymeningitis.  I  have  elsewhere  stated  my 
conviction  that  this  is  more  frequent  than  is  generally  supposed.  It  may 
be  due  to  traumatism,  where  it  is  also  from  the  dura  mater;  or  from 
the  acute  hyperaemia  accompanying  paroxysms  of  pertussis,  where  it  may 
be  from  the  dura  or  the  pia ;  or  it  may  be  secondary  to  thrombosis  of  the 
superior  longitudinal  sinus.  The  association  of  hajmorrhage  with  sinus- 
thrombosis  is  not  very  infrequent.  It  was  found  in  one  of  my  autopsies 
upon  a  patient  who  died  of  pneumonia.  The  bleeding  in  these  cases  is 
usually  from  the  pia.  Cerebral  hajmorrhage  is  extremely  rare,  but  it 
occurs  even  in  infants ;  I  once  saw  it  in  one  only  two  months  old. 

Embolism  is  rarely  found  unless  associated  with  acute  rheumatic  endo- 
carditis, and  then  usually  in  children  who  are  over  seven  years  old.  ±\s 
in  adults,  tlie  usual  seat  of  the  embolus  is  a  branch  of  the  middle  cere- 
bral artery.  It  may  be  single  or  multiple.  Thrombosis  has  been  met  with 
in  a  small  number  of  cases,  but  it  is  extremely  rare. 

2.  Lesions  of  the  membranes. — These  are  generally  the  result  of  old 
cerebro-spiual  meningitis  ;  sometimes  they  may  be  of  syphilitic  origin.  In 
both,  however,  the  process  is  rarely  confined  to  the  membranes;  it  is  a 
meningo-encephalitis. 

3.  Lesions  of  the  brain  substance. — Atrophy  and  sclerosis  are  terminal 
conditions  found  in  a  large  number  of  the  autopsies  made  upon  cases 
where  the  paralysis  has  been  of  long  standing.  They  vary  in  severity 
and  extent,  and  are  followed  by  secondary  degeneration  in  the  cord,  as  in 
cases  of  birth  paralysis.  There  may  be  the  same  development  of  cysts  of 
the  pia  mater,  or  an  accumulation  of  fluid  in  the  arachnoid  cavity,  these 
taking  the  place  of  the  atrophied  convolutions.  What  the  primary  lesion 
is  in  these  cases  is  still  a  matter  of  debate.  Striim2)ell  believes  many  of 
them  to  be  due  to  an  acute  polieucephalitis,  analogous  to  acute  poliomy- 
elitis. Cases  are  not  infrequently  seen  clinically,  which  this  pathology 
seems  to  explain  very  satisfactorily.  However,  there  is  as  yet  lacking  suffi- 
cient anatomical  evidence  to  establish  this  view. 

In  this  connection  may  be  mentioned  a  case  of  acute  paralysis  in 
which  no  lesion  was  found.  In  the  spring  of  1894,  there  was  admitted  to 
my  service  in  the  Babies'  Hospital,  an  infant  with  pneumonia,  who  had 
developed,  a  few  days  before,  typical  right  hemiplegia.  The  pneumonia 
antedated  the  paralysis  by  several  days.  The  latter  came  on  suddenly, 
with  convulsions,  and  involved  the  face,  arm,  and  leg.  The  arm  and  leg 
appeared  to  be  completely  paralyzed,  but  in  the  face  the  paralysis  was 
incomplete.  The  paralysis  had  begun  to  improve  somewhat  at  the  time 
of  the  child's  death,  which  occurred  a  little  over  a  week  after  its  onset. 


INFANTILE  CEREBRAL   PARALYSIS.  747 

At  the  autopsy  no  gross  lesion  could  be  discovered.  A  careful  microscop- 
ical examination  was  made  by  two  expert  pathologists,  Drs.  C.  A.  Herter 
and  J.  S.  Thacher,  who  could  find  no  explanation  of  the  paralysis.  Xoth- 
ing  abnormal  was  found  except "  a  slight  increase  of  small  spheroidal  cells 
about  some  of  the  meningeal  and  cortical  vessels  of  the  motor  area.  The 
frontal  and  occipital  lobes  were  normal." 

Symptoms. — While  diplegia  and  paraplegia  are  occasionally  seen,  the 
great  majority  of  cases  of  acquired  cerebral  palsy  are  of  the  hemiplegic 
variety.  When  diplegia  and  paraplegia  occur,  it  is  usually  in  early  in- 
fancy, and  their  symptoms  and  course  differ  in  no  wise  from  the  birth 
palsies.  We  may  therefore  regard  hemiplegia  as  the  chief  manifestation 
of  acquired  cerebral  palsy. 

The  onset  of  the  paralysis  is  almost  invariably  sudden,  with  convul- 
sions, which  are  usually  repeated,  and  in  severe  cases  followed  by  loss  of 
consciousness.  In  the  secondary  cases  these  are  generally  the  only  symp- 
toms. In  one  of  my  cases  the  patient  went  to  bed  apparently  well,  and 
awoke  in  the  morning  with  hemiplegia.  Such  an  onset,  however,  is  very 
exceptional.  AVhen  the  paralysis  is  apparently  primary,  fever  is  usually 
present,  and  in  addition  to  the  convulsions  there  may  be  vomiting,  de- 
lirium, and  other  symptoms,  strongly  suggestive  of  an  acute  inflammatory 
process  in  the  brain,  which  continue  for  a  variable  time,  usually  two  or  three 
days,  before  paralysis  is  seen.  The  temperature  in  most  cases  is  from 
100°  to  102°  F.,  and  the  rise  of  temperature  follows  more  frequently  than 
precedes  the  convulsions.  After  the  child  recovers  consciousness,  and 
sometimes  before  this,  the  paralysis  is  discovered.  If  there  is  a  very  ex- 
tensive lesion  there  may  be  diplegia,  deep  coma,  and  death,  but  this  is 
very  infrequent.  Usually  the  lesion  is  more  limited,  and  the  symptom^ 
are  those  of  typical  hemiplegia.  It  is  rare  that  the  face  is  much  involved, 
and  often  it  escapes  altogether.  The  paralysis  of  the  arm  and  leg  is  at 
first  complete,  but  may  improve  very  rapidly  in  the  course  of  a  few  days. 
Disturbances  of  sensation  are  usually  of  a  transient  character.  After  a 
variable  period,  from  one  to  several  weeks,  the  patient  begins  to  use  the 
paralyzed  extremities,  the  arm  recovering  more  slowly  than  the  leg,  as  in 
adult  hemiplegia.  The  convulsions  may  be  repeated  for  the  first  day  or 
two,  but  prolonged  or  contintious  convulsions  are  rare.  With  lesions  of 
the  left  side  of  the  brain,  speech  may  be  affected,  and  not  infrequently 
in  yoiing  children  when  the  lesion  is  upon  the  right  side.  The  reflexes 
are  increased  upon  the  affected  side,  and  slight  ankle-clonus  may  be  present. 

In  the  course  of  a  few  weeks  the  child  may  be  able  to  walk,  dragging 
the  affected  leg ;  the  recovery  in  the  leg  is  sometimes  complete,  but  in  most 
cases  a  slight  halt  in  the  gait  remains.  The  arm  usually  recovers  more 
slowly  than  the  leg,  and  contractures  are  likely  to  develop  after  a  variable 
time,  generally  two  or  three  years.  In  Fig.  123  is  shown  a  frequent  de- 
formity of  the  upper  extremity.     Contractures  of  the  leg  lead  to  various 


748 


DISEASES  OF   TflE   NERVOUS  SYSTEM. 


forms  of  talipes,  generally  equimis,  from  shortening  of  the  tendo-Achillis. 
Sometimes  the  arm  or  the  leg  recovers  so  perfectly  that  the  case  may 

be  regarded  as  one  of  monoplegia.  In  old 
cases  the  paralyzed  limbs  are  atrophied ; 
there  is  more  or  less  rigidity,  and  the  spas- 
tic condition  may  be  quite  marked.  I  have 
seen  this  limited  to  a  single  group  of  mus- 
cles in  the  leg.  Aphasia  is  common  in 
right  hemiplegias,  and  it  is  not  very  rare 
in  those  of  the  left  side,  because  infants 
appear  to  use  both  sides  of  the  brain  with 
nearly  equal  facility. 

The  mental  condition  of  these  children 
is  usually  normal,  in  striking  contrast  with 
the  cases  of  congenital  diplegia.  The 
earlier  the  paralysis  occurs  the  more  likely 
are  mental  symptoms  to  be  present,  since 
we  have  here  not  only  the  direct  effect  of 
the  lesion,  but  an  arrested  development  of 
some  part  of  the  brain.  Epilepsy  is  not 
an  uncommon  sequel ;  it  may  be  of  the 
Jacksonian  type,  or  there  may  be  attacks 
of  general  convulsions.  In  other  cases 
there  are  post-hemiplegic  movements  of  a 
choreic  or  athetoid  character,  or  irregular 
ineo-ordinate  movements. 

Prognosis  of  Infantile  Cerebral  Paraly- 
sis.— In  diplegia  and  paraplegia  the  outlook 
is  always  unfavourable.    A  very  large  num- 
ber of  these  cases  which  are  due  either  to 
intra-uterine  or  birth  lesions,  never  reach 
the  third  year,  but  die  in  infancy  of  maras- 
mus or  acute  intercurrent  disease.     Those  who  survive  usually  show  seri- 
ous mental  defects,  and  many  are  practically  helpless  on  account  of  the 
extreme  spastic  condition  of  the  muscles  of  the  extremities. 

In  hemiplegia  the  prognosis  is  much  more  favourable.  In  most  of 
these  cases  the  paralysis  is  of  the  acute  acquired  variety,  and  the  later  the 
period  of  onset,  the  less  likely  is  the  brain  to  be  seriously  damaged.  In 
some  of  these  patients  complete  recovery  takes  place  ;  in  others  the  residual 
paralysis  is  so  slight  as  to  be  easily  overlooked  except  on  careful  examina- 
tion, the  occurrence  of  epilepsy  being  perhaps  the  first  thing  which  leads 
one  to  suspect  that  a  previous  paralysis  has  existed.  The  great  majority  of 
children  who  have  suffered  from  infantile  cerebral  palsy  have  some  degree 
of  permanent  paralysis  and  usually  some  deformities  from  contractures, 


.  1  ■!'",. — Dffoniiity  of  left  liand  tlie 
result  of  contractures  followintj 
an  attack  of  hemiplegia  four 
years  before ;  child  seven  years 
old. 


INFANTILE   CEREBRAL    PARALYSIS.  749 

the  extent  of  both  varying,  of  course,  with  the  severity  of  the  primary 
lesion.  In  all  cases  seen  in  young  infants  it  is  exceedingly  difficult  to 
give  a  prognosis  in  regard  to  future  mental  development.  As  a  rule,  the 
impairment  is  directly  proportionate  to  the  extent  of  the  paralysis  and 
its  intensity ;  although  in  exceptional  cases  we  find  a  good  deal  of  men- 
tal disturbance  with  only  moderate  paralysis,  and  vice  versa. 

Diagnosis. — The  diagnosis  between  the  congenital  and  acquired  forms 
of  cerebral  palsy  is  of  no  great  practical  importance,  and  it  may  be  im- 
possible ;  for  the  symptoms  in  congenital  cases  are  often  not  sufficiently 
marked  to  attract  attention  until  children  are  old  enough  to  sit  alone  or 
to  walk. 

It  may  be  quite  difficult  to  distinguish  cerebral  paralysis  from  infantile 
spinal  paralysis.  The  history  of  an  acute  onset,  the  atrophied  limbs,  the 
deformities,  and  the  absence  of  sensory  disturbances,  may  be  found  in  both 
conditions.  Spinal  paralysis  is,  as  a  rule,  monoplegic,  and  often  affects 
but  a  single  group  of  muscles.  Cerebral  paralysis  is  either  diplegic  or 
hemiplegic  in  character,  and  even  though  only  a  leg  or  an  arm  may  seem 
to  be  affected,  a  critical  examination  will  usually  reveal  the  fact  that 
the  other  limb  of  that  side  has  also  suffered.  The  presence  of  rigidity  and 
exaggerated  reflexes  is  quite  as  important  evidence  of  this  as  loss  of  power. 
The  electrical  reactions,  however,  are  conclusive ;  the  reaction  of  degen- 
eration is  absent  in  cerebral  paralysis,  while  it  is  present  in  sj^inal  paralysis. 

Simple  as  the  differentiation  may  seem  in  most  cases,  the  mistake  is 
frequently  made  of  confounding  cerebral  diplegia,  particularly  of  the  flac- 
cid type,  with  rickets.  But  a  careful  history  and  a  thorough  examina- 
tion will  nsually  dispel  all  doubt  (see  pages  232,  233).  Cases  of  acute 
acquired  paralysis  at  the  onset  may  be  mistaken  for  acute  meningitis, 
but  early  loss  of  consciousness,  the  early  development  of  the  paralysis,  its 
permanent  character,  and  the  short  duration  of  the  acute  symptoms,  dis- 
tinguish cases  of  haemorrhage  from  those  of  meningitis ;  but  when  it  fol- 
lows traumatism,  and  when  it  occurs  in  the  course  of  some  other  dis- 
ease such  as  pneumonia  or  scarlet  fever,  it  may  be  difficult  or  impossible 
to  make  a  diagnosis  between  the  two  conditions. 

Treatment. — The  course  and  the  result  of  cerebral  paralysis  depend 
upon  the  extent  of  the  injury  to  the  brain,  its  nature,  and  the  age  at 
which  it  is  inflicted, — all  these  being  conditions  which  are  beyond  the 
power  of  the  physician  to  modify  or  control.  Tlie  treatment  of  cerebral 
palsy  is  therefore  extremely  unsatisfactory.  For  the  congenital  cases  jn'ac- 
tically  nothiiig  can  be  done,  except  for  the  deformities  and  complications. 
The  acquired  cases  during  the  acute  onset  are  to  be  managed  like  all  other 
cases  of  acute  cerebral  congestion  or  inflammation, — absolute  rest,  ice  to 
the  head,  and  bromides.  Electricity  is  never  to  be  used  in  early  cases,  and 
little  or  nothing  is  to  be  expected  from  it  in  the  late  ones.  Much  can  be 
accomplished  in  an   educational  way  for   the    mental  derangements   re- 


750  DISEASES   OF   THE   NERVOUS  SYSTEM. 

suiting  from  cerebral  palsy ;  this,  however,  belongs  more  properly  to  the 
subject  of  idiocy. 

An  important  part  of  the  treatment  relates  to  the  deformities.  Many 
of  these  may  be  prevented  by  the  early  use  of  orthopaedic  apparatus. 
Serious  deformities  in  old  cases  may  be  greatly  benefited  by  tenotomy 
or  myotomy,  followed  by  the  application  of  suitable  apparatus.  In  fact, 
very  little  can  be  done  for  these  patients  except  by  the  orthopedic  surgeon. 
Epilepsy  is  to  be  treated  as  in  cases  depending  on  other  causes. 

FEEBLE-MINDEDNESS,   IDIOCY,    IMBECILITY. 

By  these  terms  are  designated  the  different  forms  of  mental  impair- 
ment, seen  in  children  as  a  result  either  of  arrested  develoinnent  or  dis- 
ease of  the  brain.  They  differ  in  degree  rather  than  in  kind,  and  may  be 
associated  with  a  variety  of  pathological  conditions.  Following  somewhat 
the  classification  of  Ireland,  these  cases  may  be  grouped  as  follows : 

1.  Those  depending  upon  the  arrested  development  of  the  brain  as  a 
whole,  or  upon  that  of  the  frontal  lobes.  An  excellent  example  of  this 
class  of  cases  is  shown  in  Fig.  124.  Another  form  is  "agnesia  corti- 
calis"  (page  741). 

2.  Those  associated  with  hydrocephalus. 

3.  Those  associated  with  microcephalus,  with  or  witliout  premature 
ossification  of  the  cranial  bones. 

4.  The  paralytic  cases, — including  the  varieties  which  occur  in  the  dif- 
ferent forms  of  cerebral  paralysis,  the  greater  part  of  which  are  due  to 
meningeal  hfemorrhage  at  the  time  of  birth,  and  associated  with  spastic 
diplegia  or  paraplegia;  a  smaller  luimber  are  associated  with  acquired 
palsy,  which  is  most  frequently  due  to  meningeal  haemorrhage. 

5.  Those  of  inflammatory  origin.  They  follow  cerebro-spinal  men- 
ingitis, and  possibly  also  there  may  be  added  a  group  dependent  upon 
poliencephalitis  (Striimpell). 

6.  Those  associated  with  epilepsy,  in  which  the  condition  is  a  result  of 
changes  in  the  brain  produced  by  the  repetition  of  the  epileptic  seizures. 

7.  Sporadic  cretinism  (page  752). 

Cases  of  mental  impairment  probably  do  not  follow  ordinary  attacks 
of  infantile  convulsions  or  traumatism  without  some  definite  lesion  of 
the  brain,  and  hence  have  been  included  in  some  of  the  foresrointr 
varieties. 

In  addition  to  the  etiological  factors  belonging  to  the  separate  con- 
ditions described,  there  are  to  be  considered  influences  of  heredity, 
nervous  diseases  in  the  family,  alcoholism,  syphilis,  and  some  other  in- 
herited vices  of  constitution  in  the  parents,  and  intermarriage  among 
blood  relations. 

Most  cases  of  idiocy  exhibit  to  a  greater  or  less  degree,  the  stigmata 
of  degeneration   (page  757).      In    an    examination   of  five  hundred  and 


FEEBLE-MINDEDNESS,   IDIOCY,   IMBECILITY.  751 

seventeen  idiots  by  Howe,  there  were  found  blindness  in  twenty-one  ;  deaf- 
ness in  twelve ;  some  defect  of  the  nose  or  mouth,  such  as  hare-lip,  high 


Fio.  124.— Arrested  development  of  the  frontal  lobes  of  the  brain,  particularly  of  the  right  side, 
from  an  idiotic  chihl  twelve  months  old.* 


palatal  arch,  or  cleft  palate,  in  twenty-three  cases  ;  and  some  deformity  of 
the  hands  or  feet  in  fifty-four  cases ;  while  in  ninety-six  there  was  pa- 
ralysis of  one  or  more  limbs.f 

*  A  microscopical  examination  by  Dr.  ^Martha  Wollstein  .showed  the  cortex  in  the 
affected  region  to  be  only  one-third  the  normal  thickness;  the  cortical  layers  were  ill- 
defined;  there  was  a  strikiiifr  absence  of  the  characteristic  nerve  cells,  both  the  large 
and  small  pyramidal  cells  beinj^  few  in  nnmljer.  There  was  no  {growth  of  connective 
tissue.     The  white  snbstance  was  normal,  as  were  also  the  dura  and  pia. 

f  For  the  symptoms  of  idiocy  in  detail,  reference  is  made  to  works  on  diseases  of 

the  nervous  system,  especially  to  the  Monograiih  of  Langdon  Down,  and  to  the  article 

by  Brush  in  Keating's  Cyclopaedia,  vol.  iv,  p.  1019,  in  which  will  be  found  references  to 

recent  medical  literature  upon  the  subject. 
4!) 


752 


DISEASES   OF  THE   NERVOUS  SYSTEM. 


SPORADIC   CRETINISM. 

Synonyms:  Cretinoid  Idiocy;   Myxcederaatous  Idiocy;   Idiocy  with  Pachydermatous 

Cachexia. 

Since  the  early  description  of  this  disease  by  Fagge,  in  1871  and  1874, 
numerous  cases  have  been  published  in  England,  on  the  continent  of 
Europe,  and  in  America,  showing  that  the  disease  is  not  confined  to  any 
country.  During  the  last  six  years,  five  cases  have  come  under  my  own 
observation.  While  the  disease  is  rare,  cretins  are  much  more  common 
than  was  formerly  supposed. 

Etiology. — It  is  now  well  established  that  this  condition  depends  either 

upon  a  congenital  absence  of  the 
thyroid  gland,  or  something 
which  abolishes  its  functions. 
In  Bramwell's  series  of  forty- 
four  cases,  ten  autopsies  are  re- 
ported ;  in  nine  of  these  no  trace 
of  the  thyroid  gland  could  be 
found,  and  in  the  tenth  one  lobe 
was  the  seat  of  a  large  tumour. 
The  symptoms  are  practically 
identical  with  the  myxoedema  of 
adults  which  follows  the  removal 
of  the  thyroid  gland.  Eegarding 
the  causes  which  destroy  the 
thyroid  gland  or  abolish  its  func- 
tions little  is  as  yet  known.  In 
most  cases  it  is  a  congenital  con- 
dition. In  some  instances  it  has 
followed  acute  disease.  As  a 
rule,  only  one  case  occurs  in  a 
family,  the  other  members  of 
which  present  nothing  abnormal 
in  mental  or  physical  develop- 
ment. 

Symptoms. — The  symptoms 
of  cretinism  in  most  cases  make 
their  appearance  during  the  first  year,  sometimes  not  until  children  are 
two  or  three  years  old,  and  occasionally  none  may  be  seen  until  the  seventh 
or  eighth  year.  The  general  appearance  of  the  cretin  is  very  striking,  and 
so  characteristic  that  when  once  seen  the  disease  can  hardly  fail  to  be  rec- 
ognised (Figs.  125  and  126).  The  body  is  greatly  dwarfed,  and  children 
of  fifteen  years  are  often  only  two  and  a  half  or  three  feet  in  height.     All 


Fig.  125. — A  typical  cretiu,  nine  years  old ;  height, 
28J  inches.     (After  Brarawell.) 


SPORADIC  CRETINISM. 


753 


754  DISEASES  OF  THE   NERVOUS  SYSTEM. 

the  extremities,  the  fingers  and  tlie  toes,  are  short  and  stumpy.  The 
subcutaneous  tissue  seems  very  thick  and  boggy,  but  does  not  pit  upon 
pressure  like  ordinary  oedema.  The  facies  is  extremely  characteristic : 
The  head  seems  large  for  the  body,  the  fontanel  is  open  until  the  eighth 
or  tenth  year,  and  it  may  not  be  closed  even  in  adults ;  the  forehead  is 
low  and  the  base  of  the  nose  is  broad,  so  that  the  eyes  are  wide  apart ;  the 
lips  are  thick,  the  mouth  half  open,  and  the  tongue  usually  protrudes 
slightly ;  the  cheeks  are  baggy,  the  hair  coarse,  straight,  and  generally 
light  coloured.  The  teeth  appear  very  late — in  one  of  my  cases  none  were 
present  at  two  years — and  are  apt  to  decay  early. 

Fatty  tumours  are  quite  constant  in  older  children,  although  they  were 
wanting  in  two  of  my  infantile  cases.  They  are  seen  in  the  supra-clavicu- 
lar region,  just  behind  the  sterno-mastoid  muscle,  sometimes  in  the  axilla, 
or  between  the  scapulae,  and  sometimes  in  other  j)arts  of  the  body.  In 
distribution  they  are  apt  to  be  symmetrical,  and  are  usually  about  the  size 
of  a  hen's  egg.  The  neck  is  short  and  thick.  In  some  cases  there  is  a 
depression  corresponding  to  the  location  of  the  thyroid  gland.  The  chest 
is  not  deformed.  The  abdomen  is  large,  pendulous,  and  resembles  that 
of  rickets.  The  skin  is  dry,  perspiration  scanty,  and  eczema  is  common. 
The  voice  is  hoarse  and  rough.  Patients  often  do  not  walk  until  they 
are  five  or  six  years  old,  and  then  they  waddle  in  a  clumsy  way.  All  the 
movements  of  the  body  are  slow  and  lethargic,  and  everything  indicates 
a  mental  and  physical  torpor.  The  rectal  temperature  is  usually  sub- 
normal. I  had  once  an  opportunity  to  observe  an  attack  of  acute  broncho- 
pneumonia in  one  of  these  cretins  two  years  old.  The  symptoms  and 
physical  signs  were  typical,  but  during  the  greater  part  of  the  disease 
the  rectal  temperature  fluctuated  between  95°  and  98'5°  F.  Only  once 
was  a  temperature  above  99°  F.  recorded.  On  account  of  their  low  tem- 
perature and  torpid  condition  these  patients  are  very  sensitive  to  cold. 
The  mental  condition  is  always  impaired,  and  they  are  usually  idiotic. 
Speech  is  acquired  late,  and  in  some  cases  not  at  all.  Cretins  are  dull, 
placid,  and  good-natured,  rarely  troublesome  or  excitable ;  and  when 
fifteen  or  eighteen  years  old  they  appear  like  children  of  two  or  three 
years.  There  is  an  absence  of  development  of  the  sexual  organs,  and 
almost  invariably  they  suffer  from  chronic  constipation. 

Diagnosis. — The  diagnosis  is  usually  easy,  although  the  early  cases 
are  sometimes  miscalled  rickets.  The  low  temperature,  the  facial  ex- 
pression, the  torpor,  and  the  fatty  tumours  are  enough  to  differentiate 
the  two  diseases. 

Prognosis  and  Treatment. — There  is  no  tendency  to  spontaneous 
improvement.  Many  of  these  cases  die  in  childhood,  but  a  few  live 
to  adult  life.  Until  within  the  last  few  years  they  have  been  con- 
sidered hopeless.  The  improvement  which  followed  the  use  of  the 
thyroid  extract  in  cases  of  adult  myxoedema  has  led  to  a  trial  of  this 


INSANITY.  755 

remedy  in  sporadic  cretinism.  A  sufficient  number  of  cases  have  now 
been  recorded  to  establish  the  fact  that  the  thyroid  extract  is  a  specific 
remedy  for  this  disease.  Peterson  and  Bailey  *  have  collected  forty 
cases  treated  in  this  manner.  No  case  failed  to  improve  when  the  ex- 
tract was  properly  given.  In  twenty-five  cases  the  improvement  was 
very  striking,  and  in  several  it  was  truly  remarkable  (Figs.  126,  127,  128). 
After  a  few  months'  treatment  the  entire  appearance  of  the  child  is  in 
most  cases  changed  :  The  idiotic  expression  of  the  features  is  lost ;  the 
thickening  of  the  skin  and  subcutaneous  tissues  disappears;  there  is  a 
marked  increase  in  weight,  and  in  the  growth  of  the  whole  body ;  muscu- 
lar power  is  rapidly  developed,  so  that  many  soon  become  able  to  walk  ; 
and  progress  is  seen  in  dentition,  and  in  some  older  girls  in  the  establish- 
ment of  menstruation.  Intellectual  progress  is  much  slower  than  phys- 
ical changes ;  however,  nearly  all  the  children  become  brighter  and  more 
intelligent,  and  a  few  learn  to  talk.  In  none  of  the  cases  so  far  reported 
has  treatment  been  continued  longer  than  eighteen  months,  so  that  it  is 
as  yet  imijossible  to  say  whether  improvement  will  continue  indefinitely, 
and  whether  complete  recovery  is  to  be  expected.  From  present  knowl- 
edge the  latter  seems  very  improbable.  In  all  cases  the  thyroid  extract 
must  be  given  indefinitely,  for  otherwise  improvement  ceases  at  once,  and 
cases  may  even  relapse.  The  earlier  the  treatment  is  begun  the  more 
marked  is  the  improvement  usually  noticed. 

The  preparation  most  used  in  America  is  Parke,  Davis  &  Co.'s  desic- 
cated extract,  prepared  from  the  thyroid  gland  of  the  sheep.  Of  this 
from  one  half  to  one  grain  is  given  twice  a  day.  Some  disturbances  are 
often  seen  at  the  beginning  of  the  treatment — perspiration,  fretfulness, 
and  sometimes  a  rise  in  temperature — but  these  soon  pass  off.  In  some 
cases  a  smaller  dose  must  be  used  at  first,  and  the  increase  made  very 
gradually. 

•    INSANITY. 

Insanity  is  so  special  a  subject,  that  all  that  will  be  attempted  here  will 
be  to  mention  the  most  frequent  varieties  seen  i;i  early  life,  with  the  im- 
portant etiological  factors  which  operate  at  this  period.  For  a  full  dis- 
cussion of  the  subject  the  reader  is  referred  to  works  upon  insanity,  and 
to  Sachs,  in  whose  book  f  will  be  found  quite  a  full  bibliography  of  this 
branch  of  the  subject. 

Insanity  is  distinguished  from  idiocy  in  that  it  affects  a  mind  previ- 
ously sound,  however,  the  two  conditions  may  be  associated.  Undoubted 
cases  of  mental  disease  have  been  observed  before  the  seventh  year,  but 

*  Pediatrics,  May  1,  1896.  See  also  Osier,  Araedcan  Journal  of  the  Medical  Sci- 
ences, November,  1893;  and  Bramwell's  Monograph  on  Cretinism. 

f  Nervous  Diseases  of  Children,  New  York,  1895.  See  also  Mills,  in  American  Text- 
Book  of  Diseases  of  Children,  edited  by  Starr,  Philadelphia,  1894. 


756  DISEASES  OF  THE   NERVOUS  SYSTEM. 

they  are  extremely  rare.  From  this  time  up  to  puberty,  however,  nearly 
all  the  varieties  seen  in  adult  life  occasionally  occur,  but  they  are  very  in- 
frequent even  at  this  period.  The  form  which  insanity  in  childhood  most 
frequently  assumes  is  mania. 

Etiology. — Insanity  is  sometimes  seen  as  a  sequel  of  one  of  the  infec- 
tious diseases,  more  often  typhoid  fever  than  any  other,  although  it  may 
follow  measles,  scarlet  fever,  diphtheria,  or  variola.  Another  cause  is 
masturbation,  although  its  effect  is  much  more  frequently  seen  after 
puberty  than  before.  Hereditary  syphilis  is  sometimes  the  cause  of  de- 
mentia, which  comes  on  about  the  fourth  or  fifth  year,  or  even  later. 
Alcoholism,  epilepsy,  insanity,  or  other  nervous  diseases  in  the  parents 
are  important  causes.  Prolonged  or  continuous  mental  strain,  the  result 
of  overwork  in  school,  is  a  cause  of  considerable  importance,  especially  in 
girls  about  the  time  of  puberty.  As  exciting  causes  may  also  be  men- 
tioned various  reflex  conditions,  such  as  intestinal  worms,  phimosis,  delay 
in  the  establishment  of  menstruation,  and  abnormal  conditions  of  the  nose 
and  throat ;  these,  however,  can  not  have  much  influence  except  where  the 
predisposition  is  a  strong  one.  Insanity  may  be  associated  with  or  may 
follow  hysteria,  chorea,  or  epilepsy.  It  has  sometimes  followed  injury  to 
the  brain,  acute  meningitis,  and  occasionally  other  forms  of  brain  disease. 

Symptoms. — Certain  forms  of  insanity  are  practically  never  seen  in 
children,  such  as  paranoia  or  primary  delusional  insanity,  acute  demen- 
tia, paretic  dementia,  periodic  or  circular  insanity,  and  cataleptic  insanity. 

Mania  is  one  of  the  most  frequent  forms,  and  is  the  most  common 
variety  of  post-febrile  insanity.  Its  symptoms  may  be  quite  intense,  but 
are  usually  of  short  duration,  lasting  but  a  few  days  or  weeks.  In  rare 
cases  it  may  continue  for  months,  and  it  may  even  be  permanent. 

Melancholia  is  not  uncommon.  It  is  seen  as  a  result  of  prolonged 
mental  strain  in  school,  it  may  be  due  to  fear  of  punishment,  and  some- 
times may  follow  masturbation.  It  is  usually  associated  with  some  very 
marked  disturbance  of  the  general  health.  It  shows  itself,  as  in  the  adult, 
by  fits  of  depression,  self-mutilation,  and  even  by  suicidal  tendencies. 

Epileptic  insanity  mhy  follow  epilepsy  in  children  who  were  previously 
mentally  sound,  where  it  may  take  the  form  of  true  epileptic  dementia, 
or  there  may  be  attacks  of  mania  which  occur  in  the  place  of  an  epileptic 
seizure  or  follow  such  a  seizure.  Transitory  attacks  of  fury  or  frenzy 
coming  on  without  apparent  cause  should  always  suggest  the  possibility 
of  epilepsy. 

Other  forms  which  insanity  assumes  in  early  life  are  :  transitory  psy- 
choses, such  as  delirium,  night-terrors,  attacks  of  sobbing  or  weeping, 
sometimes  from  fright;  moral  insanity,  as  shown  by  perversion  of  the 
moral  sense  from  injury  or  disease,  and  by  various  vicious  tendencies; 
morbid  impulses,  which  may  be  homicidal  or  sexual,  or  a  disposition  to 
thieving,  lying,  pyromania,  etc. ;  morbid  fears,  of  which  there  may  be  an 


THE  STIGMATA   OF   DEGENERATION.  757 

almost  endless  variety.  These  are  sometimes  associated  with  a  low  state 
of  physical  health ;  this,  however,  is  usually  not  the  case. 

Prognosis. — On  the  whole,  insanity  in  childhood  has  a  better  progno- 
sis than  in  the  adult.  In  most  of  the  cases  of  mania,  melancholia,  the 
various  transitory  psychoses,  or  the  choreic  and  hysterical  forms,  recovery 
occurs  with  proper  treatment.  The  outlook  for  the  other  varieties  is 
much  worse,  especially  in  those  in  which  there  is  a  strong  hereditary 
tendency  to  mental  disease. 

The  treatment  is  to  be  conducted  along  the  same  general  lines  as  in 
adults. 

THE   STIGMATA  OF   DEGENERATION. 

These  marks  are  of  much  importance  in  relation  to  the  different  forms 
of  nervous  disease  in  children,  especially  epilepsy,  idiocy,  and  insanity. 
They  are  of  great  value  in  determining  existing  nervous  disease,  or  as 
showing  latent  neuropathic  tendencies. 

The  physician  should  be  familiar  with  these  various  signs  in  order  that 
he  may  connect  them  Avith  each  other  and  refer  them  to  their  proper 
source,  and  at  the  same  time,  by  appreciating  their  significance,  be  able 
to  advise  parents  with  regard  to  the  care,  education,  mode  of  life,  and 
occupation  of  children,  in  whom  to  a  greater  or  less  degree  these  signs 
may  be  present.  These  stigmata  are  not  of  equal  importance  as  marks  of 
degeneration.  Some  of  them,  such  as  facial  asymmetry  and  most  of  the 
deformities  of  the  palate,  are  always  to  be  so  regarded;  the  speech  defects 
are  often  so,  while  many  of  the  others  may  or  may  not  be,  according  to 
their  association.  The  stigmata  are  divided  into  anatomical,  physiological, 
and  psychical.     The  following  is  the  classification  given  by  Peterson  :  * 

Anatomical  Stigmata. — Cranial  anomalies  :  Facial  asymmetry ;  de- 
formities of  the  palate  ;  anomalies  of  the  teeth,  tongue,  lips,  or  nose. 

Anomalies  of  the  eye  :  Flecks  on  the  iris ;  strabismus ;  chromatic 
asymmetry  of  the  iris ;  narrow  palpebral  fissure  ;  albinism  ;  congenital 
cataract ;  pigmentary  retinitis. 

Anomalies  of  the  ear. 

Anomalies  of  the  limbs  :  Polydactyly;  syndactyly;  ectrodactyly ;  sym- 
elus  ;  phocomelus  ;  excessive  length  of  the  arms. 

Anomalies  of  the  trunk  :  Herniae ;  malformation  of  the  breasts  and 
thorax  ;  dwarfishness  ;  giantism  ;  infantilism  ;  femininism  ;  masculinism  ; 
spina  bifida. 

Anomalies  of  the  genital  organs. 

Anomalies  of  the  skin  :  Polysarcia  ;  hypertrichosis  ;  absence  of  hair  ; 
premature  grayness. 


*  Deformities  of  the  Hard  Palate  in  Degenerates,  by  Frederick  Peterson,  M.  D., 
International  Dental  Journal,  December,  1895. 


/^58  DISEASES  OF  THE   NERVOUS  SYSTEM. 

Physiological  Stigmata. — Anomalies  of  motor  function :  Walking  late  ; 
tics  ;  tremors  ;  nystagmus  ;  epilepsy. 

Anomalies  of  sensory  function  :  Deaf-mutism  ;  neuralgia  ;  migraine  ; 
hyperaesthesia  ;  anaesthesia  ;  blindness ;  myopia ;  liypermetropia ;  astig- 
matism ;  Daltonism ;  hemeralopia ;  concentric  limitation  of  the  visual 
field. 

Anomalies  of  speech  :  Mutism  ;  defective  speech  ;  stuttering ;  stam- 
mering. 

Anomalies  of  genito-urinary  function  :  Enuresis ;  sexual  irritability  ; 
impotence  ;  sterility. 

Anomalies  of  the  instinct  or  appetite  :  Merycism  ;  uncontrollable  ap- 
petites for  food,  liquor,  drugs,  etc. 

Diminished  resistance  to  external  influences  and  diseases. 

Eetardation  of  puberty. 

Psychical  Stigmata. — Insanity;  idiocy;  imbecility;  feeble-mindedness; 
eccentricity  ;  moral  delinquency  ;  sexual  perversion. 

DEAF-MUTISM, 

Excluding  the  cases  in  which  idiocy  is  present,  which  are  not  con- 
sidered in  this  chapter,  deaf-mutism  may  be  due  either  to  congenital  or 
acquired  conditions  ;  the  larger  proportion  of  the  cases  belong  in  the  lat- 
ter class.  When  congenital,  deaf-mutism  may  result  from  ostitis,  or  peri- 
ostitis of  the  temporal  bone,  encroaching  upon  the  cavity  of  the  middle 
ear,  from  anchylosis  of  the  ossicles,  from  absence  of  the  internal  ear  or 
any  of  its  parts.  There  may  also  be  colloid  degeneration  of  the  labyrinth. 
It  may  result  from  atrophy  of  the  auditory  nerve,  and  it  may  be  due  to  a 
lesion  of  the  brain.  These  congenital  conditions  are  often  hereditary. 
Acquired  deaf-mutism  is  most  frequently  the  result  of  scarlet  fever,  and 
is  due  to  otitis.  The  second  important  cause  is  cerebro-spinal  meningitis, 
where  it  may  be  due  to  a  lesion  of  the  brain,  the  auditory  nerve,  or  the 
ear.  It  occasionally  follows  mumps,  diphtheria,  measles,  and  other  infec- 
tious diseases.  It  may  result  from  repeated  attacks  of  acute  otitis  associ- 
ated with  adenoid  growths  or  chronic  rhino-pharyngitis. 

The  younger  the  child  at  the  time  the  deafness  occurs  the  sooner  the 
power  of  speech  is  lost.  In  most  of  the  infectious  diseases,  if  the  attack 
occurs  before  the  fifth  year  speech  is  lost.  According  to  Love,*  total  deaf- 
ness is  rare  among  deaf-mutes;  hearing  for  speech  is  present  to  a  useful 
degree  in  about  twenty-five  per  cent  of  the  cases,  while  hearing  by  cranial 
conduction  exists  in  nearly  all  cases.  Deaf-mutism  should  be  suspected 
if  a  child  not  idiotic  shows  at  the  end  of  two  years  no  signs  of  beginning 
to  talk.  A  careful  distinction  should  be  made  between  deaf-mutism  and 
idiocy  resulting  either  from  congenital  conditions  or  acquired  disease. 


*  Deaf-Mutism,  by  James  K.  Love.     Macmillan  &  Co.,  1896. 


MALFORMATIONS   OP   THE  SPINAL   CORD.  Y59 

It  is  necessary  that  this  condition  be  recognised  as  early  as  possible,  in 
order  that  the  child  may  have  the  advantages  of  proper  training  during 
its  early  years.  The  physician  should  insist  upon  the  child  being  sent  to 
an  institution  where  it  may  be  taught  to  speak  as  early  as  the  third,  and 
certainly  by  the  fourth  year. 

The  treatment  is  mainly  prophylactic.  The  most  important  relates  to 
the  care  of  the  ears  in  scarlet  fever,  and  the  removal  of  adenoid  vegeta- 
tions of  the  pharynx  and  other  causes  which  produce  attacks  of  acute  or 
chronic  otitis.  For  the  condition  itself  education  is  the  only  thing  to  be 
considered. 


CHAPTER    IV. 
niSUASES  OF   THE  SPINAL   GOBI). 

MALFORMATIONS. 

Malformations  of  the  cord  are  very  frequently  associated  with  those 
of  the  brain,  and  bear  a  certain  degree  of  resemblance  to  them.  (1)  The 
cord  may  be  absent  (amyelia) ;  this  condition  may  exist  alone  or  with  ab- 
sence of  the  brain.  (2)  The  lack  of  development  may  be  only  partial 
(atelomyelia),  as  where  some  of  the  tracts  are  wanting.  The  most  impor- 
tant one  is  defective  development  of  the  lateral  tracts,  which  may  be  a 
cause  of  spastic  paraplegia  (Charcot).  (3)  There  may  be  a  malposition  of 
some  of  the  gray  matter  (heterotopia).  (4)  Tliere  may  be  a  double  cord 
(diplomyelia) ;  the  division  is  generally  incomplete,  and  is  attributed  to  an 
abnormal  development  of  the  central  canal ;  it  is  usually  associated  with 
other  deformities.  All  of  these  malformations  are  extremely  rare  and  of 
very  little  practical  interest. 

There  remains  to  be  mentioned  the  only  one  wliich  is  really  impor- 
tant— spina  bifida. 

Spina  Bifida. — This  is  a  malformation  of  the  vertebral  canal  with  a 
protrusion  of  some  part  of  its  contents  in  the  form  of  a  fluid  tumour.  The 
tumour  is  elastic,  compressible,  usually  increased  by  crying,  and  sometimes 
by  pressure  upon  the  anterior  fontanel.  The  contained  fluid  is  clear  serum, 
resembling  in  all  respects  the  cerebro-spinal  fluid.  It  is  one  of  the  most 
frequent  congenital  deformities. 

According  to  Humphrey,  spina  bifida  is  due  to  an  early  failure  in 
develoj)ment, — in  most  cases  before  the  cord  is  segmentated  from  the  epi- 
blastic  layer  from  which  it  is  developed.  Hence  it  remains  adherent  to 
the  epiblastic  covering,  and  the  structures  which  should  be  formed  between 
the  cord  and  the  skin  are  undeveloped.  For  this  reason  we  have  in  the 
wall  of  the  sac  a  fusion  of  the  elements  of  the  cord,  nerves,  meninges,  ver- 
tebral arches,  muscles,  and  integument.     If  the  error  in  development  occurs 


760 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Fig.  129.  —  Meningo- 
cele (partially  dia- 
grammatic). A, the 
membranes ;  £,  the 
spinal  cord  ;  6',  the 
integument.  The 
accumulation  '  of 
fluid  i.s  behind  the 
cord,  which  does 
not  enter  the  sac. 


later,  the  cord  and  nerves  may  be  attached  to  the  sac,  but  not  intimately 
fused  with  it ;  in  still  other  cases  the  cord  does  not  enter  the  sac  at  all. 
The  malformation  may  occur  before  the  central  canal 
is  closed ;  or,  if  closed,  it  may  reopen  from  the  accu- 
mulation of  fluid.  It  is  probable  that  the  accumula- 
tion of  fluid  first  occurs,  and  that  this  prevents  the 
union  of  the  parts  of  the  vertebral  arches. 

Although  the  tumour  is  generally  associated  with  a 
bifid  spine,  this  is  not  necessarily  the  case.  The  pro- 
trusion may  take  place  through  the  intervertebral 
notch  or  foramen,  or  there  may  be  a  fissure  of  the 
bodies  of  the  vertebrge,  and  an  anterior  tumour  project- 
ing into  the  cavity  of  the  thorax,  abdomen,  or  pelvis, — 
spina  bifida  occulta.  The  principal  anatomical  varie- 
ties are  meningocele,  meningo- myelocele,  and  syringo- 
myelocele.* 

Meningocele. — In  this  form  there  is  a  protrusion 
of  the  membranes  only  (Fig.  129).     The  accumulation 
of  fluid  is  either  in  the  arachnoid  cavity  or  the  subarachnoid  space  poste- 
rior to  the  cord.     The  opening  of  communication  between  the  tumour  and 

the  spinal  canal  is  small  in  this  variety, 
usually  being  about  one  twelfth  to  one 
sixth  of  an  inch  in  diameter.  There  may, 
however,   be    no    communication.      The 

/^■P'     ^gr  'Wta      skin  is  usually  fully  developed  (Fig.  130). 

^F •    ^^  ^  ^   The  tumour  is  frequently  globular,  some- 

times pedunculated,  and  may  attain  a 
very  large  size,  being  as  much  as  five  or 
six  inches  in  diameter.  This  is  because 
spontaneous  rupture  is  not  likely  to  oc- 
cur, and  the  tumour  does  not  become  in- 
fected except  by  operative  interference. 
With  such  tumours  patients  may  live  to 
adult  life.  This  variety  is  most  frequent- 
ly seen  in  the  cervical  region.  It  has 
the  best  chance  of  natural  recovery,  and 
in  it  operation  gives  the  best  results. 

Meningo-myelocele. — This  is  by  far  the 
most  frequent  variety  of  spina  bifida,  oc- 
curring in  thirty-five  of  the  fifty-seven 
cases  reported  by  Demme.  It  is  the  form 
usually  seen  in  the  sacro-lumbar  region. 


Fig.  130.- 


-Meningocele,  in  a  child  one 
year  old. 


*  See  Report  of  London  Clinical  Society,  1885:  and  Humphrey,  Lancet.  March  28, 
1885. 


SPINA  BIFIDA. 


761 


The  accumulation  of  fluid  takes  place  in  the  anterior  subarachnoid  space, 
less  frequently  in  the  anterior  arachnoid  cavity  (Fig.  131).  In  this  form 
the  cord  is  contained  in  the  sac,  and  usually  forms  a  part  of  its  wall. 
The  tumour  is  smaller  than  the  meningocele,  the  usual  size  being  that  of 
a  mandarin  orange.  It  is  sessile,  never  pedunculated.  As  a  rule  it  is  only 
partly  covered  by  skin,  but  has  a  central  area,  elliptical  in  shape,  where 
there  is  only  a  thin,  translucent  membrane.  This  sur- 
face, which  is  known  as  the  central  cicatrix,  is  some- 
times covered  with  granulations,  and  frequently  ulcer- 
ates. The  tumour  often  has  a  vertical  furrow  or  a  cen- 
tral umbilication,  corresponding  to  the  attachment  of 
the  cord  on  its  inner  surface.  The  usual  relation  of 
the  parts  is  for  the  cord  to  run  horizontally  across 
the  upper  part  of  the  tumour  to  the  central  cicatrix, 
with  which  it  becomes  blended,  and  from  which  again 
the  nerves  arise.  These  re-enter  the  canal  at  the  lower 
part  of  the  tumour,  and  are  distributed  below  as  usual. 
In  other  cases  the  cord  joins  the  wall  of  the  sac  soon 
after  its  entrance,  and  its  attenuated  fibres  are  found 
spread  out  all  over  the  sac,  coming  together  again  be- 
low and  entering  the  spinal  canal. 

The  following  case,  upon  which  I  recently  made  an 
autopsy,  is  a  good  example  of  the  common  variety : 
The  child  died  on  the  third  day  after  birth  from  rup- 
ture of  the  sac.  The  tumour  occupied  the  sacral  region.  The  first 
sacral  vertebra  was  normal,  and  beneath  this  the  cord  passed,  termina- 
ting in  the  cauda  equina  soon  after  entering  the  sac,  and  continued 
back  to  the  central  cicatrix.  Here  nerve  filaments  blended  with  the 
other  tissues  in  an  indefinite  structure,  from  which  again,  with  toler- 
able distinctness,  they  could  be  seen  to  pass  over  the  wall  of  the  sac  and 
return  to  the  canal.  The  afferent  and  efferent  nerves  and  the  part  of  the 
meinbranes  they  carried  with  them  formed  several  septa,  making  a  smaller 
separate  sac  within  the  larger  one.  The  large  sac  was  clearly  a  dilatation 
of  the  anterior  subarachnoid  space,  and  communicated  freely  Avith  the 
same  space  in  the  cord  above. 

Syringo-myelocele. — In  this  variety  the  accumulation  of  fluid  is  in  the 
central  canal  of  the  cord,  the  lining  of  the  sac  being  here  the  attenuated 
and  atrophied  cord  elements.  This  is  the  rarest  form  of  tumour,  but  the 
one  most  frequently  associated  with  hydrocephalus,  and  consequently  hav- 
ing the  worst  prognosis.  It  is  usually  found  in  the  dorsal  or  dorso-lumbar 
region,  rarely  in  the  lumbo-sacral  (Fig.  132). 

With  spina  bifida  other  deformities  are  frequently  associated,  the  most 
common  being  club-foot,  hydrocephalus,  more  rarely  encephalocele  or 
cerebral  meningocele,  and  hare-lip.     If  hydrocephalus  exists,  there  is  in 


Fig.  131.  —  Meningo- 
myelocele (partially 
diagrammatic).  A, 
the  membranes  ;  £, 
the  cord  ;  C.  the  in- 
tegument. The  ac- 
cumuhition  of  Huid 
is  in  front  of  the 
cord,  the  filaments 
of  which  are  spread 
out,  forming  a  part 
of  the  wall  of  the 
sac. 


T62 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


I 


Fig.  13'J. — Syriiiiro-niye 

dorsal  region,  in  a  child  four  months 
old,  who  also  had  hydrocephalus. 


most  cases  a  dilatation  of  the  central  canal  of  the  cord  and  a  direct  com- 
munication between  the  tumour  and  the  lateral  ventricles  of  the  brain. 

Pressure  upon  the  anterior  fontanel 
causes  an  increase  in  the  size  of  the 
tumour,  and  conversely.  Club-foot  is 
usually  double,  most  frequently  tal- 
ipes equino-varus.  In  a  number  of 
cases  there  is  a  history  of  some  de- 
formity in  other  members  of  the  fam- 
ily. I  once  saw  two  successive  chil- 
dren in  the  same  family  with  spina 
bifida. 

Si/mptoms. — The  tumour  is  pres- 
ent at  birth,  and  is  most  frequently 
situated  just  above  the  sacrum.  Pa- 
ralysis is  frequent  in  myelocele  and 
syringo- myelocele,  but  is  not  seen  in 
meningocele  ;  its  degree  and  its  loca- 
tion depend  upon  the  situation  of  the 
tumour  and  the  extent  to  which  the 
cord  is  involved.  It  is  rare  in  cervi- 
cal tumours,  and  most  marked  in  those  situated  in  the  lumbo-sacral  re- 
gion. In  the  worst  cases  there  is  complete  paraplegia,  with  paralysis  of 
the  bladder  and  rectum.  If  the  tu- 
mour is  sacro-lumbar  or  sacral,  only 
the  Cauda  equina  is  likely  to  be  in- 
volved, and  this  but  partially,  so 
that  the  paralysis  of  the  extremities 
is  incomplete,  and  the  bladder  and 
rectum  may  escape. 

In  Fig.  133  is  shown  a  very  re- 
markable case  of  sacral  spina  bifida 
in  a  boy  of  five  years,  who  came 
under  observation  for  incontinence 
of  faeces.  The  tumour  was  a  little 
more  to  the  left  than  to  the  right 
side,  and  had  been  overlooked.  It 
had  evidently  pressed  upon  the  lower 
branches  of  the  sacral  plexus,  so  as 
to  involve  the  sphincter  and  the 
gluteal  muscles  of  the  left  side.  The 
atrophy  was  very  marked,  as  shown 
in  the  illustration. 

The  natural  course  of  spina  bifida  Fig.  133.— Sacrai  spina  bifida. 


SPINA   BIFIDA. 


763 


is  to  increase  steadily  in  size;  and  if  the  tumour  is  covered  by  skin, 
its  growth  may  be  almost  unlimited.  It  has  been  known  to  attain  a  cir- 
cumference of  twenty-two  inches.  If  the  integument  is  wanting,  and  the 
sac  wall  is  very  thin,  rupture  is  pretty  certain  to  take  place,  either 
spontaneously  or  by  some  accident,  in  the  course  of  the  first  few  months ; 
death  then  results  from  convulsions  owing  to  the  rapid  draining  away  of 


**-- 


Fig.  134.— Spina  bifida,  with  dilatation  of  the  central  canal  of  the  cord,  and  spinal  meningitis. 
The  central  canal  is  filled  with  round  cells,  among  which  are  many  cocci.  A'A  is  the  pelli- 
cle of  fibrin  upon  the  posterior  surface  of  the  pia  mater,  also  containing  many  cocci.  The 
pia  is  every wli ere  infiltrated  with  cells,  even  to  the  bottom  of  the  anterior  fissure.^  The 
gray  matter  of  the  cord  is  much  congested.  FJi  is  the  posterior  nerve  root.  The  section  is 
from  the  dorsal  region  of  the  cord. 


the  cerebro-spinal  fluid,  or  from  secondary  infection.  In  a  large  number 
of  cases  death  is  due  to  marasmus  dependent  upon  the  associated  condi- 
tions. Infection  of  the  tumour  may  take  place  without  rupture,  the  germs, 
passing  through  the  wall  of  the  sac.  If  the  opening  communicating  with 
the  spinal  canal  is  small,  this  infection  may  excite  an  inflammation  limited 

to  the  wall  of  the  sac,  and  result  in  a  cure  of  the  spina  bifida,  usually  with 
49* 


764  DISEASES   OP   THE   NERVOUS  SYSTEM. 

sloughing.  I  have  now  under  observation  a  girl  ten  years  old  in  whom 
this  occurred  in  infancy.  The  site  of  the  former  tumour  is  marked  by  a 
large  dense  cicatrix,  and  there  still  remains  partial  paralysis  of  the  legs. 
If  the  opening  into  the  spinal  canal  is  large,  inflammation  of  the  sac  is 
usually  followed  by  spinal  meningitis,  which  may  extend  upward  and  in- 
volve also  the  meninges  of  the  brain.  In  a  case  published  by  Van  Gieson 
and  myself,*  in  which  there  was  dilatation  of  the  central  canal  of  the 
cord  and  hydrocephalus,  bacteria  penetrated  the  wall  of  the  sac  and  trav- 
elled up  the  central  canal  of  the  cord  (Fig.  134),  finally  exciting  a  sup- 
purative inflammation  in  the  ventricles  of  the  brain,  in  addition  to  a 
spinal  meningitis.  Sections  of  the  wall  of  the  sac  and  of  the  cord  at 
various  levels  showed  the  same  cocci.  The  child  died  at  the  age  of  three 
weeks. 

Prognosis. — This  depends  chiefly  upon  the  anatomical  variety  and  the 
existence  of  complications.  Simple  meningocele,  when  covered  by  integu- 
ment, gives  the  best  prognosis,  and  complete  recovery  may  occur.  In 
meningo-myelocele,  if  complete  paralysis  exists,  the  prognosis  is  bad  ;  and 
if  there  is  hydrocephalus,  the  case  is  hopeless.  In  quite  a  number  of 
cases  in  which  cure  has  followed  operation,  hydrocephalus  has  subse- 
quently developed.  Of  fifty-seven  cases  reported  by  Demme,  twenty-five 
were  operated  upon,  with  seven  recoveries  and  fifteen  deaths,  while  in  three 
there  was  no  result ;  of  the  thirty-two  cases  not  operated  upon,  twenty- 
eight  died  within  the  first  month,  and  not  one  lived  over  two  years, — the 
causes  of  death  being  marasmus,  rupture  of  the  sac,  and  meningitis. 

Diagnosis. — It  is  usually  easy  to  recognise  spina  bifida,  but  it  is  often 
difficult  to  distinguish  between  the  different  varieties.  The  absence  of 
a  palpable  fissure  in  the  spine,  perfect  translucency,  and  a  pedunculated 
tumour,  all  point  strongly  to  meningocele.  Paralysis  of  the  sphincters 
and  lower  extremities,  umbilication  of  the  centre  of  the  tumour,  a  sessile 
tumour,  a  palpable  bony  fissure,  and  a  large  central  cicatrix,  point  to 
meningo-myelocele.  The  coexistence  of  hydrocephalus  points  to  syringo- 
myelocele. 

Treatment. — In  all  cases  the  tumour  should  be  protected  from  pres- 
sure, and  care  taken  where  it  is  not  covered  by  integument,  that  the 
surface  is  kept  absolutely  clean  and  aseptic.  It  should  be  covered  with 
iodoform  and  bismuth  and  surrounded  by  a  large  pad  of  absorbent  cot- 
ton, or  a  rubber  ring-cushion.  Complete  paraplegia  with  involvement 
of  the  bladder  and  rectum,  hydrocephalus,  or  extreme  marasmus, — all 
contra-indicate  operative  interference.  In  other  cases,  operation  should 
be  considered.  The  time  of  operation  will  depend  somewhat  upon  the 
nature  of  the  tumour.  If  it  is  covered  by  integument  and  growing  slowly, 
it  is  well  to  wait  until  the  child  is  at  least  six  months  old.     In  other  cases 

*  Journal  of  Nervous  and  Mental  Diseases,  December,  1890. 


SPINAL  MENINGITIS.  765 

delay  is  dangerous,  because  of  the  liability  to  spontaneous  or  accidental 
rupture. 

Xothing  is  to  be  exj^ected  from  simple  aspiration  and  compression. 
The  methods  of  treatment  which  have  been  successfully  employed  are 
ligation,  aspiration  and  injection,  and  excision  of  the  sac.  Ligation  is 
admissible  only  where  there  is  a  pedunculated  tumour;  and  even  for  these 
cases  some  surgeons  prefer  the  clamp.  Aspiration  and  injection  have 
been  widely  used  both  in  Europe  and  America.  The  needle  should  never 
be  inserted  near  the  median  line.  The  tumour  having  been  aspirated 
and  about  one  half  of  its  contents  evacuated,  there  is  injected,  without  re- 
moving the  needle,  a  drachm  of  Morton's  fluid  (iodine,  gr.  x  ;  iodide  of 
potassium,  gr.  XXX  ;  glycerin,  f  j).  If  the  tumour  is  pedunculated,  pres- 
sure should  be  made  at  its  neck  to  prevent  the  entrance  of  fluid  into  the 
canal.  In  all  cases  the  child  should  be  kept  in  a  recumbent  position  fori 
several  hours.  The  operation  is  not  entirely  free  from  danger,  as  in  some 
cases  it  has  been  followed  by  convulsions  and  death  in  a  few  hours.  Con- 
siderable inflammatory  reaction  usually  occurs,  lasting  from  two  to  four 
days.  After  this  period  there  is,  in  a  favourable  case,  a  subsidence  of  the 
swelling,  with  a  gradual  contraction  and  finally  obliteration  of  the  tumour. 
In  some  cases  two  or  three  injections  may  be  required.  The  mortality  of 
cases  treated  by  this  method  is  from  forty  to  fifty  per  cent.*  My  own  ex- 
perience includes  four  cases,  with  two  recoveries. 

The  dangers  of  this  operation  and  the  uncertainty  as  to  its  results 
have  led  many  surgeons  to  discard  it  altogether  in  favour  of  excision, 
which  with  the  technique  of  modern  surgery  is  almost  devoid  of  risk. 
For  a  description  of  this  and  the  various  plastic  operations  that  have  been 
proposed  in  connection  with  comi^lete  or  partial  excision  of  the  sac,  the 
reader  is  referred  to  works  upon  operative  surgery.  In  operating,  it  should 
not  be  forgotten  that  in  the  great  proportion  of  the  cases  (ninety-five  per 
cent,  according  to  the  Clinical  Society's  Eeport,  which,  however,  refers 
only  to  fatal  cases)  some  part  of  the  cord  is  in  the  sac.  The  cord  is  often 
present  in  tumours  situated  below  the  third  lumbar  vertebra?,  owing  to  its 
attachment  to  the  sac. 

Although  recovery  may  follow  operation,  in  a  very  large  number  of 
cases  it  is  incomplete  ;  some  degree  of  paralysis,  with  atrophy,  contrac- 
tures, and  deformities,  remaining  because  of  the  implication  of  cord  ele- 
ments in  the  sac. 

SPINAL   MENINGITIS. 

In  acute  meningitis  usually  only  the  pia  mater  is  involved.  This  rarely 
occurs  alone,  unless  it  is  due  to  traumatism.  It  is  most  frequently  asso- 
ciated with  inflammation  of  the  pia  of  the  brain,  and  may  occur  either  with 

*  Report  of  the  London  Clinical  Society. 


706  DISEASES   OF   THE  NERVOUS  SYSTEM. 

the  simple  or  the  tuberculous  variety.  A  certain  amount  of  acute  in- 
flammation of  the  pia  mater  accompanies  most  of  the  cases  of  acute  my- 
elitis. 

Chronic  spinal  meningitis  in  children  usually  involves  the  dura  only. 
Inflammation  of  the  external  layer  (external  pachymeningitis)  is  usually 
secondary  to  caries  of  the  vertebra?.  This  is  considered  in  the  article 
on  Compression-Myelitis. 

Symptoms. — The  symptoms  of  inflammation  of  the  spinal  membranes, 
no  matter  with  what  pathological  condition  it  may  be  associated,  are  due 
to  irritation  of,  or  pressure  upon,  the  cord  or  nerve  roots.  Those  which 
are  most  common  are :  pain  in  the  back,  which  is  increased  by  move- 
ment, and  usually  by  pressure  upon  the  spinous  processes  ;  radiating  pains 
following  the  course  of  the  spinal  nerves,  felt  in  the  extremities  or  in 
the  trunk ;  rigidity  of  the  spinal  column  due  to  spasm  of  the  spinal  mus- 
cles, or  rigidity  of  the  muscles  of  the  extremities ;  and  hypera?sthesia 
along  the  spine,  which  may  be  quite  acute.  When  pressure  upon  the  cord 
is  added,  there  is  paralysis  or  paresis,  sometimes  muscular  atrophy  and 
anesthesia.  Any  of  the  above  symptoms  may  be  acute  or  chronic,  accord- 
ing to  the  nature  of  the  primary  disease. 

The  diagnosis  between  spinal  meningitis  and  myelitis  is  often  not  easy, 
for  except  in  acute  cases  the  two  processes  are  usually  associated ;  and  in  a 
given  case  it  may  be  difficult  to  decide  whether  the  lesion  of  the  cord  or 
of  the  membranes  is  the  more  important  one.  In  meningitis,  pain,  ten- 
derness, spasm,  and  irritative  symptoms  are  generally  more  prominent, 
while  loss  of  power  and  anaesthesia  are  usually  partial.  In  myelitis  the 
pain,  tenderness,  and  other  irritative  symptoms  are  less  marked,  while 
paralysis  and  anaesthesia  may  be  complete. 

Treatment. — This  is  first  of  the  disease  with  which  it  is  associated  ;  in 
addition,  counter-irritation  by  means  of  the  Paquelin  cautery,  rest  in  bed, 
and  in  severe  cases  even  immobilization  of  the  spine  by  a  mechanical  sup- 
port.    Iodide  of  potassium  is  often  useful. 

MYELITIS. 

Myelitis  is  a  rare  disease  in  children,  with  the  exception  of  two  varieties, 
which  are  discussed  under  separate  heads,  viz.,  compression-myelitis  and 
acute  poliomyelitis.  Otherwise  myelitis  usually  results  from  injury,  but 
it  may  occur  as  a  complication  of  any  of  the  acute  infectious  diseases,  es- 
pecially typhoid  or  scarlet  fever,  and  diphtheria,  and  even  as  a  primary 
disease,  where  it  is  attributed  to  exposure  or  cold,  but  where  it  is  probably 
infectious.     Chronic  myelitis  may  be  due  to  hereditary  syphilis. 

Myelitis  usually  occurs  in  children  over  ten  years  of  age.  In  situation, 
it  may  be  transverse,  diffuse,  or  disseminated  ;  the  process  may  be  acute, 
subacute,  or  chronic.  The  lesions  and  the  symptoms  are  essentially  the 
same  as  when  the  disease  occurs  in  the  adult. 


MYELITIS.  767 

Symptoms. — Myelitis  usually  comes  on  rather  gradually,  with  only 
local  symptoms;  but  the  onset  may  be  quite  acute,  with  severe  general 
symptoms, — fever,  pain,  prostration  and  localized  or  general  convulsions. 
The  local  symptoms  vary  with  the  seat  and  the  extent  of  the  disease. 

In  transverse  myelitis  loss  of  power  and  anesthesia  are  present  below 
the  level  of  the  lesion ;  either  of  these  may  be  partial  or  complete.  At  the 
level  of  the  lesion  there  is  a  zone  of  hyperaesthesia  and  "  girdle-pains." 
All  the  reflexes  below  the  seat  of  the  lesion  are  exaggerated.  Those  at 
the  level  of  the  lesion  are  lost.  There  may  be  loss  of  control  of  the 
sphincters,  bed-sores,  degenerative  changes  in  the  paralyzed  muscles,  con- 
tractures, and  vaso-motor  disturbances.  The  paralyzed  muscles  may  be 
rigid  or  flaccid  according  to  the  seat  and  extent  of  the  lesion. 

When  transverse  myelitis  is  situated  in  the  cervical  region  there  are 
paralysis  and  anaesthesia  of  the  arms,  legs,  and  trunk.  All  the  reflexes  are 
•exaggerated,  and  there  is  general  rigidity  of  the  paralyzed  muscles.  There 
are  incontinence  of  faeces  and  retention  of  urine,  followed  by  incontinence 
from  overflow.  The  pupils  are  frequently  contracted,  and  there  may  be 
optic  neuritis.  Atrophy,  when  present,  usually  affects  the  muscles  of  the 
arms,  and  indicates  that  the  cord  to  a  considerable  extent  is  involved. 
There  is  great  danger  to  life,  owing  to  paralysis  of  the  muscles  of  respiration. 

When  the  seat  of  disease  is  the  dorsal  region,  the  symptoms  are  similar 
to  those  above  described,  with  the  exception  that  the  arms  escape,  and 
that  the  eye-symptoms  are  usually  wanting.  This  is  the  most  favourable 
seat  for  the  disease. 

When  the  disease  is  situated  in  the  lumbar  region,  in  addition  to  para- 
plegia and  anaesthesia  of  the  legs,  there  is,  from  the  beginning,  inconti- 
nence of  urine  and  faeces.  The  knee  reflexes  are  lost ;  the  muscles  atrophy, 
and  usually  give  the  reaction  of  degeneration.     Bed-sores  are  frequent. 

In  diff'use  myelitis  the  symptoms  are  a  combination  of  the  above 
groups.  If  a  large  part  of  the  cord  is  involved,  there  are  general  paraly- 
sis and  anaesthesia,  loss  of  reflexes,  marked  trophic  disturbances,  bed- 
sores, etc. 

The  course  of  myelitis  is  slow,  and  it  usually  progresses  steadily  from 
bad  to  worse.  Death  is  due  to  exhaustion  or  complications — cystitis,  bed- 
sores, or  hypostatic  pneumonia — or  to  some  intercurrent  disease.  In  a 
small  proportion  of  the  cases  there  may  be  partial  recovery,  but  very 
rarely  is  this  complete.  The  diagnosis  is  to  be  made  from  spinal  menin- 
gitis, tumours,  and  haemorrhage. 

Treatment. — The  treatment  of  the  early  stage  consists  in  the  use  of  ice 
to  the  spine,  or  counter-irritation  by  means  of  dry  cups,  mustard,  or  the 
Paquelin  cautery.  Later,  the  iodide  of  potassium  should  be  given  in  all 
cases ;  improvement  may  follow  its  use,  even  when  there  is  no  suspicion 
of  syphilis,  but  large  doses  are  required,  and  for  a  long  period.  Electricity 
is  contra-indicated  except  in  chronic  cases,  and  then  but  little  improvement 
50" 


768  DISEASES   OF  THE  NERVOUS  SYSTEM. 

is  likely  to  result  from  its  use.  In  these  patients  the  most  important  thing 
is  careful  attention  to  cleanliness  and  to  posture,  in  order  to  prevent  bed- 
sores, cystitis,  and  pneumonia. 

COMPRESSION-MYELITIS. 

Synonyms :  Pressure- Paralysis  of  the  Spinal  Cord  ;  Pott's  Paraplegia. 

Compression-myelitis  is  usually  the  result  of  caries  of  the  spine.  It 
most  frequently  complicates  this  disease  when  the  cervical  or  upper  dorsal 
vertebrse  are  involved,  it  being  quite  rare  when  the  lower  half  of  the 
spinal  column  is  affected.  This  difference  is  probably  due  to  the  smaller 
size  of  the  spinal  canal  in  its  upper  portion.  According  to  Gibney,*  para- 
plegia is  seen  in  fifty  per  cent  of  the  cases  of  caries  of  the  upper  half  of 
the  spine.  Essentially  the  same  condition,  so  far  as  the  cord  is  concerned, 
may  result  from  tumours  of  the  spinal  cord,  or  from  anything  else  causing 
pachymeningitis.     These,  however,  are  exceedingly  rare  in  childhood. 

Lesions. — In  spinal  caries  there  occurs  as  a  result  of  tuberculous  dis- 
ease a  softening  of  the  bodies  of  the  vertebrae,  which  fall  together  from  the 
pressure  due  to  the  superincumbent  weight  of  the  body.  This  causes  a 
backward  projection  known  as  the  kyphosis,  or  angular  deformity.  The 
spinal  canal  is  encroached  upon  by  the  remains  of  the  vertebral  bodies 
whose  ligamentous  attachments  have  been  loosened,  and  also  by  inflam- 
matory products  the  result  of  periostitis,  and  localized  inflammation  of  the 
dura  mater,  chiefly  of  the  external  layer,  but  which  sometimes  affects  the 
internal  layer  also.  All  these  conditions  lead  to  the  production  of  a  mass 
of  inflammatory  material,  often  containing  tuberculous  deposits,  which  is 
chiefly  in  front  of  the  cord,  but  may  surround  it.  The  compression  takes 
place  slowly  in  most  of  the  cases,  from  the  gradual  progress  of  the  lesions 
mentioned.  In  a  small  number  of  cases  there  may  be  a  sudden  pressure 
from  the  slipping  backward  of  one  of  the  vertebral  bodies. 

In  recent  cases  the  cord  at  the  seat  of  compression  is  a  little  smaller 
than  normal.  It  is  usually  involved  to  the  extent  of  from  half  an  inch 
to  two  inches.  Paraplegia  may  have  existed  where  the  changes  found  in 
the  cord  are  very  slight,  and  sometimes  where  no  changes  are  visible  to 
the  naked  eye.  In  more  protracted  and  more  severe  cases,  the  cord  is 
much  smaller  at  the  point  of  disease,  and  under  the  microscope  shows  the 
changes  of  interstitial  myelitis  (Gowers)  with  meningitis.  In  old  cases 
there  are  degeneration  of  the  nerve  elements,  atrophy,  and  sometimes  dis- 
appearance of  the  ganglion  cells,  with  more  or  less  destruction  of  the  nerve 
fibres ;  sometimes  all  distinction  between  the  gray  and  white  substance  is 
lost.  In  addition  to  these  marked  changes  at  the  point  of  pressure,  there 
may  be  ascending  or  descending  degeneration,  as  from  other  focal  lesions. 

*  Journal  of  Mental  and  Nervous  Diseases,  April,  1878. 


COMPRESSION-MYELITIS.  769 

There  is  usually  inflammation  of  the  nerve  roots,  which  have  also  suffered 
compression.  It  is  in  many  cases  surprising  to  see  to  what  degree  the 
cord  may  be  compressed  and  still  preserve  its  functions. 

Symptoms. — In  caries  of  the  cervical  region  the  symptoms  of  com- 
pression-myelitis not  infrequently  precede  the  deformity,  and,  in  fact,  the 
other  objective  symptoms  of  bone  disease.  The  earliest  symptoms  of 
caries  usually  arise  from  irritation  of  the  nerve  roots,  and  consist  of 
acute  pains  not  often  referred  to  the  spine,  but  radiating  to  the  differ- 
ent regions  to  which  these  nerves  are  distributed.  They  are  felt  in  the 
neck,  in  the  chest,  in  the  epigastrium,  and  sometimes  in  the  loins.  Such 
symptoms  indicate  the  presence  of  pachymeningitis,  and  may  be  present 
whatever  the  location  of  the  vertebral  caries.  Accompanying  these  pains, 
there  is  noticed  a  gradual  weakness  in  the  lower  extremities,  and  some- 
times also  in  the  arms,  according'  to  the  location  of  the  disease.  This 
may  steadily  increase  for  several  weeks  until  there  is  complete  paralysis. 
Other  symptoms  are  then  commonly  present.  There  is  usually  some  degree 
of  anaesthesia,  but  in  many  cases  there  is  none,  and  there  may  be  numbness, 
tingling,  formication,  and  pain.  The  sphincters  are  not  often  involved. 
When  the  disease  is  in  the  upper  half  of  the  cord,  there  are  rigidity  of  the 
extremities  and  great  exaggeration  of  all  the  reflexes,  with  marked  ankle- 
clonus.  In  the  rare  cases  in  which  the  lumbar  enlargement  is  involved, 
there  may  be  loss  of  reflexes,  paralysis  of  the  sphincters  and  bed-sores. 

The  distribution  of  the  paralysis  will  depend  upon  the  point  of  com- 
pression. If  this  is  in  the  cervical  region,  all  four  extremities  will  be  para- 
lyzed ;  if  in  the  dorsal  region,  only  the  legs.  In  rare  cases  the  paralysis 
is  unilateral,  and  if  there  is  no  spinal  deformity  the  condition  may  be  a 
most  puzzling  one.  According  to  the  extent  of  the  secondary  lesions  in 
the  cord,  there  may  occur  muscular  atrophy  and  contractures.  With  dis- 
ease in  the  upper  cervical  region,  death  may  result  from  sudden  pressure 
upon  the  cord,  owing  to  a  dislocation  of  the  odontoid  process,  which  hap- 
pened in  one  of  Gibney's  cases ;  or  there  may  be  vomiting,  pupillary 
symptoms,  irritation  of  the  phrenic  nerve  causing  hiccough,  or  pressure 
causing  paraly.sis  of  the  diaphragm. 

Course  and  Prognosis.— These  depend  much  upon  the  treatment  of  the 
case.  In  many  cases  of  paralysis  occurring  early  in  caries,  complete  re- 
covery takes  place  in  the  course  of  a  few  weeks,  sometimes  in  a  few  days, 
after  the  application  of  a  proper  mechanical  support.  This  may  be  true 
even  where  the  paralysis  has  continued  for  three  or  four  months.  In  the 
cases  which  have  been  long  neglected,  or  those  in  which  the  paralysis  de- 
velops while  proper  mechanical  treatment  is  being  carried  out,  the  chances 
of  improvement,  or  at  least  of  rapid  improvement,  are  not  nearly  so  good. 
Gibney  gives  the  following  statistics  of  fifty-eight  cases  under  his  personal 
observation  :  thirteen  proved  fatal,  six  dying  from  myelitis,  five  from 
other  diseases  subsequent  to  recovery  from  the  paralysis,  and  two  from 


Y70  DISEASES  OP   THE   NERVOUS  SYSTEM. 

tuberculosis  before  complete  recovery  ;  twenty-nine  recovered  from  the 
paraplegia,  but  relapses  occurred  in  eight,  all  but  one  of  these,  however, 
recovering  subsequently ;  fifteen  cases  were  under  observation  at  the 
time  of  the  report.  The  usual  duration  of  the  disease  is  from  twelve  to 
eighteen  months.  Complete  recovery  has  often  taken  place  in  cases  that 
have  persisted  for  four  or  five  years.  No  case  should  be  considered  hopeless 
no  matter  how  long  the  symptoms  have  lasted,  unless  there  is  marked 
atrophy  with  loss  of  electrical  reactions,  and  contractures  have  taken  place. 

Diagnosis. — This  is  rarely  difficult.  Spinal  caries  should  be  suspected 
in  every  case  where  the  symptoms  point  to  transverse  myelitis  coming 
on  without  definite  cause.  The  gradual  onset,  the  radiating  pains,  the 
stiffness  of  the  spine  in  walking,  the  gradual  loss  of  power,  the  increased 
reflexes  and  ankle-clonus, — all  are  usually  present  and  characteristic. 
They  are  sufficient  to  warrant  the  diagnosis  of  spinal  caries,  even  when 
no  deformity  exists.  When  there  is  deformity,  the  symptoms  are  un- 
mistakable. 

Treatment. — The  most  important  indications  are  the  removal  of  pressure 
and  the  fixation  of  the  spine  by  means  of  a  proper  mechanical  support.  If 
for  any  reason  this  is  impossible,  the  patient  should  be  kept  in  bed.  The 
two  other  measures  which  promise  most  are  the  use  of  the  Paquelin  cau- 
tery, and  the  internal  administration  of  potassium  iodide.  From  his  very 
extensive  experience,  Gibney  has  more  confidence  in  this  drug  than  in  all 
else  except  mechanical  treatment.  Large  doses  are  required,  often  from 
sixty  to  ninety  grains  being  given  daily  for  months.  Erom  personal  ob- 
servation of  many  of  Gibney's  cases  I  can  bear  testimony  both  to  the  bene- 
ficial effect  of  the  iodide,  and  to  the  ease  with  which  it  is  generally  borne 
by  children  in  the  doses  indicated.  Very  often  patients  gained  steadily 
in  weight  while  taking  the  drug,  and  acne  was  the  exception.  The 
iodide  should  always  be  largely  diluted.  In  all  cases  patients  should  be 
carefully  watched,  kept  scrupulously  clean,  and  the  position  changed  fre- 
quently to  prevent  the  formation  of  bed-sores.  Electricity  is  contra- 
indicated.  When  the  paralysis  develops  rapidly  or  occurs  suddenly,  relief 
may  sometimes  be  obtained  by  the  operation  of  laminectomy ;  but  little 
is  to  be  expected  from  this  in  the  slow  cases. 

INFANTILE   SPINAL    PARALYSIS. 

Synonyms:  Acute  Poliomyelitis;  Acute  Atrophic  Paralysis. 

This  disease  is  characterized  by  an  acute  onset,  generally  with  febrile 
symptoms,  by  an  early  and  usually  extensive  loss  of  power,  and  by  a  con- 
siderable degree  of  spontaneous  improvement  except  in  certain  groups  of 
muscles  which  remain  permanently  paralyzed,  and  undergo  a  very  rapid 
and  marked  atrophy.  A  chronic  form  of  tlie  disease  is  described  in 
adults,  but  this  is  rarely,  if  ever,  seen  in  children. 


INFANTILE  SPINAL  PARALYSIS.  Y71 

Acute  poliomyelitis  is  the  most  frequent  cause  of  paralysis  in  early  life 
and  it  is  often  designated  simply  as  infantile  paralysis. 

Etiology. — In  566*  cases  the  age  at  which  the  paralysis  developed  was 
as  follows : 

During  the  first  year 20  per  cent. 

"         "    second  year 38       " 

"  "    third  year 23        " 

"         '•    fourth,  and  fifth  years.  .  .    15        " 

After       "    fifth  year 5        '* 

From  this  table  it  will  be  seen  that  the  great  proportion  of  cases  develop 
before  the  fifth  year,  and  that  eighty  per  cent  of  them  begin  during  the 
first  three  years,  the  most  frequent  period  being  the  second  year. 

Boys  are  rather  more  frequently  affected  than  girls.  In  the  series  re- 
ferred to,  fifty-five  per  cent  were  males  and  forty-five  per  cent  were 
females.  Hereditary  influences  seem  to  have  but  little  effect  in  the  pro- 
duction of  this  disease.  It  is  rare  to  find  several  cases  in  the  same  family, 
or  to  trace  any  relation  to  nervous  antecedents.  The  onset  of  the  great 
proportion  of  the  cases  is  in  summer.  Of  Sinkler's  cases,  eighty  per  cent 
began  during  the  five  warm  months.  This  fact  is  decidedly  against  the 
theory  so  often  advanced,  that  the  disease  results  from  exposure  to  cold. 
There  are,  however,  a  few  cases  in  which  the  connection  between  exposure 
and  the  disease  seems  to  be  a  close  one.  On  account  of  the  time  of  on- 
set— most  frequently  in  the  second  year — the  disease  is  often  ascribed 
to  dentition.  In  my  series  this  was  given  as  the  cause  in  one  fifth  of 
the  cases.  The  connection  is  at  most  merely  a  coincidence.  Traumatism 
is  sometimes  given  as  a  cause,  but  the  proportion  of  cases  in  which  the 
paralysis  can  be  fairly  attributed  to  injury  is  very  small,  yet  there  are  a 
few  in  which  a  definite  injury  of  considerable  severity  has  immediately  pre- 
ceded the  onset.  In  about  twelve  per  cent  of  the  cases  above  mentioned 
the  paralysis  came  on  as  a  sequel  to  some  other  acute  disease ;  this  list  in- 
cludes nearly  all  the  diseases  of  infancy,  those  most  frequently  noted  being 
diarrhoea,  scarlet  fever,  and  measles ;  but  in  the  great  proportion  of  the 
cases  the  patient  was  in  good  health  at  the  time  of  the  attack. 

The  essential  cause  of  the  disease  is  as  yet  unknown.  On  account  of 
the  close  relation  of  the  lesion  to  the  distribution  of  the  blood-vessels, 
there  has  been  of  late  a  disposition  on  the  part  of  many  observers  to 
regard  it  as  infectious,  the  cord  changes  being  the  result  of  infectious  em- 
bolism or  thrombosis. 

Lesions. — Infantile  spinal  paralysis  is  due  to  an  acute  inflammation 
of  the  gray  matter  of  the  anterior  portion  of  the  spinal  cord.     The  late 


*  These  statistics  and  those  which  follow  in  this  article  are  derived  from  the  follow- 
ing sources:  Sinkler,  in  Kcating's  Cyclopaedia,  vol.iv,  355  cases;  Galbraith,  American 
Journal  of  Obstetrics,  1894,  75  cases;  the  remaining  14fi  are  personal  cases  and  others 
taken  from  the  records  of  the  Hospital  for  Ruptured  and  Crippled,  New  York, 


1^72  DISEASES  OP   THE  NERVOUS  SYSTEM. 

changes  which  occur  in  the  cord  as  a  result  of  this  process  have  for 
many  years  been  well  established  ;  but  the  early  changes  are  even  yet  a 
matter  of  dispute,  owing  to  the  lack  of  opportunities  of  examining  the 
cord  during  the  stage  of  acute  inflammation. 

In  autopsies  made  upon  cases  of  long  standing,  the  part  of  the  cord 
affected  is  distinctly  smaller  than  normal.  One  lateral  half  is  usually 
involved.  The  microscope  shows  that  the  ganglion  cells  are  few  in 
number  or  that  they  have  entirely  disappeared.  Those  that  remain  are 
shrunken  and  deformed  and  scarcely  recognisable  as  ganglion  cells.  The 
entire  gray  horn  is  much  smaller  than  that  of  the  opposite  side,  and  many 
of  its  normal  elements  have  disappeared.  The  white  matter  also  is 
smaller  than  in  the  sound  half  of  the  cord.  The  anterior  nerve-roots 
of  the  affected  side  are  smaller  than  normal,  and  are  degenerated  quite 
to  the  muscles.  The  general  changes  in  the  cord  are  of  a  sclerotic  char- 
acter. The  affected  muscles  are  degenerated,  and  there- may  be  in  ex- 
treme cases  a  complete  disappearance  of  muscle  fibres,  their  place  being 
taktm  by  adipose  and  fibrous  tissue.  In  places  where  the  lesion  is  less 
severe  the  fibres  are  small.  The  affected  limb  is  shorter  and  the  bones 
smaller  than  upon  the  sound  side.  These  lesions  are  all  secondary  to 
those  of  the  anterior  ganglion-cells. 

The  most  recent  observations  upon  the  early  stage  of  the  process  by 
Siemerling,  Goldscheider,  and  others,  tend  to  show  that  primarily  the 
lesion  is  an  interstitial  inflammation,  and  not  a  parenchymatous  one,  as 
was  formerly  believed.  Goldscheider's  *  theory  of  the  disease  is  that  the 
first  changes  are  in  the  blood-vessels,  from  which  the  process  extends  to 
the  neuroglia  and  produces  a  proliferation  of  cells  ;  the  changes  in  the 
ganglion  cells  are  degenerative  in  character,  and  are  secondary  to  those 
just  described ;  the  same  is  true  of  the  changes  in  the  nerve  fibres. 
Accompanying  the  process  in  some  cases  small  haemorrhages  have  been 
observed. 

The  region  of  the  cord  most  frequently  involved  is  the  lumbar  en- 
largement, but  there  may  be  more  than  one  focus  of  disease.  Usually 
only  one  lateral  Ijalf  of  the  cord  is  affected,  but  it  is  not  rare  for  both 
sides  to  be  involved.  In  such  cases  the  lesions  are  generally  more  ad- 
vanced upon  one  side  than  the  other. 

Symptoms. — A  frequent  form  of  onset  is  for  a  child  to  be  taken  quite 
suddenly  ill  with  vomiting,  pains  in  the  legs,  or  general  hyperaesthesia,  and 
a  temperature  of  from  101°  to  103°  F.  After  these  symptoms  have  lasted 
a  variable  time,  usually  from  one  to  four  days,  the  paralysis  is  discov- 
ered. In  a  smaller  number  of  cases — about  ten  per  cent  of  the  entire 
number — the    attack  is  ushered  in  by  more  severe  constitutional  symp- 

*  Goldscheider,  Zeitsehrift  fiir  klin.  Med.,  1893,  p.  494.  See  also  Sachs,  Nervous 
Diseases  of  Children,  1895,  p.  310. 


INFANTILE  SPINAL   PARALYSIS.  7Y3 

toms.  There  are  convulsions,  delirium,  a  temperature  of  103°  or  104°  F., 
marked  general  prostration,  constipation,  severe  pains  in  the  back  and 
extremities, — in  short,  all  the  symptoms  of  a  severe  acute  inflammation. 
These  symptoms  last  from  two  days  to  a  week,  often  engrossing  the 
attention  of  the  physician,  so  that  the  paralysis  may  not  be  noticed  until 
the  patient  has  been  sick  for  some  time,  or  possibly  not  until  the  be- 
ginning of  convalescence.  In  quite  a  large  number  of  cases  the  general 
symptoms  are  very  slight,  and  they  may  be  absent  altogether.  A  not 
infrequent  history  is  that  the  child  went  to  bed  apparently  well ;  during 
the  night  was  noticed  only  to  be  a  little  restless,  and  that  the  next  morn- 
ing the  paralysis  was  discovered.  In  two  cases  of  my  series  the  paralysis 
came  on  quite  suddenly  while  the  child  was  walking  in  the  street,  and 
was  able  to  reach  home  only  with  considerable  difficulty.  In  such  cases 
it  is  not  improbable  that  previous  symptoms  were  present,  but  were  so 
slight  as  to  have  escaped  notice. 

In  most  of  the  cases  there  are  pains  in  the  back,  in  the  muscles  of  the 
extremities,  or  along  the  course  of  the  spinal  nerves.  With  these  pains 
general  hyperaesthesia  is  commonly  associated,  and  there  may  be  other 
disturbances  of  sensation  such  as  numbness  and  tingling.  The  develop- 
ment of  the  paralysis  is  quite  rapid,  it  often  attaining  its  maximum  in 
twenty-four  hours ;  although  sometimes  it  will  be  two  or  three  days,  or 
even  a  week,  before  its  full  extent  is  seen. 

Extent  and  distribution  of  the  primary  jiciralysis. — In  560  cases  in 
which  this  point  was  noted  the  distribution  was  as  follows : 

One  lower  extremity 229  cases. 

Both  lower  extremities 176     " 

General  paralysis  of  all  extremities,  and  more  or  less  of  trunk       79     " 

One  lower  and  one  upper  extremity 36     " 

Both  lower  extremities  and  one  upper  extremity 16     " 

One  upper  extremity  alone 14 

Both  upper  extremities 2     " 

All  other  varieties 8     " 

In  paralysis  of  the  trunk,  the  diaphragm  and  other  respiratory  muscles 
are  very  rarely  affected.  In  combinations  of  an  upper  and  a  lower  ex- 
tremity, the  limbs  are  more  frequently  affected  upon  opposite  sides  than 
upon  the  same  side.     The  sphincters  almost  invariably  escape. 

Course  of  tlie  disease. — The  rapid  development  of  the  paralysis  is  fol- 
lowed by  a  period  of  from  one  to  four  weeks'  duration  in  which  but  little 
change  is  seen  in  the  affected  muscles.  This  is  followed  by  spontaneous 
improvement,  which,  according  to  Gowers,  begins  in  the  muscles  last 
affected,  and  generally  reaches  its  limit  in  about  three  months.  After 
this  time  but  little  spontaneous  improvement  is  to  be  looked  for,  and  the 
residual  paralysis  is  likely  to  be  permanent.  By  the  end  of  two  months 
marked  atrophy  is  present  in  the  paralyzed  muscles.  The  affected  limb 
is  distinctly  smaller    than  its  fellow,  this  being  quite  apparent  even  in 


T74 


DISEASES  OP   THE  NERVOUS  SYSTEM. 


infants.  Except  at  the  onset,  sensory  disturbances  are  absent ;  the  knee- 
jerk  is  lost  in  paraplegic  cases,  and  in  those  in  which  the  extensors  of 
the  thigh  are  paralyzed.  There  is  arrested  growth  in  the  whole  limb 
(Fig.  135).  It  becomes  much  smaller  and  shorter  than  its  fellow.  The 
great  relaxation  of  the  ligaments  at  the  joints  may  allow  subluxation, 
especially  at  the  knee  and  at  the  shoulder.  The  circulation  in  the  af- 
fected limb  is  poor ;  it  is  often  blue  and  cold,  but  bed-sores  are  never 
seen. 

Electrical  reactions. — Very  early  in  the  disease  the  atrophied   muscles: 

begin  to  lose  their  power 
to  respond  to  faradism. 
In  the  muscular  groups 
which  are  to  be  perma- 
nently paralyzed,  the  fara- 
dic  resi^onse  may  be  lost 
in  a  week.  The  muscles 
in  which  recovery  is  to 
take  place  often  preserve 
a  certain  degree  of  con- 
tractility, although  this  is- 
less  than  normal,  and  im- 
proves later.  The  response 
to  the  galvanic  current- 
may  be  increased  for  a  few 
months,  and  then  slowly 
fail  as  the  muscular  fibres 
themselves  degenerate,  and 
at  the  end  of  two  or  three 
years  it  may  disappear  al- 
together. The  reaction 
of  degeneration  is  present 
with  great  uniformity  in 
the  atrophied  muscles,  but- 
in  them  alone. 
Residual  paralysis  and  deformity. — Only  one  lower  extremity  is  in- 
volved in  half  the  cases,  and  the  paralysis  is  usually  incomplete  and  con- 
fined to  certain  groups  of  muscles.  The  extensors  both  of  the  thigh  and 
of  the  leg  are  nearly  always  involved  to  a  greater  degree  than  the  flexors, 
and  in  very  many  cases  only  the  extensor  groups  are  paralyzed.  The 
muscles  most  frequently  affected  are  the  anterior  tibial  group,  and  next 
the  peroneal  group.  The  most  frequent  deformity  resulting  from  this 
paralysis  is  talipes  valgus,  and  next  to  this  talipes  varus,  botli  of  these 
being  usually  associated  with  a  certain  amount  of  equinus.  In  very  rare 
cases  there  is  talipes  calcaneus.     Most  children  with  paralysis  of  only  one 


Fig.  \-:,:>. — An  old  case  of  infantile  spinal  paralysis  of  the 
entire  left  lower  extremity,  showing  extreme  atrophy 
of  the  thiyh  and  leg,  and  a  very  characteristic  deform- 
ity of  the  foot. 


INFANTILE   SPINAL   PARALYSIS. 


775 


lower  extremity  are  able  to  walk  alone,  or  with  the  assistance  of  a  steel 
brace. 

Paralysis  of  both  lower  extremities  is  the  next  in  frequency.  This 
also  is  rarely  complete.  In  forty-three  cases  of  my  series  there  was 
originally  complete  paraplegia,  but  it  was  permanent  in  only  three.  The 
extent  of  recovery  varies  much  in  different  cases.      Usually  one  leg  re- 


Fio.  136.— An  old  case  of  infantile  spinal  paralysis  of  the  left  arm  and  shoulder  muscles,  with 
resultincr  lateral  curvature.  The  spinal  deformity  is  increased  by  the  fact  that  the  patient 
had  also  suffered  from  empyema  of  the  left  side. 


covers  to  a  much  greater  degree  than  the  other.  Most  of  these  patients 
are  able  to  walk  with  the  assistance  of  braces,  a  few  only  by  the  aid  of 
crutches.  Some  walk  while  they  are  young,  but  are  unable  to  do  so 
when  fully  grown,  because  the  disproportion  between  the  size  of  the  body 
and  the  limbs  is  then  much  greater. 


^^Q  DISEASES  OF  THE   NERVOUS  SYSTEM. 

Paralysis  of  one  upper  extremity  rarely  occurs  alone,  but  is  associated 
with  paralysis  of  one  or  both  lower  extremities.  Complete  paralysis  of 
an  arm  is  rarely,  if  ever,  seen.  The  muscular  groups  affected  may  be  the 
small  muscles  of  the  hand,  the  muscles  of  the  forearm, — especially  the 
extensors, — or  the  shoulder  group.  Of  single  muscles,  the  one  most 
frequently  involved  is  the  deltoid ;  this  may  result  in  subluxation  of  the 
shoulder.  From  paralysis  of  the  muscles  of  the  trunk  or  shoulder  of  one 
side,  lateral  curvature  may  develop  (Fig.  136).  If  the  serratus  magnus  is 
affected  the  scapula  stands  out  prominently,  giving  rise  to  the  so-called 
"  angel-wing  "  deformity. 

Diagnosis. — The  general  symptoms  of  the  onset  have  nothing  charac- 
teristic about  them,  and  no  diagnosis  can  be  made  until  the  paralysis  has 
taken  place.  The  acute  onset,  the  rapid  wasting,  the  spontaneous  im- 
provement in  certain  groups  of  muscles,  the  absence  of  sensory  symptoms, 
and  finally  the  reaction  of  degeneration, — all  constitute  a  type  which  it  is 
difficult  to  confound  with  any  other  disease. 

At  the  onset  this  paralysis  may  resemble  that  resulting  from  acute 
transverse  myelitis.  In  the  latter,  however,  we  get  ansesthesia,  exagger- 
ated knee-jerk,  ankle-clonus,  generally  involvement  of  the  sphincters, 
a  tendency  to  bed-sores,  slight  wasting,  and  no  reaction  of  degeneration. 
It  is,  besides,  extremely  rare. 

Multiple  neuritis  is  in  most  cases  easily  distinguished  from  poliomye- 
litis by  its  gradual  onset,  by  the  presence  of  pain  and  other  sensory  symp- 
toms as  well  as  loss  of  power,  and  by  the  fact  that  spontaneous  recovery 
generally  occurs  within  two  or  three  months.  Besides,  there  is  usually  a 
history  of  antecedent  diphtheria.  But  multiple  neuritis  sometimes  begins 
suddenly  with  febrile  symptoms,  and  paralysis  may  occur  early,  precisely 
as  it  does  in  poliomyelitis.  Furthermore,  in  some  cases  of  neuritis,  the 
sensory  symptoms  are  not  marked,  and  they  may  have  entirely  disappeared 
before  the  patient  is  seen.  In  such  cases  the  diagnosis  from  poliomyelitis 
may  be  difficult  or  even  impossible  except  by  the  course  of  the  disease ; 
for  atrophy  is  common  to  both  conditions,  and  even  the  electrical  reac- 
tions may  be  identical.  There  is  no  doubt  that  some  cases  formerly  re- 
ported as  examples  of  poliomyelitis  terminating  in  complete  recovery  were 
really  cases  of  multiple  neuritis. 

The  diagnosis  from  acute  cerebral  palsy  is  chiefly  difficult  when  the 
spinal  paralysis  has  been  hemiplegic  or  diplegic  in  type,  or  when  after 
cerebral  hemiplegia  the  leg  or  the  arm  has  recovered  so  completely 
that  the  case  resembles  monoplegia.  In  cerebral  palsies  there  is  usually 
rigidity  ;  there  is  no  reaction  of  degeneration  ;  other  cerebral  symptoms 
are  commonly  present,  or  there  is  a  history  of  an  onset  with  cerebral 
symptoms;  and  the  atrophy  is  less  marked.  The  most  diagnostic  point 
is  the  electrical  reactions. 

Infantile  spinal  paralysis  may  be  mistaken  for  other  than  nervous  dis- 


INFANTILE  SPINAL   PARALYSIS.  777 

eases.  In  the  early  stage  it  may  be  confounded  with  the  pseudo-paralysis 
of  scurvy.  I  have  several  times  seen  the  mistake  made  of  diagnosticating 
paralysis  where  scurvy  was  present.  In  scurvy,  however,  there  are  seen 
excessive  tenderness  and  hyperaesthesia,  pain  upon  motion,  especially  about 
the  knees,  spongy  gums,  and  sometimes  ecchymoses  about  the  joints.  The 
muscular  weakness  of  rickets  is  sometimes  mistaken  for  infantile  paralysis. 
However,  in  rickets  the  symptoms  are  always  bilateral,  the  electrical  reac- 
tions are  normal,  and  other  signs  of  rickets  are  present.  In  all  doubtful 
cases  the  chief  reliance  for  the  diagnosis  of  paralysis  should  be  placed 
upon  the  character  of  the  electrical  reactions.  The  lameness  resulting 
from  paralysis  may  resemble  somewhat  that  due  to  hip-disease;  but  with 
a  careful  examination  there  can  rarely  be  any  diflficulty  in  making  the 
differential  diagnosis. 

Prognosis. — Infantile  spinal  paralysis  is  accompanied  by  little,  if  any, 
danger  to  life.  It-is  possible  that  death  may  take  place  during  the  stage 
of  acute  inflammation,  but  this  is  certainly  extremely  rare.  The  most 
important  question  in  early  prognosis  is  whether  there  will  be  any  per- 
manent paralysis,  and,  if  so,  what  will  be  its  extent.  The  important 
symptoms  for  prognosis  are  the  amount  of  wasting  and  the  condition  of 
the  electrical  reactions.  Muscles  which  in  ten  days  have  lost  completely 
their  faradic  contractility  are  almost  certain  to  waste  rapidly  and  severely. 
The  best  indication  of  coming  improvement  is  the  return  of  faradic  con- 
tractility. If  this  is  completely  lost  for  six  months,  recovery  is  doubtful ; 
if  for  one  year,  improvement  in  these  muscles  is  not  to  be  expected.  If 
faradic  contractility  has  never  been  lost,  very  great  and  early  improvement 
in  the  paralyzed  muscles  may  be  confidently  predicted.  After  three 
months  but  little  spontaneous  improvement  is  to  be  looked  for,  and  after 
two  years  none  at  all.  Complete  recovery  is  possible  only  with  a  lesion 
of  very  limited  extent ;  and  while  it  may  occur,  it  is  so  infrequent  that  it 
is  never  to  be  expected. 

Treatment. — Unfortunately,  most  of  the  cases  do  not  come  under  ob- 
servation during  the  acute  stage,  or  the  nature  of  the  disease  is  overlooked 
until  the  paralysis  has  occurred.  In  the  early  stage  the  indications  are,  to 
induce  free  perspiration  by  hot  baths,  to  keep  the  patient  in  a  prone  or 
lateral  position,  and  to  use  counter-irritation  to  the  spine  by  means  of 
dry  cups,  mustard,  or  the  Paquelin  cautery,  or  an  ice-bag  may  be  placed 
along  the  spine.  The  natural  course  of  the  disease  is  to  be  kept  in  mind, 
for  the  tendency  is  to  overestimate  the  effect  upon  the  paralysis  of  the 
drugs  used  in  the  early  stage.  On  theoretical  grounds,  ergot  is  indicated, 
but  it  is  doubtful  whether  any  drugs  have  much  efi'ect. 

After  all  acute  symptoms  have  subsided,  or  at  the  end  of  two  or  three 
weeks,  electricity  may  be  used,  but  its  curative  effects  have  been  very 
greatly  overestimated.  The  object  in  using  electricity  is  to  keep  up  the 
nutrition  of  the  muscles  until  the  cord  has  recovered,  which  it  is  almost 


Y78  DISEASES  OF  THE  NERVOUS  SYSTEM. 

certain  to  do  to  a  considerable  degree.  But  no  amount  of  electrization 
can  preserve  muscles  whose  ganglion  cells  have  completely  disappeared. 
These  continue  to  waste  and  lose  their  faradic  contractility,  no  matter 
how  early  electricity  is  begun  nor  how  faithfully  it  is  continued.  Faradism 
may  be  used  for  such  groups  as  respond  to  it ;  otherwise  galvanism  should 
be  employed.  The  beneficial  results  from  electricity  are  to  be  obtained 
in  the  first  year,  chiefly  in  the  first  six  months.  Too  much  can  not  be 
said  against  the  routine  use  of  electricity  in  cases  which  have  been  para- 
lyzed three  or  four  years,  with  the  vain  hope  that  some  good  may  be  done, 
even  though  there  is  no  response  to  either  current.  Strychnine  may  be 
used  in  conjunction  with  electricity  after  all  symptoms  of  central  irrita- 
tion have  subsided,  but  there  is  still  great  diversity  of  opinion  regarding 
its  effect. 

Friction  and  massage  are  of  undoubted  value  in  improving  the  circula- 
tion and  the  nutrition  of  a  limb,  and  should  be  continued  regularly  twice 
a  day  for  a  long  period. 

Mechanical  Treatment.— T\\q  first  use  of  mechanical  appliances  is  the 
prevention  of  deformity.  All  cases  of  paralysis  should  be  carefully 
watched,  and  braces  applied  as  soon  as  any  tendency  to  deformity  from 
muscular  contraction  shows  itself.  This  is  much  easier  than  to  overcome 
deformities  which  have  been  allowed  to  develop,  and  quite  as  important 
for  the  patient.  The  second  use  of  apparatus  is  to  furnish  support  to  the 
limb  in  order  to  enable  the  child  to  walk.  By  such  means  many  get 
about  with  tolerable  comfort,  for  whom  locomotion  without  apparatus 
is  impossible  except  with  crutches.  The  third  purpose  of  apparatus  is,  to 
overcome  existing  deformities  in  neglected  cases.*  Braces  are  generally 
used  in  conjunction  with  myotomy  or  tenotomy  of  the  various  shortened 
tendons,  excision  of  portions  of  elongated  tendons,  and  the  production 
of  artificial  anchylosis  in  cases  of  "  flail  joints."  By  these  means  the 
orthopaedic  surgeon  is  able  to  give  a  great  deal  of  relief  to  these  unfortu- 
nate and  sometimes  helpless  patients. 

On  the  whole,  the  treatment  is  extremely  unsatisfactory,  and  the  result 
depends  upon  the  severity  and  extent  of  the  original  disease,  rather  than 
upon  the  particular  line  of  treatment  adopted  or  the  time  at  which  it  is 
begun. 

TUMOURS   OF   THE   SPINAL   CORD. 

Tumours  of  the  cord  are  exceedingly  rare  in  childhood,  and  almost 
unknown  in  infancy.  The  most  common  varieties  seen  in  early  life  are 
glioma,  sarcoma,  and  tuberculous  tumours.  Eisenschitz  has  reported  a 
case  of  tuberculous  tumour  in  the  dorsal  region  occurring  in  a  child  of 

*  See  Gibney,  New  York  Medical  Journal,  April  3,  1886,  Oa  the  Limitation  of 
Therapeutics  in  Infantile  Paralysis, 


SYRINGO-MYELIA.  779 

three  and  a  half  years.  There  was  a  similar  growth  in  the  cerebellum. 
The  symptoms  were  essentially  those  of  compression-myelitis. 

In  my  service  at  the  Babies'  Hospital  I  recently  had  a  case  of  glioma 
of  the  cord  in  a  child  only  one  year  old,  which  was  in  many  respects 
unique.  The  early  symptoms  were  gradual  paralysis  of  the  upper  extrem- 
ities, to  which  were  added  later,  stiffness  of  the  neck,  and  finally  immo- 
bility of  the  head, — the  position  being  that  of  typical  cervical  caries. 
During  the  sixteen  days  of  observation  there  was  high  fever,  from  101°  to 
104°  F.  There  were  no  pupillary  or  vaso-motor  symptoms.  At  the  au- 
topsy the  cord  was  found  to  be  the  seat  of  a  diffuse  gliosis.  In  the  cer- 
vical region  there  was  marked  enlargement,  the  cord  being  fully  four  times 
its  natural  size.  A  microscopical  examination  by  Dr.  C.  A.  Herter  showed 
that  the  growth  apparently  began  in  the  vicinity  of  the  ^litral  canal, 
and  that  the  gliomatous  process  involved  the  entire  length  of  the  cord.* 

A  somewhat  similar  case  has  been  reported  by  Miura  in  a  boy  of 
eight  years. 

The  diagnosis  of  tumours  of  the  spinal  cord  in  infancy  is  practically 
impossible.  In  later  childhood  they  are  most  apt  to  be  mistaken  for 
Pott's  disease,  but  the  symptoms  are  the  same  as  those  seen  in  tumours  of 
adult  life. 

SYRINGO-MYELIA. 

Syringo-myelia,  although  a  rare  disease,  is  sometimes  seen  in  early  life. 
The  term  is  applied  to  a  condition  in  which  there  is  a  cavity  in  the  cord 
the  result  of  a  jDathological  process,  in  contradistinction  to  the  cases  in 
which  a  cavity  is  the  result  of  a  malformation,  or  hydromyelus,  although 
it  is  not  infrequent  for  the  two  conditions  to  be  associated.  The  patho- 
logical process  which  precedes  the  cavity  formation  is  now  thought 
to  be,  in  most  cases  at  least,  an  infiltration  of  the  substance  of  the 
cord  with  gliomatous  cells.  The  process  is  somewhat  similar  to  that  just 
described  in  the  case  of  tumour  of  the  spinal  cord,  with  the  exception 
that  where  it  results  in  cavity  formation  it  is  slower.  The  infiltration  in 
these  cases  usually  begins  near  the  central  canal.  It  is  followed  by  a  de- 
generation and  breaking  down  of  the  infiltrated  areas,  beginning  at  the 
centre.  As  the  cavity  forms  it  extends,  and  usually  first  invades  the  gray 
matter  of  the  commissure,  later  the  posterior  gray  horns,  the  posterior 
columns,  or  the  anterior  horns.  The  resulting  cavity  is  usually  irregu- 
lar in  shape,  and  may  be  very  small,  or  may  extend  through  a  large  part 
of  the  length  of  the  cord.  It  is  most  frequently  situated  in  the  lower 
cervical  and  upper  dorsal  regions.  It  is  filled  with  fluid,  and  surrounded 
by  gliomatous  tissue. 

*  For  a  full  report  of  this  case  by  Dr.  Herter  and  myself,  see  American  Journal  of 
the  Medical  Sciences,  April,  1895.  See  also  Kohts,  Beitrag  zur  Diagnostik  der  Riick- 
enmarkstumoren  im  Kindesalter,  Dresden,  1886. 


780  DISEASES  OF  THE  NERVOUS  SYSTEM. 

According  to  Starr,  the  essential  symptoms  are  of  three  kinds:  (1) 
There  is  progressive  muscular  atrophy,  with  paralysis  of  some  or  all  the 
muscles  of  one  limb,  usually  extending  to  the  opposite  limb  and  to  the 
trunk,  sometimes  accompanied  by  the  reaction  of  degeneration  ;  (2)  vaso- 
motor and  trophic  disturbances  in  the  affected  limb,  such  as  cyanosis, 
coldness,  bullous  eruptions,  ulceration,  abscesses,  atrophy,  and  sometimes 
fragility  of  the  bones  and  diminution  of  perspiration  ;  (3)  sensory  dis- 
turbances, which  are  probably  the  most  characteristic  symptoms  of  the 
disease, — there  is  loss  of  the  sense  of  pain  and  of  temperature  in  the  atro- 
phied part,  while  the  sense  of  touch  and  of  location  may  be  preserved. 
The  extent  and  distribution  of  these  symptoms  will  of  course  depend 
upon  the  position  of  the  disease. 

The  course  of  syringo-myelia  is  essentially  chronic,  the  duration  being 
usually  several  years ;  and  although  spontaneous  arrest  sometimes  occurs 
the  disease  is  in  most  cases  steadily  progressive. 

The  cause  is  unknown,  and  it  is  not  influenced  by  any  form  of 
treatment. 

FRIEDREICH'S   ATAXIA. 

This  is  a  chronic  disease  of  the  spinal  cord  and  medulla,  which  begins 
most  frequently  in  childhood  or  about  puberty.  The  lesion  affects  first 
the  posterior  columns,  afterward  the  crossed  pyramidal  tracts,  the  direct 
cerebellar  tracts  in  the  lateral  columns,  and  Clarke's  vesicular  columns 
in  the  gray  matter  of  the  cord.  There  is  probably  some  disease  of  the 
medulla,  the  pons,  and  possibly  of  the  cerebellum  and  the  posterior 
nerve-roots.  In  advanced  cases  other  parts  of  the  cord  may  be  involved. 
The  disease  is  seen  in  certain  families,  often  affecting  several  mem- 
bers in  succession  at  about  the  same  age.  It  occurs  particularly  in 
families  where  alcoholism,  insanity,  and  other  nervous  diseases  are  fre- 
quent. 

Bramwell,  in  his  monograph  upon  this  disease,  gives  the  following  as 
the  characteristic  symptoms :  There  is  ataxia,  first  of  the  lower  extremities, 
but  gradually  extending  to  the  upper  extremities  and  the  face.  Early  in  the 
disease  there  is  some  weakness  in  the  legs,  especially  in  the  anterior  group 
of  muscles.  In  the  late  stages  this  is  marked  and  accompanied  by  atrophy. 
The  gait  is  peculiar,  like  that  of  ordinary  ataxic  patients,  the  difficulty  in 
walking  being  due  to  the  ataxia  and  not  to  the  paresis.  After  a  time  there 
is  produced  a  characteristic  deformity  of  the  foot, — it  is  shortened,  as  if 
from  pressure  against  the  toes  and  the  heel,  the  instep  is  high,  and  the  ex- 
tensor tendon  of  the  great  toe  stands  out  prominently.  This  deformity  is 
seen  quite  early  in  the  disease.  There  is  often  lateral  curvature  of  the 
spine.  The  knee-jerk  is  absent.  Unprovoked  and  uncontrollable  laughter 
is  quite  a  characteristic  symptom  of  the  disease.  The  patient  is  unable  to 
stand  with  his  eyes  closed.     There  are  palpitation,  occipital  headache,  and 


THE   MUSCULAR  ATROPHIES.  fgl 

sometimes  vertigo.  In  the  later  stages  speech  is  slow  and  difficult,  and 
the  patient  talks  like  one  intoxicated.  The  expression  of  the  face  is 
vacant,  and  often  nystagmus  is  present.  There  may  be  choreic  move- 
ments. The  symptoms  steadily  progress  until  the  patient  may  be  help- 
less, although  the  general  health  may  remain  good  for  years. 

The  disease  is  distinguished  from  locomotor  ataxia  by  the  absence  of 
the  "  lightning  pains,"  and  of  the  bladder,  rectal,  or  genital  symptoms,  the 
pupillary  changes,  the  optic-nerve  atrophy,  and  the  trophic  changes  in  the 
bones  and  joints.  It  is  distinguished  from  cerebral  tumour  by  the  absence 
of  headache,  vomiting,  and  optic  neuritis,  and  by  its  longer  course.  The 
progress  of  the  disease  is  slow  but  steady.  It  may  last  from  twenty  to 
thirty  years.     It  is  incurable. 

LANDRY'S  PARALYSIS  (ACUTE   ASCENDING   PARALYSIS). 

This  rare  disease  is  occasionally  seen  in  early  life.  In  regard  to  its  eti- 
ology but  little  is  definitely  known,  the  usual  causes  assigned  being  the 
same  as  those  of  myelitis. 

It  is  characterized  by  a  paralysis — sometimes  preceded  by  general 
symptoms  of  malaise,  fever,  etc. — which  begins  in  the  legs  and  spreads 
rapidly  to  the  muscles  of  the  trunk  and  upper  extremities ;  finally  it  may 
involve  the  neck,  diaphragm,  and  muscles  of  articulation.  The  paralysis 
develops  quite  rapidly,  often  attaining  its  height  in  from  twenty-four  to 
forty-eight  hours,  sometimes  even  proving  fatal  within  this  time.  In 
other  cases  it  comes  on  gradually,  and  may  be  two  or  three  weeks  in  reach- 
ing its  maximum.  There  is  dyspnoea  from  involvement  of  the  muscles  of 
respiration.  The  paralyzed  muscles  are  flaccid.  There  is  hyperaesthesia, 
followed  by  partial  or  complete  anaesthesia  and  loss  of  reflexes.  There  are 
no  changes  in  the  electrical  reactions,  no  atrophy,  no  bed-sores,  and  usually 
no  involvement  of  the  sphincters.  Occasionally  the  arms  may  be  affected 
before  the  legs,  and  even  the  bulbar  symptoms  may  be  the  first  noticed. 
Death  is  the  most  frequent  termination,  and  in  fatal  cases  the  disease  lasts 
from  two  days  to  a  week.  If  recovery  takes  place,  it  is  after  two  or  three 
months  of  illness. 

The  pathology  of  the  disease  is  as  yet  unknown.  The  indications  for 
treatment  are  the  same  as  in  acute  myelitis,  for  in  the  beginning  the  two 
diseases  can  not  usually  be  distinguished  from  each  other. 

THE  MUSCULAR  ATROPHIES. 

These  cases  may  be  broadly  divided  into  two  groups,  following  in. the 
main  the  classification  of  Sachs:*  (1)  Those  dependent  upon  disease  of 
the  spinal  cord, — the  spinal  atrophies;  (2)  those  which  are  prinuirily  dis- 
eases of  the  muscles  themselves, — the  idiopathic  atrophies. 


New  York  Medical  Journal,  December  15,  1888. 


782  DISEASES  OP  THE   NERVOUS  SYSTEM. 

In  the  group  of  atrophies  of  spinal  origin  belong  (1)  the  "  hand  type  " 
of  Aran  and  Duchenne,  which  has  been  shown  to  be  dependent  upon  a 
lesion  of  the  spinal  cord  ;  (2)  the  "  peroneal  type  "  of  Charcot,  Marie,  and' 
Tooth,  which  as  yet  lacks  positive  pathological  proof  of  its  spinal  origin, 
although  its  etiology,  symptoms,  and  course  leave  but  little  doubt  that  it 
belongs  in  the  same  category  with  the  hand  type. 

In  the  second  (idiopathic)  group  are  included  (1)  pseudo-muscular  hy- 
pertrophy, and  (2)  the  so-called  "juvenile  atrophy"  of  Erb,  which  is  a 
much  less  frequent  condition.  These  two  varieties  have  the  following  fea- 
tures in  common  :  There  is  progressive  wasting,  beginning  early  in  child- 
hood, and  associated  at  some  period  with  hypertrophy  of  certain  muscles. 
There  are  no  fibrillary  contractions,  no  reaction  of  degeneration,  and  no 
lesions  in  the  cord.  From  a  pathological  point  of  view  these  diseases 
might  be  more  properly  considered  elsewhere,  but  they  are  so  closely  asso- 
ciated clinically  with  the  spinal  atrophies  that  it  has  seemed  better  to  de- 
scribe them  in  this  connection. 

Progressive  Muscular  Atrophy  of  the  Hand  Type.— This  disease  is  char- 
acterized by  a  very  slow  but  progressive  wasting,  which  usually  begins  in  the 
muscles  of  the  ball  of  the  thumb  of  one  or  both  hands.  Then  the  palmar 
group  of  muscles  belonging  to  the  little  finger  are  affected,  and  later  the 
interossei.  When  the  wasting  has  reached  a  certain  degree,  there  is 
produced  a  peculiar  and  characteristic  deformity  of  the  hand  known  as 
mcmi  en  ^ri/f'e,  or  "  claw-hand."  Following  these  muscles,  those  of  the 
forearm  may  be  affected.  At  this  point  the  disease  is  sometimes  arrested, 
or  the  atrophy  may  extend  to  the  muscles  of  the  arm  and  shoulder,  espe- 
cially the  deltoid,  and  finally  to  those  of  the  back.  Exceptionally,  the 
atrophy  begins  in  the  muscles  of  the  shoulder  group  or  even  in  those  of 
the  leg.  The  wasting  takes  place  very  slowly,  the  muscles  disappearing 
fibre  by  fibre,  but  the  degree  which  may  be  reached  is  often  extreme. 
The  only  other  characteristic  symptoms  are  fibrillary  contractions  in  the 
muscles  which  are  soon  to  atrophy.  The  patient  is  not  conscious  of  them, 
but  they  are  visible.  The  faradic  contractility  is  preserved  just  in  propor- 
tion to  the  amount  of  muscle  remaining.  If  the  atrophy  is  complete,  it  is 
entirely  lost. 

The  course  of  the  disease  is  a  very  chronic  one,  covering  many  years. 
It  is  incurable.  In  rare  cases  the  process  may  extend  to  the  muscles  of 
the  tongue,  affecting  deglutition  and  articulation,  and  death  may  occur 
from  interference  with  respiration ;  otherwise  the  disease  does  not  tend  to 
shorten  life. 

In  this  form  of  atrophy  heredity  is  an  important  etiological  factor. 
The  disease  may  occur  in  children,  but  very  often  does  not  begin  until 
after  puberty.  The  lesion  consists  in  an  atrophy  of  the  ganglion  cells  of 
the  anterior  horns  of  the  spinal  cord,  followed  by  secondary  degeneration 
of  the  anterior  nerve-roots. 


THE  MUSCULAR  ATROPHIES.  '783 

Progressive  Muscular  Atrophy  of  the  Peroneal  Type. — This  is  much  less 
frequent  than  the  variety  just  described.  In  tiiis  form,  the  first  to  waste 
are  the  anterior  muscles  of  the  leg,  especially  the  extensor  longus  hallucis 
and  extensor  communis  digitorum,  afterward  the  peroneal  group.  The 
small  muscles  of  the  foot  are  next  affected,  and  the  disease  may  then  go 
on  to  involve  the  muscles  of  the  calf.  At  this  point  it  may  be  arrested 
permanently,  or  for  several  years,  after  which  the  thigh  muscles  may  waste 
like  those  of  the  leg.  After  many  years  the  hands  are  in  some  cases  involved 
as  in  the  type  previously  described,  and  even  the  muscles  of  the  forearm. 
As  a  rule,  the  supinator  longus,  the  muscles  of  the  shoulder,  neck,  trunk, 
and  face,  escape  altogether.  The  atrophy  is  generally  symmetrical,  but 
not  invariably  so.  The  cutaneous  reflexes  are  usually  present.  There  is 
no  pain.  The  reaction  of  degeneration  is  jDresent  in  some  of  the  muscles, 
and  fibrillary  contractions  are  frequent,  but  not  always  seen. 

In  this  variety  also  the  influence  of  heredity  may  often  be  traced.  It 
is  said  that  boys  usually  inherit  the  disease  through  the  mother.  Like 
the  previous  type,  it  begins  late  in  childhood  or  not  until  after  puberty. 

As  stated  above,  positive  proof  that  this  disease  is  due  to  a  central 
lesion  in  the  cord  is  as  yet  lacking.  Analogy,  however,  leads  to  the  belief 
that  it  depends  upon  changes  in  the  ganglion  cells  of  the  anterior  horns 
in  the  lumbar  region,  similar  to  those  found  in  the  cervical  region  in  the 
hand  type.  The  course  of  the  disease  is  very  chronic,  and  it,  too,  is  incur- 
able. The  resulting  deformity  resembles  that  seen  after  poliomyelitis,  and 
may  require  the  same  mechanical  treatment,  with  similar  operations  for 
relieving  contractions. 

Pseudo-Muscular  Hypertrophy  (Pseudo-Hypertrophic  Paralysis). — This 
is  the  most  frequent  and  best-known  variety  of  the  idiopathic  atrophies. 
It  is  a  disease  of  certain  families,  often  three  or  four  children  being  af- 
fected, the  boys  much  more  frequently  than  the  girls.  The  symptoms  as 
a  rule  come  on  early  in  childhood,  nearly  always  before  the  tenth  year. 
The  earlier  symptoms  relate  to  a  general  weakness  of  the  lower  extremities, 
which  is  accompanied  by  a  marked  increase  in  the  size  of  certain  muscular 
groups,  usually  those  of  the  calves,  but  sometimes  more  of  the  thighs  or 
the  gluteal  regions.  Children  walk  late  and  unsteadily,  and  fall  very  easily. 
They  have  special  difficulty  in  rising  from  the  floor  and  in  mounting 
stairs.  The  method  of  rising  is  quite  characteristic  :  the  patient  lifts  his 
body  until  he  touches  the  floor  only  with  the  hands  and  feet ;  then  he 
proceeds  to  "climb  up  himself"  by  putting  first  one  hand  upon  the 
knee,  and  then  the  other,  gradually  moving  his  hands  higher  and  higher 
up  the  thighs  until  the  erect  position  is  attained.  This  is  seen  in  most 
of  the  cases,  but  not  .in  all. 

The  size  attained  by  the  calves  is  sometimes  very  great.  Gowers  men- 
tions a  case  in  which  a  boy  of  twelve  had  calves  measuring  fourteen  and  a 

half  inches  in  circumference.     The  enlargement  may  affect  almost  any 
51 


784 


DISEASES  OP   THE   NERVOUS  SYSTEM. 


muscular  group  of  the  lower  extremity.  lu  the  upper  extremity,  the  in- 
fra-spiuatus  is  most  frequently  enlarged,  next  the  supra-spinatus  and  the 
deltoid.  The  pectorals  and  latissimus  dorsi  are  never  enlarged,  but  are 
generally  markedly  wasted.  Most  of  these  patients  exhibit  while  standing 
a  marked  degree  of  lumbar  lordosis,  due  to  the  weakness  of  the  extensors 
of  tlie  hip.     This  is  well  shown  in  Fig.  137.     The  patient  may  be  so  weak 

upon  his  legs  that  the  slightest  touch 
will  cause  him  to  fall,  even  with  his 
apparently  immense  muscular  devel- 
opment. The  small  muscles  are  gen- 
erally weaker  than  those  which  are 
enlarged. 

Later  in  the  disease  marked  atro- 
phy occurs  with  a  corresponding 
weakness  of  all  the  affected  groups, 
and  the  patient  may  be  unable  to 
walk  or  even  stand.  With  the  ex- 
ception of  the  use  of  his  hands,  he 
may  be  absolutely  helpless.  The 
knee-jerk  is  at  first  normal,  but  grad- 
ually diminishes  until  it  is  finally 
lost.  The  electrical  reactions  are 
normal  until  marked  wasting  occurs, 
when  there  is  a  lessened  response  to 
faradism  and  galvanism,  but  never 
the  reaction  of  degeneration.  There 
are  no  fibrillary  contractions,  and  no 
sensory  disturbances.  The  progress 
of  the  disease  is  generally  slow,  and 
sometimes  irregular.  It  is  often  more 
rapid  in  early  childhood,  and  slower 
after  puberty. 

The  lesions  are  confined  to  the 
muscles.  At  autopsy  they  appear 
yellow,  and  microscopically  there  is 
found  very  marked  atrophy  of  the 
muscle  fibres,  which  in  places  have 
been  almost  entirely  replaced  by  fat ; 
there  may  be  no  trace  of  muscle  left, 
the  structure  resembling  adipose  tissue.  In  other  places  there  is  an  accu- 
mulation of  fat  between  the  atrophied  muscle  fibres,  and  a  very  great 
increase  of  the  interstitial  tissue. 

The   prognosis   is   grave,   most   patients   dying   before    adult   life   is 
reached.      The  diagnosis  is  generally  easy  from  the  apparent  hypertro- 


FiG.  137. — Pseudo-njuscular  hypertrophy, 
showing  to  a  moderate  degree  the  large 
calves  and  gluteal  regions  with  a  marked 
lordosis.  (From  a  photograph  by  Dr.  M. 
A.Starr.)  H        -     f       -" 


MULTIPLE  NEURITIS.  7S5 

phy  and  actual  weakness  of  the  muscular  groups.  The  disease  is  incur- 
able. 

The  Juvenile  Form  of  Muscular  Atrophy. — This  is  much  less  frequent 
than  the  form  just  described,  but,  like  it,  begins  in  childhood  or  early 
youth.  It  is  characterized  by  progressive  wasting  of  certain  muscular 
groups,  especially  those  about  the  shoulders  and  pelvis,  and  hypertrophy  of 
others.  Of  the  shoulder  and  upper  extremity,  the  muscles  affected  are  the 
pectorals,  the  trapezius,  the  latissimus  dorsi,  the  serrati,  the  rhomboidei, 
the  muscles  of  the  upper  arm,  and  the  subscapularis.  The  deltoid,  infra- 
spinatus and  supra-spinatus  for  a  long  time  escape,  and  may  be  hyper- 
trophied.  The  hand  and  forearm  are  not  involved.  In  the  lower  extrem- 
ity, the  muscles  of  the  pelvis,  thighs,  and  gluteal  regions  are  affected, 
while  those  of  the  leg  and  foot  escape.  With  this  atrophy  there  may  be 
associated  a  true  or  pseudo-hypertrophy  of  certain  muscular  groups.  In 
this  disease  there  are  no  fibrillary  contractions,  no  reaction  of  degenera- 
tion, and  no  sensory  disturbances.  The  course  and  result  of  this  form 
are  essentially  the  same  as  in  the  preceding  variety.  It  is  now  generally 
regarded  as  closely  allied  to  it  in  its  pathology,  the  most  important  dif- 
ference being  that  of  localization. 

There  has  been  described,  chiefly  by  Landouzy  and  Dejerine,  another 
form  of  atrophy  known  us  the  infantile  facial  type.  In  this,  wasting  be- 
gins in  the  muscles  of  the  face ;  the  lips  are  thickened,  but  all  the  rest  of 
the  facial  muscles  are  markedly  atrophied,  giving  a  peculiar  expression  to 
the  mouth  known  as  "  the  tapir  mouth."  Later,  the  atrophy  extends  to 
the  shoulders  and  arm,  but  does  not  involve  the  supra-spinatus  or  infra- 
spinatus, or  the  flexors  of  the  hand  and  forearm.  This  is  sometimes  de- 
scribed as  beginning  in  the  shoulders,  or  even  in  the  legs.  The  descrip- 
tion therefore  corresponds  to  the  juvenile  form  of  Erb,  with  the  addition 
of  facial  symptoms,  and  it  is  probably  a  variety  of  the  same  disease. 


CHAPTER  V. 

DISEASES   OF  THE  PERIPHERAL  NERVES. 

MULTIPLE  NEURITIS. 

Under  the  term  multiple  neuritis  are  included  those  cases  in  which 
several  nerves  are  involved  in  an  inflammatory  process,  which  may  at  times 
be  general.  In  its  distribution  multiple  neuritis  is  usually  symmetrical, 
but  it  is  not  necessarily  so. 

Etiology. — The  chief  cause  of  multiple  neuritis  in  children  is  diph- 
theria, although  it  is  occasionally  seen  after  other  infectious  diseases, 
especially  malaria,  typhoid  or  scarlet  fever,  and   measles.     In  diphtheria 


786  DISEASES  OP  THE  NERVOUS  SYSTEM. 

the  inflammation  is  due  to  the  direct  action  of  the  toxines  upon  the  nerve 
structures,  since  it  can  be  induced  in  animals  by  injecting  toxines  into 
the  circulation.  There  is  little  doubt  that  in  all  infectious  diseases  the 
inflammation  is  excited  in  a  similar  way.  The  metallic  poisons,  lead  and 
arsenic,  are  rarely  the  cause  of  multiple  neuritis  in  early  life,  and  the 
same  is  true  of  alcohol,  although  a  marked  case  from  this  cause  has 
recently  come  under  my  observation  in  a  child  only  three  years  old.* 
Lastly,  there  are  cases  in  which  the  cause  assigned  is  simply  exposure  to 
cold, — those  classed  as  rheumatic. 

Lesions. — Almost  any  nerves  in  the  body  may  be  affected,  although 
the  distribution  varies  somewhat  with  the  cause  of  the  disease.  The 
musculo-spiral  and  the  anterior  tibial  nerves  are  most  frequently  involved, 
but  the  inflammation  may  affect  any  of  the  spinal  nerves,  including  the 
phrenic,  and  occasionally  the  cranial  nerves,  especially  the  pneumogas- 
tric  hypoglossal,  oculomotor,  and  abducens.  Several  nerves  in  different 
parts  of  the  body  are  usually  affected,  the  lesion  being  in  most  cases  sym- 
metrical. 

The  affected  nerve  is  sometimes  red  and  swollen,  owing  to  acute  conges- 
tion and  cedema  or  a  sero-fibrinous  exudation.  In  other  cases  the  changes 
are  almost  entirely  degenerative.  The  microscope  shows  the  changes 
sometimes  to  be  chiefly  interstitial  and  sometimes  chiefly  parenchymatous. 
There  is  an  exudation  of  cells  into  the  sheath,  between  the  sheath  and 
the  nerve  fibres,  and  even  between  the  nerve  fibres  themselves.  The 
myeline  breaks  up  into  granules,  and  in  places  may  completely  disappear. 

*  This  case  was  in  many  respects  a  remarkable  one.  The  boy  completely  emptied  a 
decanter  containing  twelve  ounces  of  whisky,  but  almost  immediately  vomited  the 
greater  part  of  it.  He  soon  after  showed  the  symptoms  of  alcoholic  intoxication,  and 
in  a  few  hours  became  comatose,  in  which  condition  he  continued  for  twelve  hours. 
After  this  he  gradually  lost  power  in  his  legs,  and  at  the  end  of  a  week  was  unable  to 
walk  at  all.  He  had  convulsions,  and  after  this  there  developed  the  usual  symptoms 
of  meningitis  at  the  convexity,  with  which  he  was  admitted  to  the  Babies'  Hospital, 
December  13,  1895,  three  weeks  after  drinking  the  whisky.  The  child  was  then  un- 
conscious and  there  was  present  incomplete  paralysis,  affecting  all  four  extremities, 
with  anajsthesia  of  the  arms.  The  active  inflammatory  symptoms  continued  for  six 
weeks  longer,  during  which  time  there  were  repeated  convulsions,  continuous  stupor, 
fever,  gradually  increasing  deformities,  marked  atrophy,  loss  of  reflexes,  and  great  dimi- 
nution in  the  faradic  contractility  of  all  the  paralyzed  muscles ;  in  the  thighs,  left  leg, 
and  abdominal  muscles  there  were  no  responses  to  a  strong  current,  but  there  was  no- 
where the  reaction  of  degeneration.  The  child  was  at  death's  door  for  three  or  four 
weeks.  Three  months  after  the  attack  the  first  signs  of  improvement  were  observed  in 
the  cerebral  symptoms.  Shortly  afterward  he  began  to  use  his  hands,  and  at  the  end 
of  six  weeks  he  was  walking  alone  and  talking  freely.  The  improvement  was  very 
rapid,  and  eight  weeks  from  the  date  of  the  first  change  for  the  better,  and  five  months 
from  the  time  of  taking  the  whisky,  he  was  as  well  as  ever.  The  diagnosis  was  mul- 
tiple alcoholic  neuritis,  with  a  convexity  meningitis.  (Fig.  138  is  from  a  photograph 
taken  while  the  symptoms  were  at  their  height.) 


MULTIPLE   NEURITIS. 


787 


The  late  changes  are  those  of  subacute  or  chronic  degeneration  of  the 
nerve  fibres.* 

With  these  changes  in  the  nerves  there  are  associated,  in  some  cases, 
inflammatory  and  degenerative  changes  in  the  ganglion  cells  of  the  spinal 
cord,  although  they  are  much  less  severe  than  are  the  lesions  in  the  nerves. 
However,  they  were  once  regarded  as  the  explanation  of  some  of  these 
cases,  particularly  of  diphtheritic  paralysis. 

Symptoms. — The  onset  of  multiple  neuritis  is  in  most  cases  a  grad- 
ual one,  it  being  usually  from  two  to  four  weeks  before  the  paralysis 
reaches  its  height.  Very  exceptionally  the  onset  may  be  abrupt,  with 
fever,  and  marked  paralysis  in  a  few  days.  It  is  characteristic  of  this 
disease  that  both  motor  and  sensory  symptoms  are  present,  and  that  they 


Fio.  138. — Alcoholic  neuritis,  showinor  characteristic  dropping  of  the  feet.     Tliis  position  of  the 
lower  extremities  was  maintained  for  over  a  month.    Boy  three  years  old. 

are  the  same  in  their  distribution.  The  symptoms  are  usually  symmet- 
rical. There  is  first  noticed  a  general  weakness  in  the  affected  muscles, 
which  slowly  increases  to  complete  paralysis.  As  the  extensor  groups 
of  the  hands  and  feet  are  apt  to  be  affected,  there  are  wrist-drop  and 
foot-drop  (Fig.  138).  The  paralysis  may  begin  in  the  feet  and  hands, 
and  gradually  extend  until  it  involves  not  only  the  four  extremities,  but 
even  the  muscles  of  the  trunk  and  the  neck,  although  this  is  rare.  The 
child  may  then  be  absolutely  helpless,  unable  to  sit  up,  or  even  to  support 
its  head.  In  such  cases  the  head  seems  loosely  attached  to  the  body,  and 
rolls  about  on  the  shoulders  like  a  ball.  Weakness  of  the  spinal  muscles 
leads  to  deformities  (Fig.  139),  which  I  have  seen  mistaken  for  Pott's  dis- 


*  For  a  full  description  of  the  lesions,  consult  Starr's  Middleton-Goldsmith  Lectures, 

New  York  Medical  Record,  1887. 


T88 


DISEASES  OP  THE   NERVOUS  SYSTEM. 


ease,  even  by  experienced  observers.  In  most  of  the  muscular  groups 
the  paralysis  is  incomplete.  The  symptoms  which  relate  to  the  phrenic 
and  the  cranial  nerves  will  be  described  with  Diphtheritic  Paralysis,  for 
they  are  rarely  seen  in  any  other  form.  It  is  characteristic  of  multiple 
neuritis  that  the  bladder  and  rectum  escape. 

Tlie  sensory  symptoms  are  marked  only  in  the  early  stage  of  the  dis- 
ease, while  the  paralysis  is  increasing ;  they  improve  so  much  more  rap- 
idly than  the  motor  symptoms,  that  they 
may  be  altogether  wanting  at  the  time 
that  the  paralysis  is  at  its  height.  In 
some  cases  they  are  so  slight  as  to  be 
overlooked.  There  is  usually  pain  along 
the  course  of  the  affected  nerves,  which 
is  sharp  and  neuralgic  in  cliaractei',  and 
generally  associated  with  acute  tender- 
ness of  the  nerve  trunks  and  of  the  mus- 
cles. Often  there  is  a  general  hyperaes- 
thesia  in  the  early  part  of  the  attack, 
followed  by  partial  anaesthesia.  The 
sensations  of  touch,  pain,  temperature, 
and  the  muscular  sense  are  all  about 
equally  affected. 

Ataxia  is  not  uncommon,  and  may 
be  a  more  striking  symptom  than  the 
loss  of  power.  All  the  reflexes  are  di- 
minished or  lost,  especially  the  knee-jerk, 
as  the  legs  are  usually  most  affected. 
Sometimes,  particularly  after  diphtheria, 
there  is  loss  of  the  knee-jerk,  when  there 
is  no  other  symptom  of  neuritis.  In  the 
severe  cases  muscular  tremor  is  frequent. 
Atrophy  is  a  prominent  symptom  of 
neuritis,  and  it  is  evident  early  in  the 
disease,  often  being  quite  as  rapid  as  in 
poliomyelitis.  The  electrical  reactions 
are  altered, — every  grade  of  reduction  in 
the  responses  being  seen,  from  a  slight 
diminution  in  the  reaction  to  faradism 
to  the  complete  reaction  of  degeneration.  Vaso-motor  symptoms,  such  as 
oedema  of  the  affected  parts,  glossiness  of  the  skin,  etc.,  are  often  present. 
Deformities  from  muscular  contraction  occur  early ;  they  may  be  severe, 
and  in  some  cases,  permanent. 

Course  and  Prognosis. — The  usual  course  of  the  disease  is  for  the  symp- 
toms gradually  to  increase  for  three  or  four  weeks  and  then  improve, 


Fki.  131). — Multiple  neuritis  attcr  diph- 
theria in  a  chikl  four  years  old.  The 
position  of  the  head  and  spine  are 
due  to  partial  paralysis  of  the  trunk 
and  neck.  The  legs  were  also  af- 
fected. 


MULTIPLE   NEURITIS,  789 

sometimes  rapidly,  but  more  ofteu  slowly,  the  case  usually  going  on 
to  complete  recovery  in  the  course  of  a  few  months.  Exceptionally 
the  paralysis  may  be  permanent.  The  sensory  symptoms  always  disap- 
pear before  the  motor  ones.  Multiple  neuritis  may  prove  fatal,  from  pa- 
ralysis of  the  heart  or  the  muscles  of  respiration,  or  death  may  be  due  to 
asphyxia  from  the  entrance  of  food  or  foreign  bodies  into  the  air  passages, 
owing  to  anaesthesia  of  the  epiglottis  and  paralysis  of  the  muscles  of 
deglutition.  Death  sometimes  follows  from  complications,  especially 
pneumonia.  The  electrical  reactions  are  of  much  prognostic  value  in 
regard  to  the  persistence  of  the  paralysis.  If  the  reaction  of  degeneration 
is  present  the  paralysis  is  certain  to  last  many  months,  and  some  muscles 
are  sure  to  be  permanently  affected.  Where  there  is  simply  a  diminution 
in  the  faradic  responses,  even  though  accompanied  by  marked  atrophy, 
complete  recovery  may  be  expected,  although  it  is  often  slow. 

Diagnosis. — The  diagnostic  features  of  multiple  neuritis  are  the  com- 
bination of  motor  and  sensory  symptoms  with  the  same  distribution,  the 
occurrence  of  atrophy,  and  the  diminution  in  the  electrical  responses,  even 
the  reaction  of  degeneration.  The  gradual  onset  and  the  wide-spread 
distribution  of  the  paralysis  are  also  characteristic.  If  all  four  extremities 
are  paralyzed,  it  is  altogether  the  probable  disease ;  and  if  to  this  is  added 
paralysis  of  the  neck  and  spinal  muscles,  the  diagnosis  is  almost  certain. 
The  facts  that  the  paralysis  is  often  incomplete,  and  that  it  involves  parts 
distant  from  each  other,  are  also  important.  It  may  be  mistaken  for 
poliomyelitis  (page  776),  for  Landry's  paralysis,  or  for  Pott's  paraplegia; 
an  important  diagnostic  point  from  the  last  mentioned  is  the  condition 
of  the  reflexes, — being  greatly  exaggerated  in  Pott's  paraplegia,  while  they 
are  diminished  or  lost  in  multiple  neuritis. 

Treatment. — As  this  disease  tends  in  the  great  nuijority  of  cases  to 
spontaneous  recovery,  it  is  difficult  to  estimate  the  value  of  any  method 
of  treatment.  Causes,  such  as  lead,  arsenic,  alcohol,  and  malaria,  are  to 
be  sought  and  removed  as  the  first  step.  During  the  acute  stage  the  pain 
may  be  so  severe  as  to  require  relief,  which  is  best  accomplished  by  the 
application  of  heat.  In  using  counter-irritation  care  is  necessary,  and 
such  active  measures  as  cauterization  should  not  be  employed,  for  trouble- 
some ulceration  may  follow.  After  the  acute  stage  has  passed,  or  at  the  end 
of  three  or  four  weeks,  electricity  should  bo  begun,  faradism  being  used  if 
the  muscles  respond  to  a  moderate  current,  otherwise  galvanism.  This 
should  be  continued  daily  until  recovery.  Strychnine  is  much  used  in 
these  cases,  but  it  is  doubtful  whether  it  has  any  specific  influence,  al- 
though as  a  tonic  it  is  valuable.  Other  tonics,  such  as  iron,  quinine, 
and  most  of  all  cod-liver  oil,  should  be  given  in  every  case.  Massage  is 
also  beneficial.  The  special  treatment  of  cardiac  and  respiratory  paralysis 
will  be  discussed  in  the  following  article. 


Y90  DISEASES  OF   THE  NERVOUS  SYSTEM. 

DIPHTHERITIC   PARALYSIS. 

This  is  not  only  the  most  frequent  variety  of  multiple  neuritis,  but  it 
has  some  peculiarities  which  make  a  separate  consideration  of  it  desirable. 

Frequency. — According  to  the  statistics  of  various  observers,  paralysis 
including  all  varieties,  occurs  after  diphtheria  in  from  5  to  15  per  cent 
of  the  cases.  Sanne  gives  11  per  cent  in  2,448  cases;  Lennox  Browne,  14 
per  cent  in  1,000  cases ;  the  Report  of  the  Collective  Investigation  by  the 
American  Paediatric  Society,  9-7  per  cent  of  3,384  cases  which  were  treated 
by  antitoxine. 

It  is  as  yet  too  soon  to  state  to  what  degree  the  frequency  of  para- 
lytic sequelae  after  diphtheria  is  to  be  affected  by  the  antitoxine  treat- 
ment; but  the  figures  above  given  would  indicate  that  the  protective 
power  of  the  serum  over  the  nervous  tissues  is  not  so  great  as  is  seen 
elsewhere,  and  that  unless  administered  very  early  it  may  have  little  or  no 
influence. 

Being  one  of  the  direct  effects  of  the  diphtheria  toxine,  neuritis  is 
much  more  likely  to  follow  severe  than  mild  cases;  however,  its  occur- 
rence after  some  very  mild  attacks  shows  how  great  is  the  susceptibility 
of  the  nervous  tissues  to  the  action  of  this  poison.  Sometimes  the  throat 
symptoms  have  been  entirely  overlooked,  and  the  development  of  paraly- 
sis has  been  the  first  thing  to  arouse  a  suspicion  of  previous  diphtheria. 

Time  of  Occurrence. — During  the  second  week,  and  sometimes  even 
during  the  latter  part  of  the  first  week,  the  early  paralysis  occurs,  affecting 
the  palate,  and  in  some  cases  the  heart.  The  most  frequent  and  most 
characteristic  paralysis — that  affecting  the  throat,  eyes,  extremities,  heart, 
or  respiration — begins  at  a  later  period,  usually  from  one  to  three  weeks 
after  the  throat  has  cleared  off,  and  sometimes  even  later  than  this. 

Extent  and  Distribution  of  the  Paralysis. — Ross  *  gives  the  following 
statistics  of  171  collected  cases  of  diphtheritic  paralysis :  Palate  affected 
in  138;  eyes  in  77,  in  54  of  which  the  muscles  of  accommodation  were 
involved ;  lower  extremities  in  113 ;  upper  extremities  in  60 ;  trunk  or 
neck  in  58 ;  muscles  of  respiration  in  33.  I  do  not  think  this  repre- 
sents the  actual  frequency  of  the  different  varieties  so  truly  as  do  the 
American  Psediatric  Society's  figures,  which  give  the  forms  of  paralysis 
noted  in  a  series  of  cases  collected  for  another  purpose.  In  328  cases  of 
paralysis,  the  variety  was  mentioned  in  189 :  in  124  the  throat  was  af- 
fected ;  in  22  the  extremities ;  in  11  the  eyes ;  in  5  the  muscles  of  respi- 
ration ;  in  32  the  heart ;  in  1  the  neck  only ;  in  8  the  2Daralysis  was 
"general." 

Symptoms. — In  the  great  majority  of  cases  the  throat  is  affected,  and 
usually  the  paralysis  is  first  noticed  there.      It  may  involve  the   palate 

*  The  Medical  Chronicle,  December,  1890. 


DIPHTHERITIC   PARALYSIS.  791 

alone,  or  the  muscles  of  the  pharynx  or  larynx  in  addition.  The  muscles 
of  the  extremities  or  of  the  eye  are  often  next  attacked.  In  severe 
cases  there  may  also  be  involved  the  muscles  of  the  trunk  and  neck,  and 
sometimes  the  diaphragm.  Cardiac  paralysis  not  infrequently  occurs 
where  no  other  parts  have  been  previously  affected,  but  in  nearly  all  the 
other  forms,  the  throat  symptoms  precede.  It  is  this  which  distinguishes 
diphtheritic  paralysis  from  other  forms  of  multiple  neuritis.  Whatever  the 
extent  or  situation  of  the  paralysis,  the  knee-jerk  is  nearly  always  lost.  The 
symptoms  in  the  extremities  and  the  trunk  do  not  differ  from  those  of 
multiple  neuritis  from  other  causes.  The  throat  paralysis  shows  itself  by 
a  nasal  voice  and  by  regurgitation  of  fluids  through  the  nose,  sometimes 
by  difficulty  in  swallowing  or  the  entrance  of  food  into  the  larynx,  owing 
to  anaesthesia  of  the  epiglottis  and  paralysis  of  the  muscles  of  deglutition. 
There  may  be  difficulty  in  protruding  the  tongue  or  in  articulation. 
Paralysis  of  the  vocal  cords  may  cause  hoarseness,  aphonia,  or  attacks  of 
spasmodic  dyspnoea.  Facial  paralysis  is  very  rare.  On  the  part  of  the 
eye  there  is  most  frequently  seen  inability  to  read,  owing  to  paralysis  of 
the  muscles  of  accommodation ;  there  may  be  dilatation  of  the  j^upils, 
rarely  strabismus  or  ptosis. 

Next  to  that  of  the  throat,  paralysis  of  the  muscles  of  respiration  and  the 
heart  are  the  most  characteristic  forms  of  diphtheritic  neuritis.  Respir- 
atory paralysis  may  be  due  to  involvement  of  the  phrenic  or  the  intercostal 
nerves,  most  frequently  the  former.  Extensive  paralysis  of  other  parts — 
the  throat,  extremities,  or  trunk — usually  precedes.  The  first  warning  is 
generally  in  the  form  of  occasional  attacks  of  dyspnoea,  sometimes  ac- 
companied by  cough.  Gradually  these  attacks  increase  in  frequency  and 
severitv.  The  voice  is  reduced  to  a  whisper.  As  the  diaphragm  is  usu- 
ally affected,  the  breathing  is  entirely  thoracic.  The  respiratory  move- 
ments are  rapid,  but  irregular,  shallow,  and  ineffectual.  There  is  cyanosis, 
also  great  subjective  as  well  as  objective  dyspnoea.  The  anxiety,  distress, 
and  apprehension  of  the  patient  are  sometimes  terrible.  There  is  a  con- 
stant dread  of  impending  suffocation,  and  the  respiratory  movements  are 
continued  only  by  the  patient's  constant  efforts,  otherwise  they  nuiy  cease 
altogether.  After  a  few  hours  these  severe  symptoms  may  subside,  to  re- 
turn after  a  short  respite.  There  may  be  several  such  attacks  during  two 
or  three  days,  in  each  of  which  death  seems  imminent.  Unfortunately,  this 
is  the  most  frequent  termination.  Of  thirty- three  such  cases  collected  by 
Ross,  only  eight  recovered.  Associated  with  these  respiratory  symptoms 
others  may  be  present,  indicating  that  the  pneumogastric  is  involved. 
There  may  be  attacks  of  abdominal  pain,  vomiting,  and  disturbance  of 
the  heart's  action, — usually  an  irregular  or  intermittent  pulse,  which  may 
be  either  unnaturally  slow  or  very  rapid.  In  many  cases  the  heart  con- 
tinues to  beat  normally,  even  though  the  respiration  is  so  much  disturbed. 

The  premonitory  symptoms  of  cardiac  paralysis  are  an  irregular  or 


792  DISEASES  OF  THE   NERVOUS  SYSTEM. 

intermittent  pulse,  often  slow,  but  becoming  very  rapid  from  even  the 
slightest  exertion.  It  is  always  weak  and  compressible.  The  first  sound 
of  the  heart  is  feeble  and  may  be  reduplicated.  As  the  symptoms  increase 
there  are  marked  pallor,  coldness  of  the  extremities,  great  restlessness, 
anxiety,  precordial  distress,  and  perhaps  orthopnoea.  Within  twenty-four 
hours  from  the  beginning  of  such  symptoms  death  usually  occurs.  In  other 
cases  it  may  come  suddenly  without  any  warning,  or  with  a  warning  so 
slight  as  to  be  overlooked.  At  such  times  it  often  follows  some  muscular 
exertion,  such  as  getting  out  of  bed,  walking  across  the  room,  or  so  slight 
an  effort  as  sitting  up  suddenly  in  bed.  Fits  of  temper  or  other  excite- 
ment have  at  times  produced  it.  It  is  by  no  means  certain  that  sudden 
heart  paralysis  is  always  due  to  a  lesion  of  its  nerves.  A  not  less  impor- 
tant cause  is  toxic  myocarditis.  In  the  cases  where  death  occurs  sud- 
denly without  premonition  after  some  muscular  effort,  it  is  in  all  prob- 
ability the  heart  muscle  which  is  most  at  fault.  However,  in  many  cases 
the  two  conditions  are  associated. 

Death  from  diphtheritic  paralysis  is  usually  due  either  to  cardiac  or 
respiratory  paralysis.  Of  one  hundred  and  seventy-one  cases  of  all  va- 
rieties collected  by  Ross,  forty-five  were  fatal. 

Treatment. — Cases  of  paralysis  of  the  trunk  or  extremities  are  to  be 
managed  like  others  of  multiple  neuritis.  In  severe  forms  of  throat 
paralysis  feeding  by  a  stomach  tube  should  always  be  employed,  on  ac- 
count of  the  danger  of  the  entrance  of  food  into  the  air  passages.  It 
must  in  most  cases  be  continued  for  several  days.  The  tube  may  be 
passed  either  through  the  mouth  or  the  nose. 

The  great  mortality  attending  paralysis  of  the  heart  and  respiration 
shows  how  unsuccessful  is  treatment  in  most  of  the  cases ;  still,  no  doubt 
there  are  instances  where  life  may  be  saved  by  judicious  treatment.  In 
cases  of  threatened  heart  paralysis,  the  drug  most  to  be  depended  upon 
is  morphine,  hypodermically  ;  this  should  be  used  every  two  or  three  hours 
in  sufficient  doses  to  keep  the  patient  under  its  influence  while  threat- 
ening symptoms  are  present.  In  some  cases  it  may  be  advantageously 
combined  with  strychnine.  The  patient  should  be  kept  absolutely  quiet, 
not  even  being  allowed  to  turn  in  bed.  In  respiratory  paralysis  the  gen- 
eral reliance  is  upon  strychnine  used  hypodermically  in  doses  sufficient 
to  produce  its  physiological  effects,  and  upon  faradization  of  the  respira- 
tory muscles,  particularly  the  diaphragm.  Faradism  is  to  be  used  in 
the  attacks  of  respiratory  failure  and  continued  while  they  last.  In  some 
cases  patients  may  by  these  means  be  tided  over  the  dangerous  stage  of  the 
disease. 

FACIAL   PARALYSIS. 

Peripheral  paralysis  of  the  face  occurring  as  a  result  of  injury  inflicted 
during  delivery  has  already  been  described  (page  108).     There  remain  to 


FACIAL  PARALYSIS. 


793 


be  considered  here  cases  which  arise  from  causes  that  operate  at  a  later 
period.  The  facial  nerve  may  be  affected  in  any  one  of  three  situations, — 
after  its  exit  from  the  cranium,  in  the  bony  canal,  and  within  the  cranium. 

In  the  first  situation,  the  principal  cause  of  neuritis  is  exposure  to  cold 
(the  "rheumatic"  cases),  but  it  occasionally  occurs  as  a  complication  of 
mumps  and  disease  of  the  lymph  glands  of  this  region.  The  nerve  is  af- 
fected just  after  it  has  escaped  from  the  stylo-mastoid  foramen,  and  all  the 
branches  given  off  beyond  its  exit  are  involved.  There  is  paralysis  of  the 
muscles  of  the  forehead,  those  about  the  eye,  the  cheek,  nose,  and  mouth. 
The  affected  side  of  the  face  is  smooth,  there  is  inability  to  wrinkle  the 
forehead,  contract  the  eyebrows,  close  the  eye  completely,  raise  the  nos- 
tril, whistle  or  blow.  The  mouth  is 
drawn  to  the  affected  side  (Fig.  140). 
If  the  paralysis  is  complete,  there  may 
be  difficulty  in  drinking  or  in  articula- 
tion. In  partial  paralysis  the  symp- 
toms may  not  be  noticeable  while  the 
face  is  at  rest.  There  are  no  sensory 
symptoms.  The  electrical  reactions 
resemble  those  of  other  forms  of  neu- 
ritis ;  there  is  diminution  in  the  re- 
sponse to  the  faradic  current,  which 
is  more  or  less  marked  according  to 
the  severity  of  the  lesion,  and  there 
may  be  the  reaction  of  degeneration. 

In  the  bony  canal,  the  facial  nerve 
is  usually  inflamed  as  a  result  of  dis- 
ease of  the  ear.  In  children  this  is 
much  more  frequent  than  from  the 
causes   just  mentioned.       AVhile  it  is 

possible  for  it  to  occur  in  acute  cases,  it  generally  accompanies  chronic 
otitis,  especially  where  there  is  caries  of  the  petrous  bone.  In  addition  to 
the  paralysis  there  is  present  or  there  is  a  history  of  a  discharge  from 
the  ear,  and  generally  there  is  some  deafness  upon  the  side  affected.  The 
facial  .symptoms  arc  usually  the  same  as  in  the  cases  first  described. 
However,  when  the  nerve  is  affected  between  the  stapedius  and  the  genic- 
ulate ganglion,  tiiere  is  a  disturbance  of  the  sense  of  taste,  and  of  the 
secretion  of  the  saliva. 

At  the  base  of  the  brain  the  trunk  of  the  nerve  may  be  involved  in 
cerebral  tumour,  basilar  meningitis,  and  in  fracture  of  the  skull.  In  any 
of  those  conditions  the  auditory  nerve  also  is  likely  to  be  affected. 

Prognosis. — The  result  is  greatly  modified  by  the  cause  in  the  dif- 
ferent cases.  In  those  which  are  due  to  cold,  spontaneous  recovery 
usuallv  occurs  in  the  course  of  a  few  weeks  or  months.     In  those  depend- 


\ 


\;- 


Fig.  140. — Facial  paralysis  from  middle- 
ear  disease  in  a  child  two  and  a  half 
veal's  old. 


794  DISEASES  OF   THE  NERVOUS  SYSTEM. 

ing  upon  disease  of  the  ear,  the  outlook  is  not  so  favourable,  and  though 
there  may  be  improvement,  it  is  not  rare  for  some  paralysis  to  be  per- 
manent. In  the  third  group  of  cases,  facial  paralysis  is  only  one  of  the 
symptoms,  and  the  result  depends  entirely  upon  the  nature  of  the  cause. 

Diagnosis. — Facial  paralysis  is  easily  recognised.  It  is  important  to 
separate  the  peripheral  paralysis  from  that  due  to  a  lesion  above  the 
pons,  as  in  cases  of  ordinary  hemiplegia.  In  the  latter  group  only  the 
lower  half  of  the  face  is  affected,  the  muscles  of  the  forehead  and  those 
about  the  eye  escaping,  and  the  electrical  reactions  are  unchanged. 

Treatment. — This  is  essentially  the  same  as  in  other  cases  of  neuritis. 
In  cases  due  to  ear  disease  the  primary  lesion  should  receive  appropriate 
treatment. 


SECTION  yilL 
DISEASES  OF   THE   BLOOD,   LYMPH  NODES,   BONES,   ETC. 

CHAPTER  I. 

DISEASES   OF   THE  BLOOD. 

Ix  general,  the  blood  in  infancy  and  childhood,  as  compared  with  that 
of  adult  life,  is  thinner  and  contains  a  larger  proportion  of  water ;  it  is 
also  poorer  in  solids  and  has  a  lower  specific  gravity. 

Specific  Gravity. — This  has  no  constant  relation  to  the  number  of 
white  or  red  corpuscles,  but  varies  with  the  amount  of  hsemoglobin.  The 
highest  specific  gravity  is  seen  in  the  blood  of  the  newly  born,  when, 
according  to  Lloyd-Jones,  it  is  1"066.  During  the  first  two  weeks  of  life 
it  sinks  rapidly  to  its  lowest  point — 1-048  to  1-052 — where  it  remains 
until  about  the  end  of  the  second  year ;  after  this  time  it  rises  gradually 
until  about  puberty.  The  average  specific  gravity  during  childhood  is 
1-052  to  1-055  (Hock  and  Schlesinger). 

Haemoglobin. — The  percentage  of  haemoglobin  is  highest  in  the  blood 
of  the  newly  born,  and  falls  rapidly  during  the  first  few  days  after  birth. 
Throughout  childhood  it  is  considerably  lower  than  in  adult  life.  The 
haemoglobin  is  lowest  between  the  third  month  and  the  fifth  year ;  after 
the  fifth  year  it  gradually  increases  up  to  puberty.  According  to  Wydo- 
witz,  the  usual  range  in  infants  and  young  children,  as  measured  by  the 
adult  standard,  is  between  60  and  80  per  cent,  60  per  cent  being  the  lowest 
limit  in  healthy  children. 

The  cells  of  the  blood  are  the  red  corpuscles  or  erythrocytes,  and  the 
white  corpuscles  or  leucocytes. 

Red  Corpuscles. — The  number  of  red  corpuscles  is  highest  in  the  newly 
born.  At  this  time  it  is  from  4,350,000  to  6,500,000  in  each  cubic  milli- 
metre. In  infancy  it  is  from  4,000,000  to  5,500,000 ;  in  later  childhood, 
from  4,000,000  to  4,500,000  (Hayem).  In  size  a  much  greater  variation 
is  seen  in  the  red  cells  of  the  newly  born  than  in  those  of  older  children 
and  adults.  In  the  blood  of  the  foetus  there  are  present  nucleated  red 
corpuscles  or  erythroblasts  (Plate  XVI,  A,  5,  and  B,  2).  These  diminish 
in  number  toward  the  end  of  pregnancy.  They  are  always  found  in  the 
blood  of  premature  infants,  but  in  infants  born  at  term  they  are  seen  only 

795 


796        DISEASES  OF   THE   BLOOD,  LYMPH   NODES,   BONES,   ETC. 

in  small  numbers  and  disappear  after  a  few  days.     In  later  infancy  their 
presence  is  always  jiathological. 

White  Corpuscles. — Of  these,  five  different  varieties  are  distinguished 
by  Ehrlich  : 

1.  Lympliocytes  or  small  mononuclear  cells  (Plate  XVI,  A,  6).  These 
resemble  the  red  blood-cells  in  size,  and  have  a  single  deeply  staining 
nucleus,  which  is  so  large  as  nearly  to  fill  the  cell  body ;  the  protoplasm 
is  non-granular.  The  source  of  these  cells  is  believed  to  be  the  lymph 
glands. 

2.  Large  mononuclear  cells.  These  are  much  larger  than  the  preced- 
ing variety,  and  have  a  single  large  ovoid  nucleus  with  quite  a  broad 
margin  of  protoplasm  surrounding  it.  They  are  not  numerous  in  normal 
blood ;  they  are  derived  from  bone- marrow  and  the  spleen. 

3.  Mononuclear  transition  forms.  These  are  derived  from  the  va- 
riety last  mentioned,  being  similar  in  size  and  colour.  The  nucleus  shows 
an  indentation  on  one  side — the  beginning  of  a  nuclear  division.  When 
further  developed,  these  cells  show  traces  of  neutrophile  granulations  in  the 
protoplasm,  usually  between  the  horns  of  the  nucleus. 

4.  Polynuclear  cells  with  neutropliile  granulations  (Plate  XVI,  A,  3). 
The  nucleus  is  long,  irregular,  and  twisted  in  various  shapes  or  divided 
into  several  parts.  The  protoplasm  contains  fine  granulations  affected 
only  by  stains  of  neutral  reaction.  These  cells  are  smaller  than  the  mono- 
nuclear forms  from  which  they  are  derived,  although  somewhat  larger 
than  the  red  cells.  They  constitute  the  largest  proportion  of  the  leuco- 
cytes in  normal  blood,  and  they  are  the  only  forms  increased  in  ordinary 
leucocytosis.  Forms  2,  3,  and  4  probably  represent  different  degrees  of 
development  of  the  same  cells.* 

5.  Eosinophile  cells  (Plate  XVI,  A,  1).  These  are  not  related  to  any 
of  the  preceding  forms.  The  protoplasm  contains  large  fat-like  granula- 
tions, which  can  be  seen  even  before  staining.  They  stain  readily  with 
acid  colors,  especially  with  eosin,  from  which  peculiarity  their  name  is 
derived.  The  granulations  of  these  cells  are  much  coarser  than  those  of 
the  polynuclear  neutrophile  cells,  while  tlieir  nuclei,  of  which  there  are 
generally  two  or  three,  do  not  stain  so  darkly.  After  the  eosinophile  cells 
have  broken  down,  the  resulting  granulations  somewhat  resemble  groups 
of  cocci.  In  normal  blood  these  cells  form  but  a  small  proportion  of 
the  leucocytes. 

The  number  of  leucocytes  in  the  blood  of  the  newly  born  is  three  or 
four  times  that  of  the  adult,  being  on  the  average  18,000  per  cubic  milli- 
metre (Hayem).  The  variations  during  later  childhood  are  from  6,000  to 
12.000. 


*  la  Uskow's  classification  these  are  derived  as  "  ripe  "  and  "  over-ripe  "  cells  from 
the  lymphocyte,  which  is  regarded  as  the  young  or  "  unripe  "  cell. 


PLATE    XVI. 


Fiq.A. 


Fig.B. 

A.  The  Blood  ix  Leuc^:mia. 

1,  Eosinophile  cells ;  2,  myelocytes:  3.  polynuclear  neutrophile  r-ells;  4,  red  cells; 
5,  nucleated  red  cells;  6,  lymphocytes. 

B.  Pernicious  Anemia. 

1,  Megaloblasts  ;    2.  nucleated   megaloblasts ;    3.    a  polynuclear  neutrophile  cell : 
4,  poikilocytes.  ^  (After  Monti  and  Berggriin.) 


SIMPLE  ANEMIA.  797 

The  white  cells  may  be  said  to  be  increased — i.  e.,  leucocytosis  exists — 
when  their  proportion  to  tlie  red  cells  is  greater  than  1  to  200.  It  is  not 
yet  possible  to  state  the  exact  percentages  of  the  different  varieties  of  white 
cells  in  normal  blood.  The  polynuclear  cells  are,  however,  the  most  nu-, 
merous,  the  lymphocytes  next,  and  the  eosinophile  cells  least  frequent. 

Before  leaving  the  subject  of  the  .cells  of  the  blood  the  so-called 
blood-shadows  deserve  a  brief  mention.  These,  according  to  Silbermann, 
are  common  in  the  blood  of  the  newly  born,  but  diminish  with  the  age  of 
the  child.  They  contain  no  hsemoglobin.  The  existence  of  such  cells  is 
denied  by  some  observers,  who  regard  the  appearance  as  due  to  the  prepa- 
ration of  the  specimen. 

The  following  are  the  principal  peculiarities  in  the  blood  of  the 
newly  born  :  The  specific  gravity  and  the  haemoglobin  are  high.  The 
number  of  red  cells  is  considerably  higher  than  the  average  during  child- 
hood, and  the  same  is  true  to  a  less  degree  of  the  leucocytes.  The  red 
cells  vary  much  in  size.  They  show  less  tendency  to  form  rouleaux,  al- 
though this  is  denied  by  some  observers.  Nucleated  red  cells,  erythroblasts, 
are  found  for  a  day  or  two  in  small  numbers,  and  the  blood-shadows  of 
Silbermann  may  be  present. 

It  is  only  within  the  last  few  years  that  the  diseases  of  the  blood 
have  been  studied  with  anything  like  scientific  accuracy.  With  our  pres- 
ent knowledge  it  is  difficult  to  classify  accurately  the  various  forms  of 
aneemia.  The  essential  character  and  the  relation  of  the  different  forms 
to  one  another,  are  matters  upon  which  there  is  still  much  difference  of 
opinion  among  good  observers.  The  classification  here  presented  is  that 
which  has  received  the  most  general  adoption,  and  may  be  accepted  as  a 
provisional  one.  With  reference  to  the  nicer  points,  most  of  the  obser- 
vations made  prior  to  1885  must  be  taken  with  considerable  allowance. 

SIMPLE   ANEMIA. 

This  consists  in  an  impoverishment  of  the  blood,  especially  the  red 
cells,  and  a  corresponding  diminution  in  the  specific  gravity  and  in  the 
amount  of  hemoglobin.  It  is  essentially  a  secondary  aua?mia,  and  occurs 
apart  from  disease  of  the  blood-making  organs.  The  important  factors  in 
its  etiology  are,  first,  an  insufficient  production  of  blood  in  consequence  of 
deficient  food  or  interference  with  the  absorption  of  food,  and,  second,  an 
increased  drain  or  destruction  of  blood,  as  in  exhausting  diseases.  In- 
fancy and  childhood  are  themselves  strong  predisposing  causes  of  anaemia, 
on  account  of  the  great  demands  made  upon  the  blood  in  the  rapid  growth 
of  the  body. 

Etiology. — In  certain  cases  anremia  may  be  congenital,  as  in  infants 
born  of  delicate  or  antemic  parents,  or  where  the  mother  during  pregnancy 
has  suffered  from  some  serious  disease,  such  as  syphilis  or  nephritis.  Ac- 
quired anaemia  may  come  on  at  any  period  in  infancy  or  childhood.     The 


798        DISEASES  OP  THE  BLOOD,   LYMPH   NODES,   BONES,  ETC. 

cause  may  be  loss  of  blood,  as  in  haemorrhages  of  the  newly  born,  epistaxis, 
purpura,  scurvy,  or  hasmophilia.  None  of  these  are  very  common  etio- 
logical factors.  More  frequently  anaemia  depends  upon  a  loss  of  albumin 
of  the  blood,  as  in  prolonged  suppuration,  chronic  nephritis,  large  serous 
effusions  occurring  in  the  course  of  cardiac  disease,  certain  forms  of  diar- 
rhoea, and  in  malignant  disease.  Very  frequently  also  it  depends  upon 
improper  food,  or  disease  of  the  organs  of  digestion  or  assimilation,  as  in 
the  various  forms  of  chronic  diarrhosa,  ileo-colitis,  or  chronic  indigestion. 
These  cases  form  a  group  sometimes  classed  as  anaemia  from  inanition. 
In  infancy,  unhygienic  surroundings,  bad  air,  and  close  confinement  to 
unhealthy  apartments,  are  important  factors  in  producing  ana3mia.  In  a 
large  number  of  cases  the  ana3mia  is  of  toxic  origin.  In  this  group  may 
be  classed  not  only  cases  in  which  aua?mia  depends  upon  mineral  poisons 
introduced  into  the  body,  such  as  mercury  or  chlorate  of  potassium,  but 
also  the  poisons  of  all  the  infectious  diseases,  notably  diphtheria.  Febrile 
ansemia  is  not  entirely  due  to  toxic  causes.  It  depends  in  part,  no  doubt, 
upon  interference  with  digestion  and  assimilation.  Anfemia  may  be  due 
to  parasites  in  the  blood,  the  most  striking  illustration  being  the  Plasmo- 
dium malarias,  and  it  may  occasionally  arise  from  some  forms  of  intestinal 
worms.  The  etiology  of  the  ansemia  accompanying  certain  constitutional 
diseases,  such  as  rickets,  tuberculosis,  or  rheumatism,  is  of  a  complex 
character. 

Symptoms. — One  of  the  most  striking  symptoms  is  the  pallor  of  the 
skin  and  mucous  membranes,  although  this  is  by  no  means  an  infallible 
guide  to  the  degree  of  antemia.  Such  children  usually  exhibit  also  symp- 
toms of  malnutrition  :  their  muscles  are  soft  and  flabby ;  they  are  fre- 
quently thin  and  poorly  nourished,  but  occasionally  have  an  unusual 
amount  of  fat.  They  almost  invariably  suffer  from  digestive  disturbances, 
such  as  coated  tongue,  poor  appetite,  and  constipated  bowels.  The  ex- 
tremities are  often  cold,  the  pulse  is  rather  weak  and  often  slightly  irregu- 
lar. The  heart-sounds  are  feeble,  and  anemic  murmurs  may  be  heard 
either  over  the  heart  or  tliie  large  vessels  even  in  infancy,  and  occasionally 
a  venous  hum  may  be  heard  in  the  neck.  In  a  certain  number  of  cases 
of  moderate  severity  there  is  found  enlargement  of  the  spleen,  but  rarely 
to  the  degree  seen  in  leucaemia,  or  in  the  pseudo-leucgemia  of  infants. 
These  cases  were  formerly  classed  separately  as  "  splenic  anfemia." 

Nervous  symptoms  are  frequent.  Anaemic  children  are  fretful,  irrita- 
ble, and  often  exhibit  a  degree  of  nervousness  amounting  almost  to  chorea. 
Others  complain  of  headache  and  indefinite  pains.  Sleep  is  restless  and 
disturbed,  and  often  there  is  insomnia.  The  urine  is  scanty,  frequently 
pale,  and  in  many  cases  contains  an  excess  of  uric  acid ;  there  may  be 
enuresis.  Such  children  are  easily  fatigued,  they  frequently  suffer  from 
shortness  of  breath  upon  exercise,  and  occasionally  have  fainting  attacks. 
They  are  especially  prone  to  chronic  catarrhal  inflammations  of  the  nose, 


CHLOROSIS.  Y99 

pharynx,  and  bronchi.  Epistaxis  is  not  an  uncommon  symptom.  Leu- 
corrhoea  may  be  present  even  in  girls  of  three  or  four  years.  Dropsy  is 
not  infrequent  in  infants,  but  is  rather  more  common  in  older  children. 
In  infancy,  if  anaemia  comes  on  rapidly,  as  in  the  course  of  diarrhoeal  dis- 
eases, cerebral  symptoms  may  be  present. 

The  hlood. — The  changes  in  the  blood  depend  much  upon  the  grade 
of  anemia.  In  the  milder  forms  there  is  only  a  moderate  diminution  in 
the  specific  gravity  (1-043  to  1-046),  in  the  haemoglobin  (50  to  55  per  cent), 
and  in  the  number  of  red  cells,  with  very  slight  changes  in  their  form  or 
size.  There  is  no  increase  in  the  leucocytes,  although  they  are  relatively 
more  numerous  on  account  of  the  reduction  in  the  number  of  red  cor- 
puscles. 

In  more  severe  cases  the  haemoglobin  may  be  reduced  to  30  or  even  20 
per  cent,  the  specific  gravity  to  1-038  or  lower,  and  the  number  of  red 
cells  to  less  than  half  the  normal.  In  cases  of  such  severity  quite  marked 
changes  are  usually  present  in  their  size  and  form.  ]\Iicrocytes,  megalo- 
cytes,  poikilocytes,  and  nuclear  red  cells  (Plate  XVI)  may  be  present. 
The  leucocytes  in  many  cases  show  only  a  relative  increase  ;  in  others 
they  are  actually  increased,  and  may  be  twice  as  numerous  as  normal. 
Cases  of  this  severity  are  to  be  considered,  according  to  Monti  and  Berg- 
griin,  as  intermediate  between  simple  and  pseud o-leucaemic  anaemia. 

Prognosis. — The  course  and  termination  of  anaemia  depend  upon  its 
cause.  If  this  can  be  removed,  steady  improvement  and  recovery  mav  be 
expected.  In  extreme  cases  death  may  take  place,  but  rarely  from  the 
anemia,  usually  from  some  complicating  disease. 

In  making  a  prognosis  there  must  be  considered  not  only  the  general 
symptoms  and  the  cause  of  the  ansemia,  but  also  the  condition  of  the 
blood.  If  there  is  only  a  moderate  reduction  in  the  haemoglobin  and  in 
the  number  of  the  red  cells,  with  slight  changes  in  their  form  and  with  no 
increase  in  the  leucocytes,  the  prognosis  is  good.  If  the  hemoglobin  is 
reduced  below  30  per  cent,  if  the  number  of  red  cells  is  less  than  half 
the  normal,  and  marked  changes  in  form  are  present,  with  or  without 
great  increase  in  the  actual  number  of  leucocytes,  the  prognosis  is  less 
favourable. 

The  treatment  of  all  the  forms  of  angemia  will  be  considered  together 
at  the  close  of  the  chapter. 

CHLOROSIS. 

Chlorosis  is  a  primary  or  essential  anemia  which  usually  occurs  in 
young  girls  about  the  time  of  puberty.  It  is  characterized  by  a  peculiar 
greenish-yellow  tint  of  the  skin,  and  is  not  accompanied  by  emaciation. 
The  changes  in  the  blood  consist  in  a  very  great  reduction  in  the  hemo- 
globin without  a  corresponding  diminution  in  the  red  corpuscles. 

Etiology. — The  exact  cause  of  chlorosis  is  not  yet  fully  understood. 

53 


800        DISEASES   OF   THE   BLOOD,   LYMPH   NODES,   BONES,   ETC. 

The  disease  rarely  occurs  in  males,  the  great  majority  of  the  cases  being 
in  girls  between  the  fourteenth  and  seventeenth  years,  and  more  often  in 
blondes  than  in  brunettes.  Heredity  appears  to  be  a  factor  in  a  consider- 
able number  of  the  cases.  Among  the  other  causes  may  be  mentioned 
occupations  deleterious  to  health,  such  as  employment  in  factories  or  con- 
finement in  ill-ventilated  rooms;  insufficient  food  or  clothing;  psychical 
disturbances,  like  grief,  care,  or  fright ;  excessive  mental  or  physical 
strain ;  and  disorders  of  menstruation — although  the  latter  are  perhaps 
more  frequently  a  result  than  a  cause  of  the  disease.  Virchow  first  called 
attention  to  the  fact  that  chlorosis  might  depend  upon  a  congenital  nar- 
rowing of  the  aorta,  sometimes  associated  with  a  small  heart.  It  is  difficult 
to  reconcile  this  etiology  with  the  rapid  recovery  under  appropriate  treat- 
ment which  is  seen  in  most  of  the  cases. .  Andrew  Clark  has  advanced 
the  view  that  the  chief  cause  of  chlorosis  is  constipation  and  the  resulting 
absorption  of  toxic  materials  from  the  intestine.  The  intestinal  origin  of 
the  disease  has  beeii  lately  urged  witli  a  good  deal  of  force  by  Forchheimer. 

Lesions. — Chlorosis  is  rarely  fatal.  In  the  few  fatal  cases  the  lesions 
noted  have  been  dilatation  of  the  right  heart  with  hypertrophy  of  the  left 
ventricle,  a  small  aorta,  small  uterus  and  ovaries,  and  occasionally  round 
ulcer  of  the  stomach.  Under  the  microscope  there  may  be  found  a  very 
marked  degree  of  fatty  degeneration  of  the  heart  muscle,  and  sometimes 
of  the  inner  coat  of  the  blood-vessels. 

Symptoms. — The  general  symptoms  of  chlorosis  are  very  like  those  of 
simple  anaemia.  There  are  observed  shortness  of  breath  upon  exercise, 
palpitation,  syncope,  attacks  of  vertigo,  disturbances  of  digestion,  amenor- 
rhoea,  and  almost  invariably  constipation.  The  appetite  is  capricious,  it 
being  a  peculiarity  of  these  patients  to  crave  all  sorts  of  indigestible 
articles.  Instead  of  the  usual  pallor  of  anaemia,  the  skin  has  a  yellowish- 
green  tint,  from  which  the  term  "green-sickness"  has  arisen.  Occasion- 
ally patches  of  pigmentation  are  seen.  Anemic  cardiac  murmurs  may  be 
heard  in  various  situations,  most  frequently  a  systolic  murmur  at  the  base 
of  the  heart,  and  usually  loudest  over  the  pulmonic  area.  There  may  be  a 
venous  hum  in  the  neck.  In  some  marked  cases  there  is  evidence  of  slight 
cardiac  dilatation,  especially  of  the  right  heart,  and  there  may  be  hyper- 
trophy of  the  left  ventricle.  The  pulse  is  weak  and  soft,  oedema  of  the 
feet  is  frequent,  and  sometimes  there  is  slight  albuminuria.  In  some  cases 
there  is  fever.  Nervous  disturbances,  such  as  vague,  indefinite  pains,  at- 
tacks of  migraine,  supra-orbital  neuralgia,  various  hysterical  manifesta- 
tions, and  chorea,  are  common.  Ulcer  of  the  stomach  is  sometimes  seen 
as  a  complication. 

The  blood. — The  blood  changes  in  chlorosis  are  quite  constant.  The 
red  corpuscles  may  be  normal  or  but  slightly  diminished  in  number.  In 
many  cases  but  little  variation  from  the  normal  size  is  seen ;  in  others 
there  are  microcytes,  megalocytes,  and  poikilocytes.     The  red  corpuscles 


PSEUDO-LEUC^MIC  ANEMIA  OP  INFANCY.  801 

have  an  unusually  pale  colour.  The  number  of  leucocytes  is  normal  or 
very  slightly  increased.  The  haemoglobin  is  uniformly  reduced,  usually  to 
a  great  degree.     Osier  gives  44-1  per  cent  as  the  average  iu  forty  cases. 

Prognosis. — The  course  of  the  disease  is  essentially  a  chronic  one, 
often  lasting  for  a  year.  Relapses  are  quite  frequent.  Except  when  de- 
pendent upon  congenital  malformations  of  the  heart  and  blood-vessels, 
these  cases  regularly  recover  when  proper  treatment  can  be  carried  out. 
A  small  number  prove  fatal  by  the  development  of  tuberculosis  or  the 
occurrence  of  gastric  ulcer. 

Diagnosis. — The  diagnosis  is  in  most  cases  easily  made  from  the  etiol- 
ogy, the  functional  derangement  of  the  heart,  the  colour  of  the  skin,  and 
a  positive  diagnosis  always  by  an  examination  of  the  blood. 

PSEUDO-LEUC^MIC   ANEMIA  OF   INFANCY. 

This  form  of  ansemia  was  first  described  by  Von  Jaksch  in  1889,  and  is 
believed  to  be  peculiar  to  infants  and  young  children.  It  is  characterized 
by  marked  leucocytosis,  marked  reduction  in  the  number  of  red  corpuscles 
and  in  the  haemoglobin,  a  great  enlargement  of  the  sjileen,  and  sometimes 
a  moderate  enlargement  of  the  liver  and  the  lymphatic  glands.  This 
disease  is  not  to  be  confounded  with  the  pseudo-leucaemia  of  adults,  or 
Hodgkin's  disease,  which  is  purely  a  disease  of  the  lymphatic  glands  with 
secondary  anfemia,  but  without  any  leucocytosis. 

Etiology. — Of  the  cases  thus  far  recorded  the  majority  have  been 
between  the  ages  of  seven  and  twelve  months,  the  oldest  being  at  three 
and  a  half  years.  Of  twenty  cases  collected  by  Monti  and  Berggriin,*  six- 
teen showed  evidences  of  rickets  and  one  was  syphilitic.  Pseudo-leuccemia, 
however,  appears  to  occur  in  this  disease  only  when  the  splenic  enlarge- 
ment has  reached  a  certain  grade.  The  exact  cause  of  the  disease  is  still 
unknown,  and  its  essential  nature  is  a  matter  of  some  doubt.  Monti  be- 
lieves that  it  may  develop  from  the  more  severe  cases  of  ana?mia  which 
are  accompanied  by  leucocytosis,  as  he  has  observed  this  condition  before 
the  development  of  pseudo-leuceemia  and  during  its  subsidence.  The 
disease  may  terminate  in  ordinary  leuctemia,  and  possibly  in  pernicious 
anaemia. 

Lesions. — The  most  characteristic  change  is  found  in  the  spleen.  This 
organ  is  very  much  enlarged,  often  forming  an  abdominal  tumour,  which 
extends  as  low  as  the  crest  of  the  ilium  and  as  far  forward  as  the  umbilicus. 
It  is  firm,  hard,  the  surface  appears  somewhat  wrinkled,  and  there  may 
be  evidences  of  perisplenitis.  The  microscope  shows  an  increase  of  cellu- 
lar elements,  a  few  cells  containing  haemoglobin  (Luzet).t  Enlargement 
of  the  liver  is  less  constant,  it  being  normal  in  more  than  half  the  cases. 
There  is  no  relation  between  the  size  of  the  spleen  and  that  of  the  liver. 

*  Die  chronisehe  Aniimie  im  Kindesiilter.  Leipsic,  1893.         f  TliOse,  Paris,  1891. 


802       DISEASES  OP  THE  BLOOD,  LYMPH  NODES,  BONES,  ETC. 

The  hepatic  cells  are  unchanged.  Enlargement  of  the  lymph  glands  has 
been  noted  in  about  half  the  reported  cases,  the  swelling  affecting  the 
cervical,  axillary,  or  inguinal  glands ;  but  it  is  rarely  great.  A  moist  ap- 
j)earance  and  a  diffuse  redness  of  the  bone-marrow  have  been  described 
by  Luzet,  the  changes  being  usually  most  marked  about  the  epiphyses. 

Symptoms. —  Tlie  blood. — The  number  of  reported  cases  is  as  yet  too 
small  to  make  positive  statements  possible  upon  all  points.  The  most 
constant  features  noted  thus  far  are  the  following : 

The  specific  gravity  is  lowered,  the  usual  range  being  between  1-035  and 
1*044.  The  reduction  of  the  hasmoglobin  is  very  great ;  in  many  of  the 
cases  it  has  been  as  low  as  30  per  cent,  and  in  a  few  below  25  per  cent.  The 
leucocytes  are  increased  in  number,  this  being  one  of  the  striking  features 
of  the  disease.  In  ordinary  cases  the  proportion  of  leucocytes  to  red  cor- 
puscles is  1  to  100  or  1  to  75.  In  severe  cases  the  proportion  may  be  as 
high  as  1  to  20  or  even  as  1  to  13.  All  the  usual  varieties  of  leucocytes 
are  seen,  the  proportions  of  these  varying  much  in  the  different  cases. 
The  red  corpuscles  are  reduced  in  number  in  proportion  to  the  severity 
of  the  disease,  usually  to  from  G5  to  75  per  cent,  but  they  may  be  as  low 
as  35  or  even  25  per  cent.  In  six  of  twenty  cases  the  actual  number  was 
below  1,600,000  (Monti  and  Berggriin).  More  characteristic  than  any  of 
the  above  features  are  the  changes  in  the  appearance  of  the  red  cells. 
Very  marked  inequality  in  their  size  and  shape  is  seen  in  most  of  the 
cases.  Many  microcytes  are  present ;  also  greo.t  numbers  of  nuclear 
red  blood-cells  (erythroblasts),  normoblasts,  and  megaloblasts  with  divid- 
ing nuclei.  These  are  seen  to  some  degree  in  other  forms  of  anaemia, 
particularly  in  the  pernicious  variety  and  in  the  severe  types  of  simple 
anaemia,  but  they  are  more  abundant  in  pseudo-leucaemia.  The  larger  the 
proportion  in  which  they  are  present  the  worse  the  prognosis.  Finally, 
there  is  occasionally  seen  a  division  of  the  nuclei  of  the  red  cells  (karyo- 
kinesis),  regarded  by  some  as  characteristic  of  the  disease,  although  this 
is  not  admitted  by  all. 

The  general  symptoms  of  the  disease  develop  slowly  and  with  the 
usual  signs  of  anemia.  In  some  cases  the  infants  continue  to  be  plump 
and  well  nourished.  Pallor  is  usually  very  marked.  Enlargement  of  the 
spleen  is  so  great  that  it  can  hardly  be  overlooked  if  the  abdomen  is  ex- 
amined. The  glandular  enlargements  are  not  marked,  and  in  many  cases 
are  wanting  altogether. 

The  coarse  of  the  disease  is  essentially  chronic.  Cases  liave  been  seen 
in  which  pseudo-leuctemia  developed  from  an  ordinary  severe  simple 
ana?mia  in  the  course  of  a  few  weeks.  The  symptoms  and  blood  changes 
generally  come  on  slowly  in  the  course  of  weeks  or  months,  and  sometimes 
remain  nearly  stationary  for  as  long  a  period  as  several  months,  aud  then 
slowly  improve.  In  other  cases  they  grow  gradually  worse,  and  the 
changes  in  the  blood  come  to  be  the  same  as  in  ordinary  leucaemia.     Some 


PERNICIOUS  ANEMIA.  803 

observers  are  inclined  to  believe  that  the  disease  is  really  an  early  stage  of 
leucffimia,  which  does  not  reach  its  full  development  because  the  children 
succumb  too  early.  In  the  cases  going  on  to  recovery,  there  is  noticed 
improvement  in  the  general  symptoms  coincident  with  a  diminution  in 
the  size  of  the  spleen,  a  reduction  in  the  number  of  leucocytes,  an  increase 
in  the  red  corpuscles,  the  haemoglobin,  and  the  specific  gravity,  and  a 
gradual  disappearance  of  the  erythroblasts. 

Prognosis. — In  Monti's  list  of  twenty  cases  four  proved  fatal ;  one  re- 
covered, in  which  the  proportion  of  leucocytes  to  the  red  corpuscles  had 
been  1  to  12.  The  prognosis  should  always  be  guarded,  for,  although 
improvement  may  take  place,  patients  are  very  apt  to  be  carried  off  by 
intercurrent  disease. 

Diagnosis. — The  diagnosis  is  to  be  made  from  simple  anajmia  with 
leucocytosis,  and  from  leuc^mia.  In  simple  anaemia  the  leucocytosis  is 
not  so  great,  and  it  is  not  accompanied  by  such  a  degree  of  splenic  enlarge- 
ment. In  leucaemia  the  reduction  in  the  red  cells  and  in  the  haemoglobin 
is  very  rarely  as  great  as  in  j)seudo-leuc£emia. 

-      PERNICIOUS   ANEMIA. 

This  is  the  most  severe  form  of  anasmia  known.  Its  cause  and  essen- 
tial nature  are  as  yet  very  imperfectly  understood.  It  is  characterized 
by  quite  uniform  blood  changes  and  by  the  general  symptoms  of  a  v^ry 
marked  autemia,  and  it  tends  to  go  on  from  bad  to  worse,  terminating 
fatally  in  the  great  proportion  of  cases. 

Etiology. — Pernicious  anaemia  is  a  rare  disease  in  childhood,  and  espe- 
cially rare  in  infancy.  In  the  cases  which  have  been  observed  in  early 
life  the  following  etiological  factors  have  been  noted  :  It  has  been  associ- 
ated with  hereditary  syphilis  and  with  severe  rickets,  especially  when  ac- 
companied by  a  marked  enlargement  of  the  spleen.  It  has  follow^ed  other 
diseases,  especially  grave  disturbances  of  nutrition.  Sometimes  simple 
anaemia,  when  severe  and  of  long  standing,  has  gradually  developed  into 
the  pernicious  type.  In  a  few  instances  parasites,  particularly  tapeworms, 
have  been  the  cause.  Pernicious  anaemia  has  in  some  instances  occurred 
in  patients  where  no  cause  whatever  could  be  assigned. 

Many  theories  have  been  advanced  in  explanation  of  pernicious  anae- 
mia. The  one  which  at  present  appears  to  have  most  in  its  favour  is  that 
the  disease  consists  in  a  great  destruction  of  the  red  blood-cells,  particu- 
larly in  the  liver,  and  that  this  is  brought  about  through  the  agency  of 
some  poison  or  poisons  taken  up  from  the  intestine  by  the  portal  circula- 
tion.* This  has  been  advanced  by  Hunter  and  others  in  explanation  of 
the  peculiar  deposit  of  iron  found  in  the  hepatic  cells. 

*  For  fuller  discussion  of  this  theory  of  pernicious  anaemia,  see  Griffith  and  Burr, 
the  Medical  News,  October  17,  1891. 


804       DISEASES   OP   THE   BLOOD,   LYMPH   NODES,   BOXES,  ETC. 

Lesions. — There  is  found  a  very  high  grade  of  anaemia  in  all  the  in- 
ternal organs,  fatty  degeneration  of  the  heart  and  blood-vessels,  and  some- 
times also  of  the  liver  and  kidneys,  with  numerous  capillary  hseraorrhages 
in  the  various  organs.  The  most  characteristic  post-mortem  change, 
however,  according  to  Hunter,  consists  in  the  deposit  of  iron  in  the 
hepatic  cells.  Its  distribution  is  peculiar  and  unlike  that  seen  in  any 
other  disease. 

Symptoms. —  The  blood. — Both  the  specific  gravity  and  hajmoglobin 
are  much  reduced,  the  latter  usually  below  25  per  cent,  and  in  several 
instances  below  15  per  cent,  but  the  percentage  is  still  distinctly  greater 
than  that  of  the  red  cells.  One  of  the  most  striking  changes  is  the  great 
reduction  in  the  number  of  the  red  blood-corpuscles,  the  number  of  which 
is  lower  than  in  any  other  form  of  anemia,  the  reduction  being  greater 
than  in  the  haemoglobin.  Very  often  the  number  has  been  reduced  below 
500,000  in  a  cubic  millimetre.  Marked  inequality  is  seen  in  the  distribu- 
tion of  the  hfemoglobin  in  the  red  corpuscles,  some  being  almost  colour- 
less while  others  are  deeply  stained.  There  is  great  variety  in  the  size 
and  form  of  the  red  cells,  this  generally  being  proportionate  to  the  severity 
of  the  disease.  There  are  found  microcytes  and  poikilocytes,  but  espe- 
cially characteristic  is  the  large  number  of  macrocytes.  There  are  many 
nuclear  red  blood-corspucles,  both  normoblasts  and  megaloblasts  (Plate 
XVI,  B).  The  reduction  in  the  number  of  the  leucocyt.es  is  usually  in 
proportion  to  that  of  the  red  corpuscles.  This  is  a  jieculiar  feature  of 
this  disease  (Monti  and  Berggriin).  In  most  of  the  other  conditions  at- 
tended by  reduction  in  the  number  of  red  cells  the  leucocytes  are  relatively 
increased. 

The  general  symptoms  are  those  of  a  most  intense  anaemia.  There  is 
marked  pallor  of  the  skin  and  mucous  membranes,  with  great  weakness 
and  prostration.  Various  anasmic  heart  murmurs  are  heard.  There  is 
dyspnoea,  and  usually  the  urine  is  scanty  and  of  low  specific  gravity. 
There  may  or  may  not  be  emaciation.  The  late  symptoms  are  haemor- 
rhages from  the  nose  and  other  mucous  membranes,  subcutaneous  ecchy- 
moses  with  dropsy  of  the  feet  and  ankles,  and  sometimes  of  the  large 
serous  cavities  of  the  body,  but  without  albuminuria.  In  many  cases  fever 
is  present.  This  may  be  so  high  as  to  lead  to  the  suspicion  of  some  acute 
infectious  process. 

The  course  of  the  disease  is  chronic,  it  being  in  most  cases  several 
months.  In  some,  however,  the  progress  is  so  rapid  that  death  may  occur 
within  two  or  three  months  from  the  beginning  of  marked  symptoms. 
As  a  rule,  the  symptoms  are  steadily  progressive  until  death  occurs ;  the 
only  exceptions  being  the  cases  in  which  the  disease  depends  upon  some 
intestinal  i:)arasite  ;  here  improvement  and  even  recovery  may  occur. 

Diagnosis. — This  is  to  be  made  from  other  forms  of  anaemia  only  by 
the  blood  examination ;  the  most  important  points  with  reference  to  red 


PERNICIOCS  ANEMIA.  805 

corpuscles  are  the  great  reduction  in  their  number,  the  unequal  distribu- 
tion of  haemoglobin,  the  marked  irregularities  in  form  and  shape,  and  the 
presence  of  many  large  nuclear  forms ;  with  reference  to  the  leucocytes,  a 
reduction  in  number  proportionate  to  that  of  the  red  cells. 

Treatment  of  the  Different  Forms  of  Anaemia. — In  secondary  ameviia 
the  thing  of  the  first  importance  is  to  discover  and  treat  the  primary 
condition  upon  which  the  antemia  depends.  In  infancy,  special  attention 
should  be  given  to  diet  and  hygiene,  particularly  with  reference  to  an 
abundant  supply  of  fresh  air.  The  whole  manner  of  life  of  these  patients 
must  be  carefully  studied  and  managed  according  to  the  directions  laid 
down  in  the  chapter  upon  Malnutrition,  with  which  condition,  especially 
in  infancy,  a  very  large  number  of  these  cases  are  associated.  The  general 
treatment  referred  to  is  often  more  important  than  the  administration  of 
the  preparations  of  iron,  which,  however,  should  never  be  omitted. 

The  preparations  of  iron  available  for  infants  are  the  Drees's  albumi- 
nate, the  pepto-manganate  (Gude),  the  bitter  wine,  the  malate  and  the 
citrate.  The  dose  should  be  regulated  according  to  the  age  of  the  child. 
Older  children  may  take  the  same  preparations  as  adults,  especially  Blaud's 
pills.  Much  benefit  is  seen  from  combining  arsenic  with  iron,  or  from 
alternating  the  two.  Arsenic  should  be  used  in  conjunction  with  iron  in 
every  anaemia  in  which  there  is  enlargement  of  the  spleen  or  lymphatic 
glands.  In  addition  to  these  remedies,  cod-liver  oil  should  be  given 
throughout  the  entire  cold  season. 

In  chlorosis  more  decided  results  are  seen  from  the  use  of  iron  than 
in  any  other  form  of  anajmia.  Blaud's  pills  are  here  the  favourite  method 
of  administration,  and  are  advantageously  combined  with  small  doses  of 
nux  vomica  and  aloin  to  overcome  the  tendency  to  constipation.  Arsenic 
is  useful  in  these  cases  also.  Great  benefit  in  chlorosis  results  from 
change  of  air  and  change  of  scene,  thus  removing  the  patient  from  all 
sources  of  nervous  excitement  or  disturbance.  The  general  condition, 
diet,  and  habits  of  life  should  also  receive  careful  attention,  particularly 
the  condition  of  the  bowels.  The  use  of  oxygen  is  a  valuable  adjuvant  in 
the  treatment  of  cases  not  yielding  to  iron  alone.  It  is  important  that  the 
administration  of  iron  should  be  continued  for  several  months  after  the 
disappearance  of  all  symptoms,  on  account  of  the  tendency  to  relapses. 

In  the  jjseudo-leiicmmic  anmmia  of  infants,  arsenic  is  decidedly  the 
most  valuable  drug,  but  should  be  given  in  combination  with  iron. 
Fowler's  solution  is  the  best  preparation  for  infants ;  the  dose  should 
rarely  be  more  than  one  drop,  which  should  be  repeated  four  or  five 
times  daily  after  feeding,  and  continued  for  a  long  time.  The  general 
treatment  of  these  patients  is  the  same  as  in  cases  of  simple  ana?mia. 
When  rickets  is  present  cod-liver  oil  and  phosphorus  should  be  added. 

In  pernicious  anmmia,  arsenic  offers  a  much  better  prospect  of  im- 
provement than  iron.     Beginning  with  small  doses,  the  amount  should  be 


806       DISEASES  OF  THE  BLOOD,   LYMPH  NODES,  BONES,  ETC. 

gradually  increased  up  to  the  point  of  tolerance,  very  much  as  in  cases  of 
chorea. 

In  every  case  of  ansemia  the  most  careful  attention  should  be  given  to 
the  general  condition,  particularly  guarding  against  exposure  to  cold  and 
dampness.  The  feeble  circulation  of  these  patients  renders  them  pecul- 
iarly susceptible.  Caution  should  also  be  given  against  much  muscular 
exercise..  With  a  severe  grade  of  ausmia  very  active  exercise  should  be 
prohibited,  and  many  of  these  patients  do  best  when  complete  rest  in  bed, 
either  for-,  the  entire  time  or  for  a  considerable  part  of  each  day,  is  in- 
sisted upon.     This  ajiplies  to  children  of  all  ages. 

LEUC^MIA. 

This  is  a  disease  in  which  the  essential  feature  is  a  great  increase  in 
the  number  of  leucocytes,  with  a  moderate  reduction  in  the  number  of 
red  corpuscles,  and  the  presence  in  the  blood  of  cellular  forms  not  found 
in  other  diseases. 

Etiology. — Leucsemia  is  a  rare  disease  in  childhood,  but  has  been  seen 
even  in  early  infancy.  Its  greater  frequency  in  males  holds  good  even  in 
childhood.  In  a  small  number  of  cases  heredity  seems  of  some  importance 
as  an  etiological  factor.  Leuc^mia  may  follow  syphilis,  rickets,  malaria, 
or  even  simple  anaemia,  or  it  may  occur  as  a  primary  disease  in  children 
previously  healthy.     In  the  great  majority  of  cases  the  cause  is  unknown. 

Lesions. — The  essential  lesions  of  leuc^mia  are  found  in  the  spleen, 
the  lymphatic  glands,  and  the  bone-marrow.  In  rare  cases  the  most  im- 
portant changes  are  in  the  lymphatic  glands,  giving  rise  to  the  lymphatic 
form  of  leucaemia.  In  such  cases  the  changes  in  the  spleen  or  marrow 
may  be  slight  or  absent.  Changes  in  the  spleen  and  marrow  are,  however, 
usually  associated,  giving  rise  to  what  is  known  as  the  s])leno-myelogen- 
ous  form  of  the  disease,  which  is  the  most  frequent  variety.  The  spleen 
is  usually  enormously  enlarged,  sometimes  filling  half  the  abdominal 
cavity.  In  the  early  stage  it  is  soft,  vascular,  and  of  a  dark-red  colour ; 
in  the  late  stages  it  is  firm  and  hard,  and  usually  deeply  fissured  at  its 
margin.  There  may  be  perisplenitis.  On  section,  light-gray  patches  of 
lymphoid  tissue  may  be  seen  scattered  throughout  the  organ,  and  in  some 
instances  there  may  be  wedge-shaped  infarctions.  The  microscope  shows 
thickening  of  the  trabecular  and  deposits  of  lymphoid  tissue,  especially 
about  the  arteries.  The  bone-marrow  is  of  a  yellowish-green  or  dark- 
brown  colour,  and  shows  immense  numbers  of  nuclear  red  corpuscles  in 
all  stages  of  development,  and  many  cells  corresponding  to  the  myelocytes 
found  in  the  blood.  The  lymphatic  glands,  when  they  are  involved,  are 
not  so  uniformly  enlarged  as  is  the  spleen.  Any  of  the  external  glands 
of  the  body  may  be  affected,  the  cervical,  axillary,  and  the  inguinal,  or 
the  mesenteric,  tracheo-bronchial,  the  tonsils,  and  even  the  lymph  nodules 
of  the  small  and  large  intestines.     The  changes  in  the  glands  are  gen- 


LEUC^MIA.  807 

erally  those  of  a  simple  hyperplasia.  The  liver  is  enlarged  in  very  many 
of  the  cases,  chiefly  from  an  infiltration  with  lymphoid  tissue,  which  may 
be  diffuse  or  may  occur  in  patches.  Less  frequently  similar  lymphoid 
masses  are  seen  in  other  organs. 

Symptoms.— T'/ie  blood  (Plate  XVI,  A).— In  gross  appearance  the 
blood  is  paler  than  normal,  and  the  clot  of  a  yellowish-green  colour.  The 
fibrin  is  usually  increased.  Both  the  specific  gravity  and  the  haemoglobin 
are  diminished,  the  latter  often  being  reduced  to  25  per  cent.  The  most 
important  change  is  in  the  leucocytes.  These  are  enormously  increased, 
the  proportion  often  being  one  to  five  of  the  red,  and  sometimes  even  one 
to  two. 

In  the  spleno-myelogenous  variety  the  predominant  form  is  the  large 
mononuclear  cells  with  neutrophile  granules,  and  are  known  as  myelocytes 
(A,  2).  The  presence  of  the  neutrophile  granules  distinguishes  them  from 
other  mononuclear  cells.  The  source  of  these  is  the  bone-marrow,  and 
they  are  not  found  in  the  lymphatic  variety  of  the  disease.  In  addition 
there  is  often  an  increase  in  the  eosinophile  cells  (A,  1).  The  lympho- 
cytes are  relatively  diminished  ;  the  percentage  of  the  polynuclear  neutro- 
phile cells  (A,  3)  is  normal  or  diminished.  The  red  corpuscles  are  mod- 
erately reduced  in  number,  usually  to  from  30  to  50  per  cent,  and  exhibit 
the  irregularities  in  form  and  shape  seen  in  other  varieties  of  anaemia. 
There  are  also  nuclear  red-corpuscles  present  whose  nuclei  are  some- 
times undergoing  division. 

In  the  lymphatic  form  of  the  disease,  the  blood  shows  quite  marked 
differences.  The  increase  in  the  leucocytes  is  not  so  great,  and  is  due 
solely  to  the  increase  in  the  number  of  lymphocytes,  the  myelocytes 
being  absent.  Occasionally  both  forms  of  the  disease  may  be  com- 
bined. 

The  other  symptoms  of  leucfemia  in  children  resemble  those  in  adults, 
with  the  difference  that,  as  a  rule,  the  progress  of  the  disease  is  much  more 
rapid  in  early  life.  In  most  of  the  cases  the  early  symptoms  are  latent. 
A  sudden  and  alarming  haemorrhage  is  sometimes  the  first  thing  to  call 
attention  to  the  serious  condition.  In  other  cases  there  are  only  the 
symptoms  of  general  weakness  and  aneemia.  Sometimes  the  splenic 
tumour  or  the  enlargement  of  the  lymphatic  glands  is  first  noticed.  In 
the  early  part  of  the  disease,  the  usual  symptoms  of  ana?mia  are  pres- 
ent,— digestive  disturbances,  shortness  of  breath,  weak  and  rapid  pulse. 
HiBmorrhages  may  occur  as  an  early  or  late  symptom ;  they  are  most 
frequently  from  the  nose,  but  severe  ha?morrhages  may  occur  from  the 
stomach,  the  mouth,  tlie  intestines,  or  there  may  be  ecchymoses  upon  the 
skin.  The  enlargement  of  the  spleen  may  be  sufficiently  marked  to  form 
an  abdominal  tumour,  so  as  to  attract  the  attention  even  of  the  parents. 
The  swelling  of  the  liver  is  not  so  great.  The  lymphatic  glands  are 
enlarged  only  to  a  moderate  degree,  and  in  many  cases  this  symptom  is 


808        DISEASES   OF   THE   BLOOD,   LYMPH   NODES,  BONES,  ETC. 

absent  altogether.  They  are  painless,  movable,  and  usually  several  groups 
are  affected. 

The  late  symptoms  are  dropsy  of  tlie  feet  or  general  anasarca,  haemor- 
rhages, diarrhoea,  headaches,  general  weakness,  and  attacks  of  fainting. 
Fever  is  quite  constant  in  the  late  stages  of  the  disease,  and  the  tem- 
perature may  be  from  101°  to  103°  F.  The  urine  may  contain  albumin 
and  casts.  Vision  is  sometimes  disturbed  by  the  formation  of  leuca?mic 
plaques  in  the  retina.  It  is  rare  that  there  are  any  symptoms  referable 
to  the  bones,  although  expansion  and  tenderness  of  the  Hat  bones  have 
been  observed." 

Course  and  Prognosis. — The  course  of  leucaemia  is  chronic,  and  in 
most  cases  slowly  progressive,  but  not  always  so.  The  prognosis  is  very 
bad,  the  great  proportion  of  the  cases  in  children  proving  fatal  within  a 
year  from  the  first  symptoms,  in  infancy  sometimes  in  two  or  three 
months.  There  has  been  described  by  Epstein  and  others  an  acute  form 
of  the  disease,  proving  fatal  in  a  few  weeks.  The  usual  causes  of  death 
are  exhaustion,  haemorrhages,  and  broncho-pneumonia. 

Diagnosis.— This,  in  children,  has  to  be  made  chiefly  from  simple 
anaemia  with  leucocytosis,  and  pseudo-leuctemic  anaemia.  Without  a  blood 
examination  this  is  impossible.  Reliance  is  to  be  placed  upon  the  enor- 
mous increase  in  the  leucocytes,  and  especially  upon  the  presence  of  mye- 
locytes. In  the  other  diseases  mentioned  there  is  simply  an  increase  in 
the  usual  varieties  of  leucocytes ;  different  forms  may  predominate  in 
different  cases,  but  no  new  ones  are  present. 

Treatment. — The  general  treatment  of  leucaemia  should  be  the  same 
as  that  of  anaemia.  Of  the  drugs  now  in  use,  arsenic  has  altogether  the 
most  testimony  in  its  favour.  It  must  be  given  in  large  doses  and  for  a 
long  period.  Next  to  this  in  value  come  iron  and  cod-liver  oil.  Leu- 
csemia,  however,  is  in  most  instances  very  little  influenced  by  treatment. 
The  reported  cures  must  be  taken  with  some  allowance,  for  most  of  these 
were  published  before  the  time  when  leuctemia  was  sharply  differentiated 
from  simple  anaemia  with  leucocytosis  and  from  the  pseudo-leucaemic 
anaemia  of  infancy. 

HEMOPHILIA. 

Haemophilia  is  an  hereditary  disease,  in  which  there  is  a  tendency  to 
profuse  or  even  uncontrollable  bleeding  from  slight  wounds,  or  some- 
times even  spontaneously.  In  many  cases  there  is  associated  an  inflam- 
mation of  the  joints.     Persons  so  affected  are  known  as  "  bleeders." 

Etiology. — The  hereditary  tendency  of  the  disease  is  very  strongly 
marked,  and  it  has  often  been  traced  through  seven  or  eight  generations. 
Males  are  much  more  frequently  affected  than  females,  the  proportion  being 
about  twelve  to  one.  In  the  matter  of  inheritance,  the  disease  is  most 
often  transmitted  through  the  mother,  who  may,  however,  herself  escape. 


PURPURA.  809 

Patients  sufiFering  from  haemophilia  lijive  nothing  else  about  them  that  is 
abnormaL  The  exact  nature  of  the  disease  is  unknown.  It  has  no  con- 
nection witli  either  purpura  or  scurvy.  Although  generally  classed 
among  the  diseases  of  the  blood,  it  has  not  been  established  that  there  are 
any  constant  changes  either  in  the  blood  or  in  the  blood-vessels. 

Symptoms. — The  first  manifestations  of  hajmophilia  are  not  often  seen 
before  the  second  year.  The  haemorrhages  of  the  newly  born  have  no 
relation  to  this  condition.  The  discovery  of  the  disease  is  generally  quite 
accidental.  The  first  hgemorrhage  may  be  traumatic  or  spontaneous.  In 
traumatic  haemorrhages  there  may  be  very  severe  bleeding  after  so  slight 
a  wound  as  the  drawing  of  a  tooth  ;  sometimes  a  large  hsematoma  forms 
between  the  muscles  as  the  result  of  a  moderate  contusion. 

The  following  is  the  relative  frequency  of  spontaneous  haemorrhages 
in  334  cases  collected  by  Graudidier :  bleeding  from  the  nose  in  169, 
mouth  in  43,  intestines  in  30,  stomach  in  15,  urethra  in  IG,  lungs  in  17. 
There  may  be  hemorrhage  from  the  skin  or  from  any  mucous  membrane 
of  the  body.  The  attacks  of  spontaneous  haemorrhage  are  often  periodical, 
and  may  be  accompanied  by  arthritic  symptoms  resembling  rheumatism. 
The  severity  of  the  haemorrhages  varies  much  in  the  different  cases. 
From  a  slight  wound  a  patient  may  bleed  until  he  is  exsanguinated, 
and  even  until  death  occurs.  Such  a  result  from  the  first  haemorrhage, 
however,  is  rare.  In  some  cases  the  disposition  to  bleed  is  outgrown  in 
later  life.  Grandidier  states  that,  of  152  boys,  over  one  half  died  before 
reaching  the  seventh  year.  It  is  striking  that  when  the  disease  affects 
females  there  is  no  tendency  to  excessive  bleeding  at  menstruation  or 
parturition. 

Treatment. — The  indications  at  the  time  of  bleeding  are,  to  arrest  the 
haemorrhage  by  the  use  of  the  ordinary  surgical  means — compression, 
styptics,  etc.— and  the  nares  should  be  plugged  for  severe  epistaxis.  Lit- 
tle benefit  is  to  be  expected  from  drugs.  In  convalescence  after  attacks 
of  hemorrhage,  iron  and  general  tonics  should  be  given.  In  all  patients 
who  are  bleeders  everything  which  might  by  any  means  excite  haemor- 
rhage should  be  avoided.  Marriage  should  be  discouraged  in  girls  who 
inherit  the  disease. 

PURPURA. 

The  term  purpura  is  used  to  designate  a  condition  in  which  there  is  a 
tendency  to  spontaneous  hemorrhages  beneath  the  skin,  from  the  various 
mucous  membranes,  and  in  some  cases  into  the  internal  organs.  The 
term  purpura  simplex  is  applied  to  those  cases  in  which  the  haemor- 
rhages are  limited  to  the  skin  ;  purpura  luemorrliagica  to  those  in  Avhich 
there  is  in  addition  bleeding  from  the  mucous  membranes  or  visceral 
hemorrhages.  It  is  impossible  to  draw  a  line  sharply  between  these  two 
classes  of  cases,  as  the  chief  difference  between  them  seems  to  be  one  of 


810       DISEASES  OP  THE  BLOOD,  LYMPH  NODES,  BONES,  ETC. 

degree.     Purpura  is  sometimes  known  as  morbus  mncvlosns  or  as  Werlkof^s 
disease. 

Symptomatic  Purpura. — This  occurs  in  quite  a  variety  of  conditions, 
the  haemorrhages  generally  being  limited  to  the  skin,  but  not  always  so. 
These  cases  may  be  grouped  in  the  following  classes : 

1.  Lifections. — This  form  of  purpura  is  very  constantly  seen  in  ma- 
lignant endocarditis,  in  the  ha?morrhagic  forms  of  the  various  eruptive 
fevers — measles,  scarlet  fever,  variola,  vaccinia,  and  typhus — also  in  epi- 
demic meningitis  and  occasionally  in  diphtheria,  pyaemia,  and  septicae- 
mia. The  occurrence  of  hemorrhages  in  these  cases  appears  to  depend 
upon  an  altered  condition  of  the  blood,  which  is  a  direct  result  of  the  in- 
fection. In  most  of  the  diseases  mentioned  it  is  a  bad  prognostic  sign, 
as  it  indicates  a  severe  form  of  the  disease,  but  it  requires  no  special 
treatment. 

2.  Cachectic. — Purpura  occurs  late  in  the  course  of  many  protracted 
and  exhausting  diseases,  especially  in  infancy.  It  is  most  frequently  met 
with  in  broncho-pneumonia,  empyema,  tuberculosis,  ileo-colitis,  in  both 
the  tuberculous  and  the  simple  forms  of  meningitis,  and  in  malignant 
disease.  It  also  occurs  from  apparently  similar  causes  in  several  of  the 
diseases  of  the  blood,  particularly  in  leucaemia  and  pernicious  anemia, 
and  occasionally  it  is  seen  in  chronic  nephritis  and  in  cardiac  disease.  In 
most  cases  of  cachectic  purpura  the  hemorrhagic  spots  are  not  very 
abundant,  and  occur  either  upon  the  abdomen  or  the  lower  extremities. 
They  are  usually  small,  but  when  once  they  have  appeared  new  spots 
usually  continue  to  come  until  death.  This  form  is  quite  common  in 
hospital  practice,  and  when  occurring  in  the  course  of  the  diseases  men- 
tioned it  is  almost  invariably  indicative  of  a  fatal  result.  Cachectic  pur- 
pura is  usually  limited  to  the  skin,  hemorrhages  from  the  mucous 
membranes  being  infrequent  and  visceral  hemorrhages  very  rare.  The 
condition  is  undoubtedly  dependent  upon  a  deterioration  in  the  blood 
possibly  also  upon  the  condition  of  the  minute  blood-vessels  themselves. 
Purpura  adds  nothing  to  the  severity  of  the  original  disease,  but  is  an 
indication  of  how  extensive  the  blood  changes  are.  It  requires  no  special 
treatment. 

3.  Toxic. — Certain  drugs,  such  as  phosphorus,  quinine,  potassium 
chlorate  and  sometimes  others,  may  produce  hemorrhages  when  long 
continued  or  in  large  doses.  The  hemorrhage  of  jaundice  may  also  be 
considered  in  this  group.  All  these  conditions  are  extremely  rare  in 
childhood. 

4.  Mechanical  hemorrhages,  such  as  those  occurring  in  pertussis  or 
epilepsy,  are  sometimes  classed  w4th  purpura.  In  convalescence  from  pro- 
tracted illness  there  are  sometimes  seen,  when  patients  first  stand  or  walk, 
purpuric  spots  on  the  lower  extremities.  I  have  seen  it  after  diphtheria. 
It  may  occur  after  prolonged  confinement  of  a  limb  in  bandages  or  splints. 


PURPURA.  811 

In  both  these  cases  the  cause  is  partly  mechanical  and  partly  due  to  the 
weakened  condition  of  the  blood-vessels. 

5.  Neurotic. — These  cases  are  occasionally  seen  in  diseases  of  the  spinal 
cord  and  sometimes  in  hysteria  in  young  adults,  but  very  rarely  in  children. 

Primary  Purpura. — This  occurs  in  children  of  all  ages,  being  not  un- 
common in  infancy.  Hemorrhages  of  the  newly  born  have  not  generally 
been  included  in  this  class,  although  there  are  some  reasons  why  they 
might  well  be.  The  age  at  which  primary  purpura  is  most  frequently 
seen  is  from  two  to  ten  years.  The  sexes  are  about  equally  ailected ; 
of  Steffen's  56  cases,  27  were  males  and  29  females.  The  disease  may 
occur  in  children  who  are  cachectic,  rachitic,  or  ana3mic,  and  in  those  whose 
surroundings  are  poor,  but  it  has  not,  like  scurvy,  any  close  relation  to 
diet.  It  may  follow  any  acute  disease,  being  associated  most  frequently 
with  derangements  of  the  stomach  and  bowels.  Quite  frequently  the 
disease  develops  abruptly,  without  any  assignable  cause,  in  children  pre- 
viously healthy.  It  is  not  contagious.  Epidemics  of  purpura  have  been 
reported,  but  these  are  somewhat  doubtful,  as  they  were  recorded  before 
this  disease  was  sharply  differentiated  from  scurvy.  The  association  of 
purpura  with  rheumatism  will  be  considered  later. 

Lesions. — The  external  haemorrhages  may  occur  upon  any  part  of  the 
body.  There  are  smaller  or  larger  ecchymoses  or  an  infiltration  of  the 
tissues  with  blood,  which  undergoes  gradual  absorption  with  the  usual 
changes.  With  the  haemorrhages,  various  forms  of  inflammation  of  the 
skin  may  be  associated,  especially  erythema  and  urticaria,  with  some- 
times more  or  less  oedema.  Free  bleeding  from  the  skin  is  very  rare. 
Haemorrhages  from  the  mucous  membranes  are  more  frequent,  because  of 
the  feebler  resistance  of  the  tissues.  There  are  seen  ecchymoses  upon  the 
visible  mucous  membranes  which  resemble  those  upon  the  skin.  At 
autopsy  they  are  occasionally  seen  in  the  trachea  or  bronchi,  but  more 
often  in  the  digestive  tract.  The  stomach  and  intestines  may  contain 
dark,  clotted  blood,  bloody  mucus,  or  even  fluid  blood.  In  the  colon,  and 
occasionally  in  the  small  intestine,  ulcers  may  be  found  ;  but  they  are 
rarely  if  ever  seen  in  the  stomach.  They  may  be  superficial  or  deep,  and 
have  even  been  known  to  cause  perforation.  The  deep  ulcers  have  gen- 
erally been  attributed  to  thrombosis.  Ulcers  are  often  absent  where  in- 
testinal haemorrhage  has  been  severe.  Associated  with  these  lesions  there 
may  be  inflammatory  changes  in  the  mucous  membrane  of  the  stomach 
and  intestines. 

Intracranial  hremorrhages  are  rare,  and  those  which  occur  are  usually 
meningeal.  These  may  be  extensive  and  sufficient  to  cause  severe  symp- 
toms. In  1893  a  case  occurred  in  the  New  York  Infant  Asylum  in  an 
infant  six  months  old,  with  an  extensive  meningeal  haemorrhage  covering 
a  large  part  of  the  brain.  In  Steffen's  paper  several  such  cases  are  men- 
tioned. 


812       DISEASES  OF   THE   BLOOD,   LYMPH   NODES,   BONES,   ETC. 

Pulmonary  hremorrhages  are  not  frequent.  They  generally  occur  as 
small  ecchymoses  just  beneath  the  pleura.  In  one  of  my  own  cases,  a 
hagmorrhagic  area  as  large  as  a  walnut  was  found  in  the  lung  at  one 
apex.  Ecchymoses  are  found  beneath  the  pericardium;  but  endocarditis 
and  pericarditis  are  extremely  rare,  probably  occurring  only  in  the  rheu- 
matic cases.  Fatty  degeneration,  with  some  degree  of  dilatation  of  the 
heart,  has  been  seen  in  some  of  the  most  protracted  severe  cases.  The 
spleen  is  occasionally  enlarged,  but  by  no  means  uniformly  so,  and  it 
may  be  the  seat  of  haemorrhages.  The  liver  is  normal,  or  the  hepatic  cells 
may  be  the  seat  of  fatty  degeneration. 

While  hfematuria  is  one  of  the  most  frequent  of  the  visceral  haemor- 
rhages, severe  nephritis  is  rare.  Acute  degeneration  of  the  renal  epithe- 
lium of  the  tubes  is  quite  common.  There  may  be  punctiform  haemor- 
rhages, and  occasionally  larger  ones  beneath  the  renal  capsule.  Ecchy- 
moses may  be  found  on  the  mucous  membrane  of  the  pelvis  of  the  kidney. 
The  suprarenal  capsules  may  be  the  seat  of  extensive  and  even  fatal 
hsemorrhage,  as  in  Wolff's  case  in  a  child  two  and  a  half  years  old.  In 
addition  to  these  lesions,  there  may  be  effusions  of  a  sero-sanguineous  fluid 
into  any  of  the  large  serous  cavities,  most  frequently  into  the  peritonaeum. 
The  articular  lesions  of  purpura  may  be  of  a  rheumatic  character,  with 
which  purpura  occurs  as  a  complication  ;  or  there  may  be  haemorrhages 
into  the  tissues  about  the  joint,  or  even  into  the  joint  itself, — usually  the 
knee  or  elbow. 

Thus  far  no  constant  or  essential  changes  have  been  demonstrated  in 
the  blood,  other  than  those  which  are  due  to  hemorrhages — viz.,  a  mod- 
erate reduction  in  the  hfemoglobin  and  the  red  corpuscles,  with  occasional 
irregularities  in  size  and  the  appearance  of  erythroblasts.  In  the  most 
severe  cases  there  is  a  moderate  degree  of  leucocytosis. 

Patliology. — Why  it  is  that  under  certain  circumstances  the  blood- 
vessels will  not  hold  their  contents,  it  is  difficult  to  understand.  There 
have  been  described  by  Cassel,  Riehl,  Wilson,  and  others,  changes  in  the 
small  blood-vessels,  usually  a  form  of  endarteritis.  These  changes  are  in 
all  probability  dependent  upon  some  alteration  in  the  tlood  itself.  It 
is  not  necessary  to  assume  a  lesion  in  the  blood-vessels,  since  we  know 
that  diseased  blood  may  pass  through  even  normal  vessels.  Henoch  has 
suggested  the  vaso-motor  origin  of  purpura,  in  which  there  is  first  a 
paralytic  distention  of  the  small  vessels,  followed  by  stasis,  haemorrhage, 
or  oedema.  In  certain  forms,  as  in  malignant  endocarditis,  it  is  well 
established  that  the  cause  is  an  infectious  thrombosis.  Although  the  bac- 
teriological examinations  made  thus  far  in  purpura  are  not  numerous 
enough  to  settle  the  question  positively,  there  is  little  doubt  that  infec- 
tion is  the  essential  factor  in  other  forms  of  the  disease,  particularly  in 
the  cases  characterized  by  sudden  onset,  high  temperature,  and  cerebral 
symptoms,  and  which  run  a  rapidly  fatal  course.     This  may  possibly  be 


PURPURA.  813 

true  of  most  of  the  primary  cases.  At  the  present  time  the  exact  pathol- 
ogy of  purpura  is  unknown.  There  are,  no  doubt,  now  included  under 
this  term,  several  diseases  quite  distinct  from  one  another. 

The  clinical  types. — 1.  The  ordinary  form. — In  the  mild  cases  the 
hasmorrhage  is  confined  to  the  skin  (purpura  simplex),  or  it  is  accom- 
panied by  slight  bleeding  from  the  mucous  membranes.  There  is  usually 
some  general  indisposition  of  an  indefinite  character  for  a  day  or  two  be- 
fore the  purpuric  spots  are  noticed ;  most  frequently  a  disturbance  of 
digestion  with  vomiting,  diarrhoea,  and  sometimes  slight  fever.  The 
haemorrhages  appear  as  small  petechige,  varying  in  size  from  a  pin's  head 
to  a  pea;  usually  first  upon  the  lower  extremities,  but  sometimes  first  upon 
the  trunk,  the  face,  or  the  upper  extremities.  There  may  be  only  a  few 
widely  scattered  spots  or  the  body  may  be  covered.  The  colour  is  first  a 
bright  red,  then  purple,  gradually  fading  in  the  course  of  a  few  days. 
New  spots  come  as  the  old  ones  disappear,  so  that  the  amount  of  eruption 
may  not  diminish  ;  often  the  spots  come  out  in  distinct  crops.  They  do 
not  disappear  upon  pressure. 

The  course  of  these  cases  is  generally  favourable,  recovery  taking  place 
in  from  one  to  four  weeks  under  the  influence  of  general  tonic  treatment. 
Relapses  are,  however,  very  frequent,  and  such  attacks  may  come  at  inter- 
vals of  a  few  weeks  or  months  for  a  considerable  period.  One  must  be 
guarded  in  giving  an  absolutely  favourable  prognosis  even  in  cases  of  such 
severity,  for  it  occasionally  happens  that  in  a  patient,  who  for  several  days 
has  had  symptoms  of  mild  purpura,  there  suddenly  develop  those  of  the 
most  severe  type  with  a  rapidly  fatal  termination. 

2.  The  severe  form. — Such  cases  are  characterized  by  haemorrhages 
from  the  mucous  membranes  (purpura  htemorrhagica)  from  the  outset. 
These  may  even  appear  before  the  spots  upon  the  skin.  The  relative  in- 
tensity of  the  two  varies  much  in  different  cases.  In  severe  attacks  the 
petechial  spots  are  more  likely  to  appear  suddenly,  and  large  ecchymoses, 
varying  in  size  from  a  pea  to  the  palm  of  the  hand,  are  more  frequent. 
There  may  be  bleeding'  from  the  nose,  gums,  mouth,  or  pharynx,  and 
eccliymoses  maybe  seen  upon  these  mucous  membranes, also  upon  the  con- 
junctivae. Vomiting  of  blood  and  bloody  discharges  from  the  bowels  are 
quite  frequent  symptoms.  The  urine  may  contain  enough  blood  to  give 
it  a  bright-red  colour.  Less  frequently  there  are  seen  haemorrhages  of  the 
retina  or  choroid  and  from  the  female  genitals.  In  one  of  my  own  cases 
there  was  almost  continuous  bleeding  from  one  ear.  Haemoptysis  and  free 
bleeding  from  the  skin  are  both  rare.  Cutaneous  ecchymoses  are  increased 
by  slight  injuries,  such  as  the  pressure  from  a  bandage  or  from  scratching. 
Epistaxis  may  be  copious  enough  to  necessitate  plugging  of  the  nares. 
The  amount  of  blood  vomited  is  not  often  large ;  its  source  may  be  the 
stomach,  the  mouth  or  the  pharynx.  The  blood  in  the  stools  is  usually 
dark  coloured,  but  there  may  be  some  bright-red  blood  even  when  there 


814       DISEASES  OF  THE   BLOOD,   LYMPH  NODES,  BONES,  ETC. 

are  no  ulcers  present.  In  one  of  my  cases  so  much  blood  was  lost  by 
the  bowels  as  to  produce  the  symptoms  of  a  very  marked  cerebral 
anaemia.  In  certain  cases  the  gastro-intestinal  symptoms  are  very  promi- 
nent, and  there  may  be  slight  icterus.  The  discharge  of  blood  from  the 
stomach  or  intestine  may  be  accompanied  by  very  severe  attacks  of  colic 
and  tenesmus.  In  some  of  these  cases  there  are  pains  and  slight  swell- 
ing of  the  joints.  Renal  symptoms  are  generally  present.  These  attacks 
of  pain  with  purpura  and  the  discharge  of  blood,  may  come  on  paroxys- 
mally  every  few  days  for  a  period  of  several  weeks.  They  have  been 
ascribed  to  thrombosis  of  the  intestinal  vessels.  This  is  sometimes  known 
as  "  Henoch's  purpura." 

Constitutional  symptoms  are  present  in  most  of  the  severe  cases. 
There  is  usually  fever,  from  101°  to  103°  F.,  and  sufficient  prostration  to 
keep  the  patient  in  bed.  If  the  amount  of  blood  lost  is  large,  there  are 
the  usual  symptoms  of  severe  anaemia, — pallor,  weak  pulse,  cold  extremi- 
ties, fainting  attacks,  and  functional  heart  murmurs.  The  loss  of  blood 
may  be  sufficient  to  cause  death,  particularly  in  infants.  Cerebral  symp- 
toms may  depend  upon  anaemia  or  upon  meningeal  haemorrhage.  They 
are  not  frequent  in  this  form  of  the  disease.  Oedema,  especially  of  the  face 
and'feet,  may  exist  without  albuminuria,  and  albuminuria  may  be  present 
in  cases  in  which  there  is  no  renal  haemorrhage.  The  amount  of  albumin 
is  generally  small,  and  casts  are  rare. 

In  some  of  the  cases  beginning  with  severe  general  symptoms,  and 
occasionally  when  the  onset  is  mild,  the  patients  after  a  few  days  pass  into 
a  typhoid  condition  with  low  delirium,  great  prostration,  weak  and  irregu- 
lar pulse,  dry,  cracked  tongue,  and  high  temperature.  Such  cases  are 
almost  always  fatal.  They  are  not  to  be  confounded  with  ordinary  typhoid 
fever  complicated  by  purpura. 

The  course  varies  much  in  the  different  cases.  It  lasts  from  one  to 
six  weeks,  the  symptoms  slowly  subsiding,  but  often  showing  a  strong 
tendency  to  recurrence.  The  prognosis  depends  upon  the  age  of  the 
patient,  the  extent  of  the  haemorrhage,  and  the  presence  or  absence  of 
septic  symptoms. 

3.  The  hyper-acute  form  (purpura  fulminaivs). — This  is  a  rare  form, 
especially  in  young  children.  Its  development  is  usually  sudden  with  a 
chill,  vomiting,  marked  prostration,  and  high  temperature.  The  purpuric 
spots  come  out  with  great  rapidity,  and  in  the  course  of  a  few  hours  or  a 
day  they  may  be  very  extensive.  In  addition  to  the  ordinary  subcutane- 
ous haemorrhages,  bloody  vesicles  may  form  upon  the  skin.  In  many  cases 
the  haemorrhages  are  limited  to  the  skin,  the  mucous  membrane  and  the 
viscera  escaping  altogether.  There  is  no  tendency  to  gangrene.  Cerebral 
symptoms  are  invariably  present  and  usually  prominent ;  there  may  be 
delirium,  dulness,  stupor,  and  finally  coma.  The  spleen  is  apt  to  be  en- 
larged.    The  urine  is  nearly  always  albuminous.     This  form  of  purpura 


PURPURA.  815 

has  all  the  characteristics  of  a  general  infectious  disease,  and  it  is  almost 
invariably  fatal.  But  little  is  as  yet  definitely  known  regarding  its  cause 
or  its  relation  to  the  other  forms. 

4.  The  gangrenous  form. — Sloughing  is  not  common  in  purpura,  but 
it  is  most  often  seen  in  the  mucous  membranes.  Osier  refers  to  two 
cases  affecting  the  uvula.  1  once  saw  a  slough  which  caused  perforation 
of  the  soft  palate.  Wickham  Legg  reports  a  case  with  gangrene  of  the 
prepuce.  The  deep  ulcers  of  the  intestine  which  are  seen  in  some  of  the 
severe  cases  are  apparently  necrotic  rather  than  inflammatory.  Gan- 
grene of  the  skin  is  even  less  frequent,  although  cases  have  been  reported 
even  in  young  children.  Charron's  case  was  only  three  years  old,  and 
several  others  in  children  are  collected  in  Gimard's  monograph  upon  this 
subject.  The  gangrene  may  involve  the  skin  only,  or  the  subcutaneous 
tissues  and  even  the  muscles.  It  has  been  seen  upon  the  upper  and  lower 
extremities  and  even  upon  the  face,  and  may  extend  over  quite  a  large 
surface.  In  some  of  the  milder  forms  of  purpura,  gangrene  results  from 
some  slight  injury,  such  as  a  blow,  the  pressure  from  a  bandage,  or  in  the 
nose,  from  the  pressure  of  a  tampon.  In  the  gangrenous  cases,  all  the 
symptoms  are  usually  severe  and  indicate  extensive  blood  alteration. 
They  are  almost  invariably  fatal.  Those  in  which  the  sloughing  is  con- 
tined  to  small  areas  of  the  mucous  membrane  of  the  mouth  often  recover. 

5.  The  rheumatic  form. — Rheumatic  purpura  (peliosis  rheumatica)  is 
applied  to  cases,  not  so  common  in  children  as  in  older  patients,  in  which 
subcutaneous  haemorrhages,  and  sometimes  bleeding  from  the  mucous 
membranes,  are  associated  with  painful  joint  swellings.  These  are  to  be 
regarded  as  cases  of  rheumatism  complicated  by  jDurpura.  The  joints 
most  frequently  affected  are  the  knee  and  the  ankle.  The  arthritic  symp- 
toms are  usually  less  severe  than  in  attacks  of  acute  rheumatism.  There 
may  be  present  erythema  exudativa  or  erythema  nodosum  or  urticaria. 
Usually  there  are  throat  symptoms  and  fever,  and  frequently  a?dema  of 
the  face  and  eyelids  with  albuminuria.  The  spleen  maybe  enlarged.  The 
usual  duration  is  from  one  to  three  weeks,  and  although  relapses  may 
occur,  the  cases  usually  recover. 

Joint  symptoms,  particularly  articular  pains,  are  not  infrequent  in  the 
course  of  milder  attacks  of  purpura  without  the  febrile  symptoms  men- 
tioned. In  severe  cases  extravasations  of  blood  have  been  reported  as 
occurring  in  the  tissues  about  the  joints,  and  even  in  the  joints  themselves, 
these  being  cases  of  true  arthritic  purpura.  It  is  probable  that,  in  the 
past,  some  oases  of  scurvy  have  been  included  in  this  category. 

Diagnosis. — The  rapid  acute  cases  may  be  confounded  with  the  hsem- 
orrhagic  forms  of  the  various  eruptive  fevers.  The  ordinary  subacute  or 
passive  forms  are  chiefly  to  be  differentiated  from  scurvy.  The  diagnosis 
is  not  difficult  and  the  mistake  need  not  be  made  if  the  essential  features 
of  scurvy  are  borne  in  mind, — its  dietetic  cause,  bleeding  gums,  hyperaes- 
53 


816        DISEASES  OF  THE  BLOOD,  LYMPH  NODES,   BONES,  ETC. 

thesia,  and  deep  rather  than  subcutaneous  heemorrhages  which  are  usu- 
ally near  the  joints. 

Prognosis. — This  depends  very  much  upon  the  form  of  the  disease. 
Of  128  cases  of  all  varieties  occurring  in  children  in  Steffen's  collection, 
there  were  40  deaths.  In  12  cases  of  severe  primary  purpura  reported  by 
Gimard,  there  were  3  deaths  and  9  recoveries.  Purpura  simplex  is  rarely 
fatal ;  cases  of  purpura  hsemorrhagica  usually  recover  unless  marked  feb- 
rile symptoms  are  present.  The  forms  classed  as  typhoid,  gangrenous, 
and  purpura  fulminans  are  almost  invariably  fatal.  The  tendency  to 
relapses  exists  in  all  varieties. 

Treatment. — The  treatment  of  symptomatic  purpura  should  have  ref- 
erence to  the  cause  of  the  disease.  The  mild  cases  of  primary  purpura 
usually  recover  promptly  under  a  tonic  plan  of  treatment.  The  more  severe 
cases  require  confinement  in  bed,  absolute  quiet,  and  care  to  avoid  expos- 
ure and  even  the  slightest  injury  or  extra  pressure  upon  any  part.  Drugs 
do  not  seem  to  influence  the  course  of  the  disease  in  any  constant  and 
uniform  way.  Those  most  frequently  employed  are  hydrastis,  hama- 
melis,  aromatic  sulphuric  acid,  the  vegetable  acids,  ergot,  and  gallic 
acid.  Iron  should  be  deferred  until  active  haemorrhage  has  ceased. 
Whether  or  not  it  is  true,  as  claimed  by  some,  that  all  hgemorrhagic  dis- 
eases are  related  to  scurvy,  the  striking  improvement  seen  in  this  disease 
from  the  use  of  fresh  fruit  and  vegetables,  suggests  their  employment  in 
purpura.  In  some  cases  very  decided  benefit  seems  to  follow  their  use  in 
the  acute  stage,  but  more  particularly  in  convalescence.  For  hyperacute 
and  gangrenous  cases,  little  can  be  done  except  to  treat  the  symptoms. 
Surgical  means  of  arresting  the  htemorrhage  are  rarely  successful.  Iron 
and  arsenic  and  alcoholic  stimulants  should  be  used  in  all  cases  during 
convalescence. 


CHAPTER  II. 
DISEASES  OF  TRE  LYMPH  NODES  {LYMPHATIC  GLANDS). 

LYMPHATISM. 

It  is  characteristic  of  infancy  and  childhood  that  the  lymphatic  glands, 
or  the  lymph  nodes,  as  they  are  now  coming  to  be  generally  called,  through- 
out the  body  are  prone  to  swelling  and  hyperplasia.  While  this  tendency 
belongs  to  all  children,  in  certain  individuals  it  is  so  marked  as  to  deserve 
a  place  as  a  distinct  diathesis.  It  was  formerly  classed  as  one  of  the  mani- 
festations of  '•  scrofula  "  or  "  struma " ;  but  the  proof  that  most  of  the 
manifestations  formerly  classed  as  "  scrofulous  "  are  really  forms  of  local 
tuberculosis,  makes  it  undesirable  to  use  that  term  any  longer  as  descrip- 


LYMPHATISM.  817 

tive  of  conditions  now  known  to  be  often  due  to  other  causes  besides 
inherited  tuberculosis.  The  term  hpnphatism  has  been  used  by  Potain 
and  other  French  writers,  and  in  this  country  by  Bosworth,  to  designate 
this  condition. 

In  stout,  robust  children,  infectious  processes  of  the  nose,  pharynx,  or 
bronchi,  cause  acute  swelling  of  the  lymph  nodes  in  the  neighbourhood, 
but  these  rapidly  subside  when  the  cause  is  removed.  In  others,  in  whom 
a  certain  constitutional  condition  exists,  the  process  in  the  mucous  mem- 
brane is  likely  to  be  protracted,  and  the  enlargement  of  the  lymphatic 
glands  once  started  continues  even  after  the  primary  cause  has  subsided  ; 
or,  diminishing  for  a  time,  it  increases  again  with  every  new  exciting 
cause  until  permanent  enlargement  may  be  produced. 

I  shall  use  the  term  lymphatism  in  the  sense  indicated, — viz.,  to  desig- 
nate an  exaggerated  susceptibility  of  the  lymphoid  tissue,  a  constitutional 
condition  in  which  any  inflammation  of  the  mucous  membranes  or  skin 
sets  up  hyperplasia  in  the  lymph  nodes  with  which  these  parts  are  con- 
nected, which  is  out  of  proportion  to  the  exciting  cause  and  which  con- 
tinues after  the  cause  has  ceased  to  operate.  Besides,  there  must  be  in- 
cluded in  this  category,  children  who  at  birth  have  an  excessive  develop- 
ment of  lymphoid  tissue,  seen  particularly  in  the  region  of  the  throat  in 
the  form  of  enlarged  tonsils,  adenoid  vegetations  of  the  pharynx,  etc. 

Lymphatism  may  be  inherited  or  acquired.  The  influence  of  heredity 
is  too  often  seen  to  be  passed  over  as  a  coincidence.  Frequently  the 
parents,  when  children,  suffered  from  the  same  condition,  and  very  often 
every  member  of  a  large  family  of  children  is  affected.  This  may  be  the 
case  in  those  who  are  in  other  respects  healthy,  who  have  been  reared  amid 
good  surroundings,  and  in  whom  no  evidence  of  any  other  constitutional 
disease  can  be  found.  Any  disease  in  the  parents  in  consequence  of  which 
children  are  born  with  tissues  having  less  than  normal  resistance,  may  be 
regarded  in  the  light  of  a  remote  cause.  As  such  may  be  mentioned  gout, 
rheumatism,  alcoholism,  syphilis,  or  tuberculosis,  the  child  under  these 
conditions  inheriting  not  the  disease,  but,  so  to  speak,  its  consequences. 

Among  the  causes  operating  after  birth  to  produce  lymphatism,  the 
surroundings  of  the  child  are  of  the  first  importance.  It  is  seen  to  per- 
fection in  children  reared  in  institutions ;  it  is  also  frequent  in  crowded 
tenements  and  in  cities  rather  than  in  the  country.  Anything  which 
produces  malnutrition  or  lowers  the  general  vitality  of  the  tissues  may  be 
ranked  as  a  cause.  Rickets  and  lymphatism  are  very  frequently  associated ; 
sometimes  rickets  is  to  be  reckoned  as  a  cause,  and  sometimes  both  con- 
ditions depend  upon  the  same  causes. 

The  local  manifestations  of  lymphatism  are  modified  by  the  age  of  the 
child.  During  infancy,  the  glands  which  are  most  frequently  affected  are 
those  connected  with  the  gastro-enteric  and  the  bronchiiil  mucous  mem- 
branes ;  in  childhood  it  is  those  which  are  connected  with  the  pharynx 


818        DISEASES  OP  THE   BLOOD,   LYMPH   NODES,   BONES,   ETC. 

and  tonsils.  This  localization,  of  course,  depends  largely  upon  the  fact 
that  the  susceptibility  of  the  different  mucous  membranes  is  greatly  influ- 
enced by  age. 

The  degree  of  enlargement  of  the  lymph  nodes  which  is  sometimes 
found  in  the  different  situations  has  often  led  to  a  misinterpretation  of 
them,  particularly  by  those  who  only  seldom  see  autopsies  upon  infants 
or  young  children.  They  have  often  been  connected  with  pathological 
conditions  or  clinical  symptoms  with  which  they  have  really  nothing  to 
do.     One  or  two  examples  will  sufltice  : 

Enlargement  of  the  mesenteric  glands  and  of  the  solitary  follicles  of 
the  large  and  small  intestine,  are  very  frequently  seen  in  infants  who  have 
died  of  marasmus,  and  have  been  regarded  as  the  cause  of  the  wasting, 
while  in  reality  they  were  only  the  consequence  of  the  chronic  indigestion 
which  is  an  almost  constant  accompaniment  of  that  condition.  The  find- 
ing of  swollen  Peyer's  patches  in  cases  of  acute  diarrhoea,  with  some 
other  symptoms  during  life  suggestive  of  typhoid  fever,  have  often  been 
looked  upon  as  a  confirmation  of  that  diagnosis,  as  in  a  recent  case 
reported  by  Northrup,  in  which  cultures  showed  that  the  disease  was  not 
tyjDhoid. 

The  condition  under  consideration  relates  not  only  to  the  larger  lymph 
nodes,  but  to  the  smaller  ones  discernible  only  by  the  microscope.  Where 
the  larger  ones  exist,  immense  numbers  of  the  small  ones  are  sure  to  be 
present. 

Lymphatism  is  essentially  a  condition  of  childhood.  As  time  passes 
we  see  a  regular  succession  of  retrograde  changes  in  the  different  series 
of  glands  unless  they  become  the  seat  of  tuberculous  infection.  Those  con- 
nected with  the  digestive  tract  begin  to  diminish  after  the  second  year,  and 
by  the  fifth  or  sixth  year  the  enlargement  has  almost  disappeared ;  while 
the  tonsils,  adenoid  growths  of  the  pharynx,  and  enlarged  cervical  glands 
are  usually  stationary  after  the  seventh  or  eighth  year  and  undergo  quite 
a  marked  atrophy  about  the  time  of  puberty.  The  presence  of  these  en- 
larged lymph  nodes,  the  catarrhal  condition  of  the  mucous  membranes 
with  which  they  are  associated,  and  the  constitutional  condition  upon 
which  both  depend,  are  important  in  relation  to  all  acute  infectious  dis- 
eases which  affect  these  mucous  membranes.  They  bring  about  an  in- 
creased susceptibility  to  scarlet  fever,  measles,  diphtheria,  diarrhoeal  dis- 
eases, and  most  of  all  to  tuberculosis. 


SIMPLE   ACUTE  ADENITIS. 


819 


Table  shoiving  the  Situation  and  the  Drainage-Areas  of  the  Various 
Gi'oups  of  Lymph  Nodes  of  the  Head  and  Neck* 


Name  of  the 
group. 


Sub-occipital 
Mastoid. 

Parotid. 


Number  and  situation. 


One  or  two  ;  at  nape  of  neck. 
Four  or  five  small  ones ;  in 

mastoid  region. 
Five  to  ten ;  on  the  surface 

and  in   the  substance  of 

the  parotid  gland. 


Submaxil-        Twelve  to  fifteen  ;  along  base 
lary,  |      of    jaw,   beneath   cervical 

;      fascia. 
Supra-hyoid. !  One  or  two;  median  line  be- 
!      tween  chin  and  hyoid  bone. 
Superficial      1  Five  or  more  ;  along  external 
cervical.      I      jugular  vein,  beneath  pla- 
tj'sma,   but   superficial   to 
the  sterno-mastoid. 
Deep    cervi-    Ten  to  sixteen  ;  about  bifur- 
cal,  upper       cation  of  common  carotid 
set.  and  along  internal  jugular 

vein.  They  are  just  above 
upper  border  of  thyroid 
cartilage  and  on  a  level 
with  hyoid  bone. 
A  chain  in  the  supra-clavicu- 
lar fossa. 


Deep  cervi- 
cal, lower 
set. 


Sub-hyoid. 


10     Retro-phar- 
yngeal. 


A  few  small  glands  below 
hyoid  bone  and  near  me- 
dian line. 

Two  small  glands  in  front  of 
spine  and  upon  preverte- 
bral muscles. 


Organs  or  areas  from  which  they  receive 
lymphatics. 


Scalp,  posterior  portion. 

Receive  efferent  vessels  from  group  1, 

and  through  them  from  part  of  scalp. 
Scalp,  frontal  and  parietal  portions; 

orbit,  posterior  part  of  nasal  fossa, 

upper  jaw,  posterior  and  upper  part 

of  pharynx. 
Mouth,  lower  lip,  gums. 


Chin  and  middle  portion  of  lower  lip. 

Auricle,  part  of  scalp,  skin  of  face 
and  neck,  and  some  efferent  ves- 
sels from  groups  1  and  2. 

Lower  part  of  pharynx,  larynx,  palate. 
tonsils  and  part  of  tongue,  part  of 
nasal  fossa,  deep  muscles  of  head 
and  neck,  and  from  inside  the  crani- 
um. Receive  also  efferent  vessels 
from  groups  3  and  4. 

Connect  with  axillary  group  by  a  chain 
along  axillary  artery;  also  with 
glands  of  mediastinum  and  with 
groups  7  and  9. 

Communicate  with  group  8,  and  may 
connect  below  with  chain  of  bron- 
chial glands. 

Pharynx  and  part  of  nasal  fossa. 


SIMPLE   ACUTE   ADENITIS. 

This  is  an  acute  iuflammation  of  the  lympli  nodes  which  in  infancy 
frequently  terminates  in  suppuration.  A  certain  amount  of  inflamma- 
tion of  the  lymph  nodes  occurs  in  children  in  all  acute  processes  affect- 
ing the  mucous  membranes,  especially  when  they  are  severe  or  j^rolonged. 
Those  in  connection  with  the  various  internal  organs  are  considered  with 
the  diseases  of  the  organs.  Acute  inflammation  of  the  external  nodes 
is  of  sufficient  frequency  to  require  separate  consideration.  While  this 
is  probably  always  secondary  to  some  pathological  process  in  the  skin 
or  mucous  membranes,  the  primary  condition  may  be  so  slight  as  to  be 
overlooked,  and  the  adenitis  may  be  the  more  important  condition  or  may 
even  assume  the  appearance  of  a  primary  disease.     It  is  particularly  in 


*  Modified  from  Treves  after  Curnow  in  the  Lancet,  1879,  vol.  i,  p.  397. 


820        DISEASES  OF   THE   BLOOD,   LYMPH   NODES,   BONES,   ETC. 

infants  that  this  is  seen,  and  it  depends  upon  the  unusually  active  absorp- 
tion and  upon  the  susceptibility  of  the  lymphoid  tissues  at  this  age.  The 
cervical  glands  are  frequently  affected,  and  occasionally  those  of  the  axil- 
lary and  inguinal  regions. 

Etiology. — Acute  adenitis  occurs  in  children  of  all  ages  in  connection 
with  diphtheria,  scarlet  fever,  measles,  and  influenza.  In  such  cases  it  is 
often  severe,  and,  particularly  with  scarlet  fever,  not  infrequently  ends  in 
suppuration.  With  the  simple  acute  catarrhal  processes  of  the  pharynx 
and  rhino-pharynx  adenitis  also  occurs,  but  it  is  usually  mild  and  rarely 
suppurates.  In  infancy,  on  the  other  hand,  acute  adenitis  is  not  only  very 
common  from  simple  catarrh,  but  often  severe,  and  frequently  terminates 
in  suppuration.  Ulcerative  stomatitis,  carious  teeth,  eczema  of  the  scalp 
or  traumatism,  may  excite  adenitis  in  children  of  all  ages.  Axillary 
adenitis  may  result  from  vaccination ;  inguinal  adenitis,  from  vaginitis. 

Of  109  cases  of  acute  adenitis,  not  including  those  associated  with 
diphtheria,  measles,  or  scarlet  fever,  more  than  three  fourths  occurred  in 
the  first  two  years,  and  half  of  them  in  the  first  year  of  life.  ■  This  sus- 
ceptibility of  infants  is  very  striking.  The  disease  occurs  frequently  in 
those  who  are  in  other  respects  perfectly  healthy,  and  often  when  the 
evidences  of  disease  of  the  mucous  membrane  are  slight.  This  is  true 
not  only  of  the  cases  of  cervical  adenitis,  but  also  of  others  in  which  the 
inguinal  glands  are  involved.  The  inflammation  is  excited  in  most  of 
these  cases  by  the  absorption  of  pyogenic  germs  from  the  mucous  mem- 
branes or  skin ;  in  some  cases,  as  in  diphtheria,  probably  by  the  action  of 
toxines. 

Lesions. — The  changes  taking  place  in  the  glands  are  acute  con- 
gestion, with  swelling,  oedema,  and  active  hyperplasia  of  the  lymphoid 
elements.  The  process  may  terminate  in  resolution  or  in  suppuration 
according  to  the  intensity  of  the  infection  and  the  susceptibility  of  the 
tissues.  When  severe  enough  to  cause  suppuration,  the  adenitis  is  accom- 
panied by  considerable  inflammation  of  the  surrounding  cellular  tissue. 

In  a  series  of  109  acute  cases  of  which  I  have  notes,  not  including  the 
specific  infectious  diseases,  96  were  cervical,  9  were  inguinal,  and  4  axil- 
lary ;  62  per  cent  terminated  in  suppuration,  the  latter_being  nearly  all 
in  infancy.  Suppurative  otitis  was  present  in  16  per  cent  of  the  cases. 
Suppurative  retro-pharyngeal  adenitis  (retro-pharyngeal  abscess)  was  seen 
in  several  cases. 

In  infancy  the  disease  is  usually  unilateral,  or,  if  bilateral,  the  glands 
of  one  side  are  much  more  severely  affected  than  those  of  the  other.  Sup- 
puration is  nearly  always  of  one  side,  and  usually  the  abscess  starts  from 
a  single  gland. 

Symptoms. — The  symptoms  and  course  of  the  adenitis  of  the  specific 
infectious  diseases  belong  to  their  clinical  history.  Suppuration  is  infre- 
quent, except  after  scarlet  fever.     It  is  very  rare  after  diphtheria,  and 


SIMPLE   ACUTE   ADENITIS. 


821 


when  present  usually  signifies  mixed  infection;  I  have  seen  it  occur  but 

twice. 

The  typical  cases  of  acute  adenitis  are  those  which  occur  in  infancy. 

There  are  present  the  symptoms  of  the  original  disease, — usually  catarrh 

of  the  nose  or  rhino-pharynx,  mouth, 

or  ear,  which  may  not  be  very  severe, 

and  sometimes   is  overlooked.      The 

glands  most  frequently  affected  are 

the  deep  cervical  group.    The  tumour 

appears  just  below  the  angle  of  the 

jaw   at   the   anterior    border   of   the 

sterno-mastoid    muscle     (Fig.    141). 

The  swelling  during  the  acute  catarrh 

is  not  rapid  or  great,  but  continues 

after  the  original  process  has  subsided 

until  it  reaches  the  size  of  a  walnut 

or  even  a  pigeon's  egg.     In  the  most 

acute  cases  there  is  marked  inflamma- 
tion of  the  periglandular  cellular  tis- 
sue, with  pain,  tenderness,  and  extra 

heat.  If  suppuration  occurs,  it  is  gen- 
erally evident  in  the  latter  part  of  the 

second  week,  but  sometimes  it  may 

be  as  late   as  the  third  or  even  the 

fourth  week.     In  the  axillary  or  inguinal  region  (Fig.  142)  the  symptoms 

of  adenitis  are  essentially  the  same  as  in  the  neck.     In  the  inguinal  cases 

the  degree  of  catarrh  of  the  mucous  membrane  is  often  very  slight. 

Most  cases  run  their  course  with 
slight  fever  and  few  general  symp- 
toms ;  but  in  young  infants  the  con- 
stitutional symptoms  are  often  severe 
and  the  physician  may  be  in  doubt 
whether  the  local  process  is  suffi- 
cient to  explain  them.  The  temper- 
ature may  be  from  102°  to  104°  F.  for 
several  days,  with  considerable  pros- 
tration, which  is  much  increased  if 
there  is  complicating  otitis.  After 
suppuration,  if  freely  opened  at  the 
proper  time,  the  abscess  heals  rapidly 
and  permanently,  a  sinus  being  rare. 
Occasionally  infection  extends  from 
one  gland  to  another,  and  a  succession 

Flo    1-i^ — Atutt  suppurative  adenitis  (in-  »    i 

guinal)  in  an  infant  three  months  old.  01  these  glandular  abSCeSSCS  OCCUrS. 


Fig.  141. — Acute  suppurative  adenitis  in  an 
infant  one  year  olcf,  showing  the  most  fre- 
quent situation  of  the  tumour  in  the  cervi- 
cal region. 


822       DISEASES  OP  THE  BLOOD,   LYMPH   NODES,   BONES,   ETC. 

In  the  non-suppurative  cases  the  swelling  may  be  even  greater  than  in 
those  which  suppurate ;  but  it  is  less  diffuse  and  apparently  limited  to  the 
gland.  It  subsides  slowly  in  the  course  of  from  four  to  eight  weeks,  often 
leaving  a  small  tumour  which  may  be  apparent  for  several  months.  In 
susceptible  children  recurrent  attacks  of  acute  inflammation  may  lead  to 
chronic  enlargement  which  may  last  indefinitely.  These  glands  do  not 
become  cheesy,  except  from  subsequent  tuberculous  infection. 

The  acute  cases  in  infancy  in  which  suppuration  occurs,  appear  to 
recover  about  as  pi'omptly  and  quite  as  completely  as  those  terminating 
in  resolution,  although  in  the  former  the  constitutional  symptoms  are 
more  severe. 

Diagnosis. — This  is  usually  easy  if  it  is  remembered  that,  with  the  ex- 
ception of  the  specific  infectious  diseases,  and  occasionally  local  causes  like 
eczema  of  the  scalp,  carious  teeth,  etc.,  acute  adenitis  is  essentially  a  dis- 
ease of  infancy.  I  have  often  seen  it  mistaken  for  mumps  when  the 
swelling  was  severe,  but  on  close  examination  there  is  but  little  resem- 
blance between  the  conditions.  The  disease  is  essentially  acute,  and  has 
nothing  in  common  with  the  slow  suppuration  seen  in  later  childhood 
from  the  breaking  down  of  tuberculous  glands. 

Treatment. — Prophylaxis  requires  that  in  all  acute  catarrhs,  the  mucous 
membrane  should  be  kept  as  clean  as  possible  by  the  use  of  nasal  or 
pharyngeal  sprays,  or  by  syringing  with  simple  solutions  like  Dobell's  or 
Seiler's  (page  56),  or  one  of  common  salt. 

In  the  stage  of  acute  inflammation  very  hot  applications  or  an  ice-bag 
may  be  used  for  the  relief  of  pain.  It  is  very  doubtful  whether  either  of 
these  means  has  much  influence  in  preventing  suppuration.  If  abscess 
forms,  incision  had  best  be  deferred  until  pointing  has  taken  place.  If 
this  plan  is  followed,  refilling  is  rare.  A  simple  free  incision  with  proper 
antiseptic  treatment  is  all  that  is  required.  Curetting  may  be  done  if 
there  is  much  broken-doTvn  tissue  present,  but  it  is  not  usually  necessary. 
In  most  of  the  cases  the  abscess  promptly  heals  and  a  perfect  cure  takes 
place.  In  cases  which  do  not  suppurate,  absorption  may  be  promoted  by 
the  internal  use  of  the  iodide  of  potassium  in  full  doses, — gr.  x  to  xv  daily 
to  an  infant  of  one  year.  I  confess  rarely  to  have  seen  any  benefit  from 
painting  with  iodine  or  from  inunctions  of  iodine  ointment  or  the  oleate 
of  mercury.  If  adenitis  is  secondary  to  carious  teeth,  eczema,  or  ulcerative 
stomatitis,  these  conditions  should  receive  appropriate  treatment.  Such 
cases  do  not  usually  suppurate,  but  subside  rapidly  when  the  primary 
cause  is  removed. 


SIMPLE  CHRONIC  ADENITIS. 

This  consists  in  a  simple  hyperplasia  of  the  lymph  nodes.     There  are 
considered  here  only  the  external  glands,  but  those  of  the  cavities  of  the 


SYPHILITIC   ADENITIS.  823 

body  are  affected  in  a  similar  way,  in  diseases  of  the  mucous  membranes 
with  wliich  they  are  connected. 

Simple  chronic  adenitis  is  not  nearly  so  frequent  as  the  acute  form 
even  in  infants  and  young  children,  and  it  is  rare  after  the' fifth  year.  It 
may  follow  one  or  more  attacks  of  acute  adenitis,  or  it  may  result  from 
subacute  or  chronic  inflammations  of  the  skin  or  of  the  various  mucous 
membranes,  infection  from  which  causes  the  acute  form.  The  same 
groups  of  glands  are  affected  in  both  varieties.  The  most  frequent  sub- 
jects are  children  who  have  the  diathesis  described  as  lymphatism. 

Symptoms. — The  glands  upon  both  sides  of  the  neck  are  usually 
involved,  and  more  often  a  group  than  a  single  gland.  The  degree  of 
swelling  is  not  generally  great,  being  much  less  than  in  acute  adenitis, 
and  usually  less  than  in  the  tuberculous  form.  There  are  no  constitutional 
symptoms.  Hypertrophy  of  the  tonsils  and  adenoid  growths  of  the  pharynx 
are  frequently  present.  There  is  seen  no  tendency  to  suppuration  or  case- 
ation. The  swelling  usually  increases  slowly  for  one  or  two  months,  then 
remains  stationary  for  about  the  same  length  of  time,  after  which  it  slowly 
subsides,  although  it  may  not  entirely  disappear  for  years.  A  subacute 
course  is  more  frequent  than  a  very  chronic  one. 

Diagnosis. — These  cases  are  especially  to  be  distinguished  from  those 
of  tuberculous  adenitis.  The  most  important  points  for  differentiation 
are :  that  they  occur,  as  a  rule,  in  children  under  five,  and  most  frequently 
under  three  years,  a  period  when  tuberculous  disease  is  not  very  common  ; 
that  some  definite  exciting  cause  is  usually  present ;  that  caseation  and 
suppuration  do  not  occur ;  that  the  glands  do  not  become  adherent  to  the 
skin  or  to  the  deeper  tissues ;  that  they  enlarge  much  more  rapidly  than 
do  the  non-caseating  tuberculous  glands ;  and  that  they  are  influenced  to 
a  much  greater  degree  by  constitutional  treatment.  There  are,  however, 
some  cases  in  which  a  differential  diagnosis  is  impossible.  Glands  in 
which  there  was  originally  only  a  simple  hyperplasia  may  undoubtedly 
become  tuberculous  by  subsequent  infection. 

Treatment. — Operative  measures  are  not  called  for.  The  local  cause 
usually  to  be  found  in  the  pharynx,  nose,  or  mouth — hypertrophied  tonsils, 
adenoid  vegetation  of  the  pharynx,  decayed  teeth,  etc. — should  be  removed 
whenever  possible.  Little  benefit  is  seen  from  local  applications.  The 
syrup  of  the  iodide  of  iron  (twenty  drops  three  times  a  day  to  a  child  of  four 
years)  or  potassium  iodide  (five  grains  three  times  a  day)  should  be  given 
for  a  long  period.  In  some  cases  more  decided  benefit  is  seen  from  arsenic 
(four  drops  of  Fowler's  solution  in  a  glass  of  water  three  times  a  day). 
In  all  cases  cod-liver  oil  should  be  given  except  during  warm  weather. 

SYPHILITIC   ADENITIS. 

It  is  quite  rare  that  a  marked  degree  of  glandular  enlargement  is  seen 
as  a  symptom  of  hereditary  syphilis ;  indeed,  so  rare  that  it  is  often  for- 


824        DISEASES  OF   THE   BLOOD,   LYMPH   NODES,   BONES,  ETC. 

gotten  that  chronic  multiple  glandular  enlargements  are  ever  due  to  this 
disease.  In  the  few  example^  that  have  come  under  my  observation,  this 
has  been  a  late  symptom  of  hereditary  syphilis.  The  glandular  enlarge- 
ments have  been  cervical  and  multiple,  and  the  degree  of  swelling  has 
often  been  marked.  They  may  be  associated  with  disease  of  the  bones  or 
mucous  membrane  of  the  throat  or  of  the  nose,  or  without  signs  of  such 
disease.  The  diagnosis  of  syphilis  rests  upon  the  association  of  other 
late  manifestations  of  the  disease — keratitis,  periostitis,  deformities  of  the 
teeth — and  the  prompt  improvement  under  anti-syphilitic  treatment.  In 
their  local  appearance  they  resemble  tuberculous  glands. 

TUBERCULOUS   ADENITIS. 
Synonym :  Scrofula. 

Tuberculous  disease  of  the  lymph  glands  of  the  cavities  of  the  body 
is  discussed  elsewhere ;  only  that  of  the  external  glands  is  here  consid- 
ered. These  present  some  striking  peculiarities, — they  are  relatively  rare 
in  infancy,  although  a  frequent  form  of  tuberculosis  in  older  children ;  it 
is  exceptional  to  find  them  associated  with  general  tuberculosis,  and  then 
they  more  often  follow  than  precede  the  general  disease.  In  the  great 
majority  of  cases  it  is  the  cervical  glands  which  are  affected. 

Etiology. — The  age  at  which  tuberculosis  of  the  cervical  lymph  glands 
is  usually  seen  is  from  three  to  ten  years.  In  my  experience  with  tuber- 
culosis in  infancy,  the  external  glands  are  rarely  involved,  this  being  in 
striking  contrast  to  the  regularity,  almost  uniformity,  with  which  the 
bronchial  glands  are  the  seat  of  infection. 

In  addition  to  infection  with  the  tubercle  bacillus,  local  causes  are 
usually  present ;  the  most  important  are  adenoid  growths  of  the  pharynx, 
chronic  pharyngitis,  and  hypertrophied  tonsils ;  less  frequently  there  are 
chronic  otitis,  chronic  conjunctivitis,  and  pathological  processes  of  the  skin 
or  the  mouth,  such  as  eczema  of  the  face  or  scalp,  ulcerative  stomatitis, 
carious  teeth,  etc.  For  the  production  of  the  disease,  therefore,  there  ap- 
pear to  be  necessary,  first,  favourable  local  conditions,  and,  secondly,  ex- 
posure to  infection.  That  the  pharynx  is  the  most  frequent  seat  of  primary 
infection,  is  shown  by  the  fact  that  the  deep  cervical  glands  are  generally 
first  affected.  The  question  often  arises  whether  the  process  in  the  glands 
is  at  first  simple,  and  later  becomes  tuberculous,  or  whether  it  is  tubercu- 
lous from  the  outset.  No  doubt  there  are  many  examples  of  both  condi- 
tions ;  however,  my  own  conviction  is  that  in  the  majority  of  cases  the 
process  is  a  tuberculous  one  from  the  beginning. 

Children  who  are  by  inheritance  predisposed  to  tuberculosis  and  those 
also  who  are  prone  to  glandular  enlargements-»-two  conditions  which  are 
by  no  means  identical — are  the  ones  most  liable  to  be  affected.  Attacks  of 
acute  infectious  diseases,  particularly  measles,  scarlet  fever,  and  influenza, 
frequently  play  the  role  of  exciting  causes. 


TUBERCULOUS  ADENITIS.  825 

The  age  of  those  affected  corresponds  very  closely  with  that  at  which 
most  children  are  seen  with  hypertrophied  tonsils  and  adenoid  growths 
of  the  pharynx.  The  subsidence  of  symptoms  about  the  time  of  puberty, 
is  also  characteristic  of  both  conditions. 

Lesions. — It  has  been  already  stated  that  in  the  great  majority  of 
cases  the  cervical  glands  are  involved,  and  generally  they  are  the  only 
ones  affected.  In  155  cases  of  tuberculous  glands  in  the  series  re- 
ported by  Treves,*  those  of  tlie  neck  were  the  seat  of  disease  in  145  and 
the  only  seat  in  131 ;  those  of  the  axilla  were  involved  in  17,  but  alone 
only  in  4 ;  the  groin  in  8,  and  alone  in  6.  This  indicates  the  close  asso- 
ciation of  the  disease  with  infection  through  the  upper  respiratory  tract. 
The  glands  first  affected  are  most  frequently  the  upper  set  of  the  deep 
cervical  group ;  sometimes,  however,  it  is  the  superficial  glands  of  the  sub- 
maxillary, or  the  parotid  group,  and  occasionally  the  submental  or  the 
pre-auricular.f  The  chain  of  deep  cervical  glands  which  is  involved, 
follows  the  carotid  artery,  and  often  extends  some  distance  below  the 
clavicle.  These  deep  glands  are  sometimes  connected  with  the  bronchial 
group. 

The  process  in  all  tuberculous  glands  is  essentially  a  chronic  one,  but 
pathologically  the  cases  may  be  divided  into  two  groups,  corresponding 
somewhat-  to  the  forms  of  disease  seen  in  the  lungs.  In  the  first  group 
the  process  is  more  rapid,  and  tends  to  early  caseation  and  softening ;  the 
products  of  inflammation  are  mainly  cellular,  and  the  amount  of  fibrous 
tissue  is  small.  In  the  second  group  the  course  is  much  slower,  and  fibrous 
tissue  predominates,  the  cells  being  fewer,  and  caseation  and  softening 
infrequent. 

In  the  first  group  the  glands  in  the  early  stage  are  swollen,  of  a  pale 
pink  colour,  and  homogeneous ;  later  they  become  more  firm,  and  show, 
as  the  first  gross  evidence  of  tuberculous  deposits,  small  grayish-white 
spots,  which  are  generally  numerous  and  scattered  through  the  affected 
gland ;  these  spots  enlarge,  and  may  coalesce  to  form  one  large  gray 
mass,  involving  nearly  the  whole  gland.  Subsequently  there  is  caseation 
and  then  softening,  usually  beginning  in  the  centre  of  the  caseous  area. 
Inflammation  within  the  gland  is  followed  by  that  of  the  surrounding 
tissues,  which  may  result  in  adhesions  or  in  the  formation  of  a  periglandu- 
lar abscess.  The  first  change  in  the  gland  is  the  production  of  epithe- 
lioid and  giant  cells,  about  which  there  is  a  zone  of  small  round  cells ; 
cheesy  degeneration  then  begins  in  the  centre.  The  caseous  masses  may 
become  encapsulated  by  the  production  about  them  of  fibrous  tissue ;  or 
softening  may  occur  at  one  or  more  foci,  and  an  abscess  form.  Such  an 
abscess  contains  curdy  materials  but  very  little  true  pus,  the  contents  being 

*  Scrofula  and  its  Gland  Diseases.    Smith,  Elder  &  Co.,  London,  1883. 
■f  NicoU,  Glasgow  Medical  Journal,  January,  1896. 


826        DISEASES  OF  THE   BLOOD,   LYMPH   NODES,   BONES,  ETC. 

chiefly  parts  of  the  gland  not  completely  broken  down.  Caseation  may  be 
followed  by  calcareous  degeneration,  although  this  is  rare,  much  more  so 
than  in  the  mesenteric  or  bronchial  glands.  Tubercle  bacilli  are  usually 
more  numerous  in  the  early  stages  of  the  process,  but  are  often  difficult  of 
detection  in  late  cases  in  broken-down  tissues,  and  the  curdy  pus  is  some- 
times sterile.  As  the  glands  soften,  the  process  gradually  extends  from 
the  centre  to  the  surface,  and  they  become  adherent  to  the  surrounding 
structures — blood-vessels,  nerves,  organs,  or  the  cellular  tissue — they  fuse 
together  and  form  large  knotty  masses,  and  when  they  ultimately  break 
down  they  lead  to  the  formation  of  abscesses  in  the  cellular  tissue,  finally 
involving  the  skin.  In  the  form  of  suppuration  which  occurs  in  and 
about  tuberculous  glands,  an  important  part  is  often  played  by  other  bac- 
teria, usually  the  staphylococcus  or  the  streptococcus. 

In  the  second  group  of  cases,  where  the  process  goes  forward  more 
slowly,  the  changes  are  not  quite  the  same,  the  essential  difference  being 
that  the  amount  of  fibrous  tissue  is  much  greater.  These  glands  are  not 
so  vascular ;  they  are  tough  and  hard,  appearing  like  small  fibrous  tumours. 
The  capsules  are  greatly  thickened,  and  under  the  microscope  is  seen 
fibrous  tissue  arranged  in  concentric  layers,  often  inclosing  small  caseous 
masses.  These  glands  less  frequently  form  adhesions  to  the  surrounding 
tissues,  and  consequently  are  freely  movable,  while  suppuration  is  quite 
exceptional.  Although  the  separate  tumours  are  much  smaller  than  in 
the  first  group,  the  glandular  mass  is  often  a  large  one,  because  of  the 
number  of  glands  involved. 

Treves  gives  some  interesting  observations  in  regard  to  the  spreading 
of  the  process  from  one  gland  to  another.  He  states  that  while  it  often 
takes  place  along  the  direct  line  of  the  lymph  current,  this  is  not  always 
the  case,  and  sometimes  it  spreads  in  exactly  the  opposite  direction.  This 
he  believes  to  be  due  to  an  extension  of  disease  from  the  gland  to  the 
afferent  lymphatics,  these  vessels  themselves  becoming  the  seat  of  disease, 
with  changes  similar  to  those  taking  place  in  the  glands.  In  consequence 
of  this  many  more  tuberculous  nodes  may  be  found  than  there  were 
originally  lymph  glands, — a  point  which  has  often  been  noticed,  but  for 
which  there  is  no  other  satisfactory  explanation. 

Symptoms. — In  the  early  part  of  the  disease  there  are  no  symptoms 
but  glandular  swelling,  and  this  begins  very  gradually,  often  insidiously. 
In  the  majority  of  the  cases  both  sides  are  involved,  although  one  fre- 
quently begins  before  the  other  and  advances  more  rapidly.  The  enlarge- 
ment is  not  always  continuous ;  it  may  increase  for  a  time  and  then  remain 
stationary  or  even  diminish,  to  take  a  fresh  start  under  the  stimulus  of 
some  new  process  in  the  mucous  membrane  with  which  the  glands  are 
associated,  such  as  an  attack  of  measles  or  scarlet  fever,  or  simply  from  a 
depreciation  of  the  patient's  general  health.  During  exacerbations,  the 
glands  maybe  painful  and  tender,  and  show  the  usual  signs  of  local  inflam- 


TUBERCULOUS   ADENITIS.  827 

mation.  The  whole  course  of  the  disease  varies  from  several  months  to  as 
many  years.  Treves  gives  three  and  a  half  years  as  the  average  duration 
where  suppuration  occurs.  The  glands  first  affected  are  usually  those 
situated  near  the  bifurcation  of  the  common  carotid  artery.  Such  tumours 
usually  make  their  appearance  just  in  front  of  the  sterno-mastoid  muscle — 
sometimes  behind  it — and  at  the  level  of  the  upper  border  of  the  larynx  or 
the  hyoid  bone.  In  the  more  rapid  cases  the  tumours  usually  attain  a  con- 
siderable size  in  three  or  four  months,  sometimes  in  half  that  time.  The 
usual  size  reached  is  from  that  of  an  almond  to  an  English  walnut.  At 
first  the  tumours  are  movable  and  preserve  their  distinct  outline ;  later 
they  become  adherent,  first  to  the  deeper  tissues  and  to  each  other,  finally 
to  the  skin,  and  there  is  formed  an  irregular  nodular  mass  in  which  it  is 
sometimes  difficult  to  make  out  the  individual  glands.  As  they  approach 
tlie  surface  there  are  small  spots  of  softening ;  then  there  is  distinct  fluc- 
tuation ;  the  skin  becomes  discoloured  and  finally  gives  way,  and  there  is 
a  discharge  of  thick,  curdy  pus,  which  may  continue  for  an  indefinite  time, 
until  the  whole  of  the  broken-down  gland  has  been  thrown  off. 

In  the  cases  which  progress  more  slowly,  a  chain  of  glands  is  usually 
involved  which  individually  are  smaller  than  the  preceding,  and  yet  to- 
gether they  may  form  quite  a  large  mass.  These  rarely  become  adherent, 
except  to  each  other,  and  suppuration  is  very  infrequent ;  the  skin  over 
them  therefore  is  generally  healthy.  In  most  of  the  cases  where  suppura- 
tion has  not  occurred  an  improvement  takes  place  about  the  time  of 
puberty.  In  what  proportion  of  these  glands  there  is  suppuration  it  is 
impossible  to  say.  Like  other  tuberculous  lesions  in  the  body,  these  glands 
are  much  more  often  the  seat  of  infection  than  was  formerly  supposed, 
and  in  many  cases  the  diagnosis  is  not  made.  Of  those  recognised  clinic- 
ally as  tuberculous  adenitis,  from  one  half  to  two  thirds  suppurate,  pro- 
vided they  are  allowed  to  run  their  natural  course.  Eesolution  is  more 
likely  to  occur  where  the  progress  is  slow,  and  where  there  are  many 
small  tumours  than  with  one  or  two  large  ones.  If  softening  has  oc- 
curred, resolution  is  not  to  be  expected,  although  even  in  such  cases 
encapsulation  of  the  cheesy  foci  may  take  place.  Occasioually  cases  are 
cured  by  intercurrent  acute  disease.  A  cure  has  been  known  to  follow  an 
attack  of  scarlet  fever,  and  erysipelas  of  the  face  (Treves).  The  usual 
effect  of  the  eruptive  fevers,  however,  is  to  accelerate  the  process. 

Two  forms  of  suppuration  occur  in  connection  with  tuberculous  glands, — 
one  an  abscess  of  the  gland  proper,  the  other  outside  of  and  usually 
over  it.  In  a  typical  case  of  the  first  variety,  the  gland  is  distinctly  out- 
lined and  often  superficial,  there  is  very  little  inflammation,  the  spot  of 
softening  and  fluctuation  is  small,  and  the  pus  discharged  is  always  curdy. 
In  the  second  variety  the  abscess  is  preceded  by  a  more  diffuse  swelling, 
and  the  outline  of  the  gland  may  not  be  made  out ;  the  signs  of  inflam- 
mation are  more  marked,  the  area  of  fluctuation  is  larger,  and  the  pus  is 


828        DISEASES  OP  THE  BLOOD,   LYMPH   NODES,   BONES,   ETC. 

more  like  that  of  any  ordinary  abscess.  Often  the  two  varieties  are  com- 
bined ;  as  when  a  gland  beneath  the  deep  fascia  breaks  down  and  there  is 
formed  directly  over  it  an  abscess  in  the  cellular  tissue,  which  communi- 
cates through  a  narrow  opening  with  the  gland  beneath.  In  such  cases 
the  discharge  may  continue  for  a  very  long  time,  until  the  whole  of  the 
gland  has  been  removed.  If  healing  occurs  before  this,  the  cicatrix  soon 
breaks  down. 

Where  abscesses  are  allowed  to  open  spontaneously,  large,  irregular, 
and  usually  very  intractable  ulcers  often  form.  The  skin  is  under- 
mined for  a  considerable  distance,  and  it  has  an  unhealthy  appearance. 


Fig.  143. — Cicatrices  following  a  neglected  case  of  tuUcrculout.  uiieiiitis,  in  u  girl  seven  years 
old.  There  is  also  a  tuberculoiis  patch  upon  the  skin  of  the  cheeli  in  a  very  frequent 
location. 

Such  ulcers  sometimes  continue  for  many  months  in  spite  of  all  treat- 
ment, particularly  if  the  patient's  general  health  is  poor.  The  scars  left 
after  them  are  large  and  unsightly,  and  sometimes  positively  deforming 
(Fig.  143).  Their  appearance  is  quite  characteristic.  They  often  have 
many  tabs  of  skin  attached  to  them ;  they  may  form  prominent  ridges 
which  may  undergo  contraction  like  those  after  burns ;  they  are  of  a  pur- 
plish-red colour,  and  adherent  to  the  deeper  tissues.  They  are  often 
sensitive  and  painful.  As  time  passes  they  atrophy  and  become  less  con- 
spicuous, though  fhey  remain  through  life. 


TUBERCULOUS  ADENITIS.  829 

The  general  health  of  children  with  tuberculous  glands  may  be  much  or 
little  a£fected,  and  not  a  few  remain  in  good  condition  throughout  the 
whole  course  of  the  disease,  particularly  when  suppuration  does  not  occur, 
but  sometimes  even  when  it  is  protracted. 

Prognosis. — In  no  case,  I  think,  does  tuberculosis  of  the  external  lymph 
glands  cause  death.  Though  the  course  is  often  protracted,  lasting  in 
some  cases  for  eight  or  ten  years,  ultimate  recovery  may  be  confidently 
predicted  in  the  great  majority  of  cases.  As  stated  at  the  beginning  of 
this  article,  it  is  a  matter  of  surprise  that  so  few  of  these  children  ulti- 
mately develop  general  tuberculosis.  Treves  *  says,  "  The  percentage  of 
those  who  fall  victims  to  diffused  tubercular  disease  is  so  small  that  the 
probability  of  that  disease  may  be  put  out  of  the  question,"  and  that  to 
urge  the  prevention  of  phthisis  as  an  argument  for  operation  "  is  unwor- 
thy of  consideration."  Poore  f  states  that  of  fifty-eight  cases,  only  two 
were  known  to  have  died  of  tuberculosis.  Nordan  on  the  other  hand 
reports  that  of  149  cases  that  were  followed,  eighteen  per  cent  were  known 
to  have  died  from  tuberculosis,  and  nine  per  cent,  though  living,  were 
suffering  from  that  disease.  Although  it  is  certainly  infrequent,  I  can 
not  believe  such  a  sequel  to  be  quite  so  rare  as  do  the  two  authors  quoted. 

Diagnosis. — Tuberculous  adenitis  is  to  be  distinguished  from  simple 
chronic  enlargement,  from  that  due  to  syphilis,  from  Hodgkin's  disease, 
and  from  malignant  disease.  The  diagnostic  features  of  tuberculous 
glands  are  the  age  of  the  patient — usually  from  three  to  ten  years — the 
site  of  the  primary  swelling,  the  indolent  course,  the  trifling  original  cause, 
and  most  of  all  the  disposition  to  slow  caseation,  softening,  and  abscess. 
The  cases  of  simple  hyperplasia  are  usually  in  children  under  five  years, 
their  progress  is  much  more  rapid,  there  is  often  some  definite  cause,  and 
they  have  in  most  cases  nearly  or  quite  disappeared  in  the  course  of  three 
or  four  months.  They  suppurate,  if  at  all,  during  the  first  month. 
Syphilitic  disease  is  to  be  recognised  mainly  by  discovering  the  evidence 
of  syphilis  elsewhere,  and  by  the  effect  of  treatment.  In  Hodgkin's  dis- 
ease, glandular  groups  in  other  parts  of  the  body  are  involved  simultane- 
ously or  in  rapid  succession.  There  are  no  signs  of  inflammation  or 
caseation ;  and  the  swellings  are  accompanied  by  very  marked  and  defi- 
nite constitutional  symptoms, — anaemia,  emaciation,  and  general  prostra- 
tion. Malignant  growths  are  very  rare,  they  increase  rapidly,  often  attain- 
ing a  great  size  in  a  few  months. 

Treatment. — The  general  treatment  of  tuberculous  glands  is  to  put  the 
child  under  the  very  best  surroundings  possible.  The  seaside  has  a  great 
reputation  for  such  cases,  and  no  doubt  the  majority  do  very  well  there ; 
but  some  are  benefited  even  more  by  a  dry,  mountain  climate.  At  all 
events,  a  child  from  the  city  should  be  sent  into  the  country  whenever 

*  Loc.  cit.,  p.  188.  t  New  York  Medical  Journal,  June  23,  1892. 


830       DISEASES  OP  THE   BLOOD,   LYMPH   NODES,   BONES,   ETC. 

this  is  possible.  Internally  the  only  remedies  which  have  any  special 
virtues  are  cod-liver  oil  and  the  syrup  of  the  iodide  of  iron.  The  latter 
should  be  given  in  full  doses — i.  e.,  twenty  or  thirty  drops,  three  times  a 
day,  to  a  child  of  six  years.  Arsenic  and  iron  are  useful  as  general  tonics. 
Local  aj^plications  are  of  little  value  and  most  of  them  positively  harmful ; 
painting  with  iodine  and  poulticing  should  be  discarded  altogether.  The 
parts  should  be  protected  against  cold,  and  should  be  rubbed  or  handled 
as  little  as  possible. 

It  is  important  in  every  case  to  remove  from  the  nose  and  throat  all 
sources  of  local  irritation.  Hypertrophied  tonsils  should  be  excised,  and 
the  adenoid  tissue  of  the  pharynx  scraped  out,  even  when  not  very  exten- 
sive, since  these  are  the  two  regions  which  most  frequently  harbour  the 
tubercle  bacilli.  Any  pathological  conditions  in  the  nose,  such  as  hyper- 
trophy of  the  turbinated  bodies,  should  receive  attention ;  so  also  should 
chronic  otitis,  chronic  conjunctivitis,  carious  :teeth  or  ulcers  in  the  mouth. 
All  these,  if  they  do  no  more,  keep  up  a  constant  glandular  irritation,  and 
produce  conditions  which  are  most  favourable  for  the  activity  of  the  tu- 
bercle bacillus. 

Operative  measures. — These  are  indicated  if,  after  two  or  three  months 
of  constitutional  treatment,  the  glands  alfected  continue  to  increase  in 
size  and  number.  The  advantages  of  operation  over  leaving  the  case  to 
Nature  are,  that  it  leaves  a  clean  scar  instead  of  a  large,  irregular  one ; 
that  it  shortens  the  disease  and  prevents  the  long,  tedious  suppuration  of 
cases  left  to  themselves ;  that  it  is  a  radical  measure  ;  and  that  it  avoids 
the  danger  of  general  infection  by  removing  the  tuberculous  focus. 

With  reference  to  the  choice  of  operations,  surgeons  are  by  no  means 
agreed.  The  indications  for  the  different  operations  laid  down  by  Treves, 
seem  to  me  to  be  the  best  that  have  been  formulated  : 

1.  Excision  and  enucleation. — Adapted  to  cases  where  there  is  no  ac- 
tive inflammation  and  no  softening ;  where  the  process  is  very  slow  and 
indolent ;  where  there  are  one  or  two  large,  hard  glands,  or  a  chain  of 
smaller  ones,  all  freely  movable  and  all  clearly  defined,  or  where  there  is 
a  single  large  tumour  causing  pressure  symptoms. 

2.  Scooping. — iVdapted  to  glands  which  have  softened  and  are  ad- 
herent, especially  to  the  skin;  also  where  the  capsules  are  thickened. 
This  operation  should  not  be  done  during  a  period  of  acute  inflamma- 
tion. 

3.  Cautery  puncture. — Useful  both  in  hard,  movable  glands  and  in 
those  which  are  soft  and  adherent ;  particularly  adapted  to  those  adherent 
to  the  skin,  and  for  these  it  is  better  than  the  scoop.  It  is  not  applicable 
to  glands  smaller  than  a  cherry.  This  operation  is  done  with  a  small 
cautery  point,  which  is  thrust  through  the  skin  into  the  gland,  and  then 
in  two  or  three  directions  through  it,  after  which  some  soothing  dressing 
is  applied.     Although  widely  used  in  Europe,  this  operation  is  but  little 


HODGKIN'S  DISEASE.  831 

employed  in  America, — not  so  often,  it  would  appear,  as  it  should  be,  from 
the  advantages  claimed  for  it. 

All  surgeons  agree  that  in  operating,  violent  tearing  out  of  the  glands 
should  be  avoided ;  that  as  little  injury  as  possible  should  be  done  to  the 
tissues ;  that  the  capsules  should  not  be  torn  nor  the  tuberculous  materials 
allowed  to  escape  into  the  healthy  tissues,  All  agree  also  that  prolonged 
dissections  are  to  be  avoided,  and  that  in  removing  deeply-seated  glands 
there  is  great  danger  of  injuring  vessels  and  nerves  and  the  dome  of  tiie 
pleura. 

Glandular  abscesses  should  in  all  cases  be  opened  as  soon  as  pus 
forms,  to  prevent  the  extensive  undermining  of  the  skin,  which  is  so  likely 
to  occur.  The  opening  should  be  a  small  one,  and  all  squeezing  of  the 
gland  or  surrounding  tissues  avoided. 

HODGKIN'S   DISEASE  (ADENIE). 

This  is  a  rare  disease  in  which  there  is  a  general  hyperplasia  of  the 
lymphatic  glands  throughout  the  body,  with  growths  of  lymphoid  tissue 
in  the  spleen,  liver,  and  other  internal  organs.  It  is  accompanied  by 
marked  anaemia,  is  progressive  in  its  course,  and  usually  terminates  fatally. 
The  cause  is  unknown.  It  is  much  more  common  in  males  than  in 
females.     Its  occurrence  in  childhood  is  exceedingly  rare. 

The  changes  in-  the  glands  consist  in  a  simple  hyperplasia,  which  may 
be  extreme.  Suppuration  and  caseation  are  very  rare,  if  indeed  they  ever 
occur.  Any  of  the  external  or  internal  groups  of  fymph  glands  may  be 
affected,  and  in  severe  cases  the  disease  may  involve  almost  every  chain  of 
glands  in  the  body.  Of  the  external  groups,  the  cervical  and  the  axillary 
are  usually  most  affected  ;  of  the  internal  groups,  those  of  the  mediastinum 
and  the  retro-peritoneal  region.  The  spleen  and  the  liver  are  moderately 
enlarged,  and  lymphoid  growths,  varying  in  size  from  a  pin's  head  to  a 
grape,  are  usually  scattered  throughout  their  substance.  There  may  be 
changes  in  the  bone-marrow. 

Symptoms. — These  come  on  very  gradually,  often  insidiously.  The 
external  glandular  swellings  are  usually  the  first  noticed,  but  sometimes  it 
is  the  anwmia  which  first  attracts  attention ;  occasionally  it  is  the  local 
symptoms  resulting  from  the  pressure  of  internal  glands,  Avhich  may  give 
rise  to  oedema,  pain,  cough,  or  dyspnoea.  The  progress  is  generally  slow 
but  steady,  and  the  glands  may  reach  an  immense  size.  The  blood  shows 
a  moderate  reduction  of  the  red  and  an  increase  in  the  white  cells,  par- 
ticularly the  lymphocytes  (Osier). 

Treatment. — The  only  remedy  which  is  of  much  avail  in  this  disease  is 
arsenic,  which  must  be  given  in  full  doses  and  for  a  long  time.  The  gen- 
eral treatment  should  be  tonic. 


54 


832       DISEASES  OF  THE  BLOOD,   LYMPH  NODES,  BONES,  ETC. 

CHAPTER   III. 

DISEASES  OF  THE  SPLEEN. 

Weight. — From  one  hundred  and  forty  observations  made  at  the  New 
York  Infant  Asylum  the  following  were  the  weights  recorded  at  the  dif- 
ferent ages : 

Weight  of  the  Spleen  in  Infancy  mid  Early  Childhood. 


Age. 

Ounces. 

Grammes. 

Birth    

i 
4- 

f 

7-7 

Three  months      

15-5 

Twelve     "        .    .  .        

23-2 

Two  years 

Three   *'     

38-5 

46-4 

Position  and  Methods  of  Examination. — The  normal  position  of  the 
spleen  is  close  against  the  diaphragm,  its  external  surface  being  opposite 
the  ninth,  tenth,  and  eleventh  ribs.  Its  anterior  border  comes  as  far  for- 
ward as  the  middle  axillary  line,  its  posterior  border  being  usually  near 
the  vertebral  column.  In  infancy  it  is  practically  impossible  to  outline 
the  spleen  by  percussion,  unless  it  is  enlarged.  During  full  inspiration 
the  spleen  is  often  depressed  enough  to  be  felt  at  the  free  border  of  the 
ribs,  but  at  other  times  it  can  not  be  felt  unless  it  is  enlarged  or  pushed 
downward  by  some  pathological  condition  in  the  chest.  Normally,  the 
long  axis  of  the  spleen  is  nearly  parallel  with  the  ribs,  but  when  the 
organ  is  much  enlarged,  its  axis  corresponds  nearly  with  a  line  drawn 
from  the  axillary  line  at  the  border  of  the  ribs  to  the  middle  of  Pou- 
part's  ligament. 

The  thin  abdominal  walls  of  young  children  render  palpation  of  the 
spleen  much  easier  than  in  adults ;  and  this  is  a  much  more  satisfactory 
method  of  examination  than  is  percussion.  In  fact,  the  results  from  per- 
cussion are  so  uncertain  and  misleading  that  in  most  cases  one  may 
dispense  with  it,  and  rely  on  palpation  to  determine  the  size  of  the 
spleen.  For  satisfactory  palpation  it  is  necessary  that  the  abdominal  walls 
should  not  be  tense.  It  is  therefore  important  that  the  child  should  be 
quiet,  and  that  the  examination  be  made  as  gently  as  possible,  and  no 
force  or  undue  pressure  used.  The  child  should  lie  upon  its  back  with 
the  thighs  flexed  and  the  skin,  of  course,  bared.  The  physician,  always 
having  taken  the  trouble  to  warm  his  hands,  should  stand  upon  the  left 
side  of  the  patient  and  make  pressure  with  the  tips  of  the  fingers,  which 
are  semiflexed.  The  pressure  should  be  at  first  light  and  gradually  in- 
creased, the  fingers  being  then  held  stationary  during  two  or  three  re- 
spiratory movements.     It  is  sometimes  better  to  use  the  fingers  of  one 


ENLARGEMENT  OF  THE  SPLEEN.  833 

hand  for  palpation,  and  make  pressure  with  the  other  directly  over  the 
tirst.  Palpation  should  be  made  in  the  axillary  line.  If  the  examination 
is  satisfactory,  and  in  the  great  majority  of  cases  it  is  so  if  the  child  is 
quiet,  the  spleen  can  easily  be  felt  when  it  is  sufficiently  enlarged  to  be  of 
any  diagnostic  importance.  With  a  little  practice  one  can  readily  detect 
even  slight  degrees  of  enlargement. 

When  moderately  enlarged,  the  lower  border  of  the  spleen  is  an  inch 
or  so  below  the  free  border  of  the  ribs ;  when  greatly  enlarged,  it  forms 
a  tumour  which  may  nearly  fill  the  left  half  of  the  abdomen.  A  tumour 
in  the  left  hypochondriac  region  is  recognised  to  be  the  spleen,  by  the  fact 
that  it  is  freely  movable  laterally  and  at  its  lower  border  or  extremity, 
while  it  is  attached  above ;  also  its  inner  border  can  usually  be  felt  to  be 
thin  and  sharp,  and  marked  about  its  middle  by  quite  a  deep  notch. 

ENLARGEMENT   OF   THE   SPLEEN. 

In  Acute  Disease. — The  spleen  is  most  frequently  and  most  constantly 
enlarged  in  malarial  and  typhoid  fevers,  but  it  is  occasionally  so  in  all 
the  acute  infectious  diseases. 

In  most  of  these  cases  the  enlargement  is  chiefly  from  congestion,  but 
there  may  be  acute  hyperplasia  and  an  increase  in  size  of  the  Malpighiau 
bodies.  It  may  contain  small  haemorrhages,  and  in  extremely  rare  cases 
the  spleen  may  rupture.  In  appearance  it  is  generally  dark-coloured, 
soft,  and  somewhat  friable.  In  the  cases  which  recover,  the  S23lenic  swell- 
ing subsides  with  the  original  disease. 

In  Chronic  Disease. — Like  the  lymph  nodes,  the  spleen  is  much  more 
often  enlarged  in  children,  particularly  young  children,  than  in  adults. 
Enlargement  is  seen  at  times  in  almost  all  the  chronic  diseases  of  early 
life ;  but  it  occurs  most  frequently  in  rickets,  syphilis,  malaria,  tubercu- 
losis, the  blood  diseases,  and  in  amyloid  degeneration.  Besides,  it  may 
be  the  seat  of  primary  disease,  either  simple  or  malignant. 

Rickets. — The  splenic  enlargement  which  accompanies  rickets  is  gen- 
erally seen  during  the  first  year ;  at  this  period  it  is  very  frequent.  The 
swelling  is  usually  moderate,  but  occasionally  it  is  so  great  that  the  lower 
border  is  three  or  four  inches  below  the  ribs.  It  belongs  to  the  most 
severe  forms  of  the  disease. 

Syphilis. — Enlargement  of  the  spleen  is  one  of  the  most  constant 
lesions  in  congenital  syphilis.  It  is  present  with  great  uniformity  in  chil- 
dren born  with  syphilitic  lesions,  and  very  frequently  during  the  active 
period  of  the  disease  in  early  infancy.  It  is  seen  at  a  later  period  during 
infancy  or  childhood,  associated  with  other  late  symptoms.  The  degree 
of  enlargement  is  often  great.  In  several  cases  I  have  seen  it  sufficient  to 
form  a  large  abdominal  tumour.  The  liver  also  is  increased  in  size,  but 
not  to  such  a  degree.  The  pathological  changes  in  the  spleen  in  syphilis 
are  considered  with  that  disease. 


834       DISEASES   OP  THE   BLOOD,   LYMPH   NODES,   BONES,   ETC. 

Kiittner  *  has  made  a  study  of  the  blood  in  cases  of  hereditary  syphilis 
and  rickets  that  were  accompanied  by  splenic  enlargement.  The  num- 
ber of  red  cells  was  found  to  vary  greatly,  as  did  also  their  ratio  to  the 
white  cells. 

Malaria. — The  swelling  in  these  cases  may  be  very  great.  The  liver 
is  not  so  often  enlarged  as  in  syphilis.  There  is  usually  a  history  of  ex- 
posure in  a  malarial  district. 

Tuberculosis. — It  is  rare  to  find  anything  more  than  a  moderate  swell- 
ing of  the  spleen  in  tuberculosis.  In  the  most  acute  cases  this  may  be 
due  to  the  fever  and  general  infection ;  in  those  which  are  less  rapid,  it 
depends  either  upon  tuberculous  deposits  or  passive  congestion  from 
venous  obstruction,  the  result  of  the  pulmonary  disease. 

The  blood  diseases. — Marked  enlargement  of  the  spleen  is  found  in 
many  cases  of  simple  anaemia  accompanied  by  moderate  leucocytosis. 
This  is  quite  peculiar  to  infancy  and  early  childhood.  The  spleen  is  con- 
stantly swollen,  and  usually  greatly  so,  in  the  pseudo-leucsemic  anaemia  of 
infants,  in  leucsemia,  and  in  Hodgkin's  disease.  In  the  last  two  diseases 
the  liver  is  also  enlarged,  but  to  a  much  less  degree  than  the  spleen ;  in 
the  others  it  is  but  slightly  changed. 

Amyloid  degeneration. — The  causes  of  this  condition  and  its  general 
symptoms  are  mentioned  in  connection  with  amyloid  disease  of  the  liver 
(page  413).  The  spleen  is  constantly  involved,  and  the  enlargement  of 
this  organ,  as  well  as  that  of  the  liver,  may  be  very  great.  The  changes 
resemble  those  found  in  the  liver. 

Cardiac  disease. — In  all  forms  of  cardiac  disease,  and  in  other  con- 
ditions in  which  there  is  obstruction  to  the  systemic  venous  circulation, 
the  spleen  is  enlarged.  It  is  seen  in  congenital  as  well  as  in  acquired 
cases.  The  liver  is  usually  enlarged  to  about  the  same  degree  as  the  spleen, 
and  there  may  also  be  dropsy  of  the  feet. 

New-growths,  tumours,  etc. — In  rare  cases  in  early  life,  the  spleen  is  the 
seat  of  new-growths ;  these  are  usually  varieties  of  sarcoma,  but  carcinoma 
has  also  been  reported.  Lymphoma,  or,  as  it  is  more  properly  called,  sim- 
ple hyperplasia  of  the  spleen,  has  occasionally  been  observed  in  early  life, 
apart  from  any  of  the  constitutional  diseases  above  mentioned. 

Acker  (Washington)  has  reported  a  remarkable  case  in  a  coloured  boy 
of  eight  years,  who  died  of  scarlet  fever  a  year  after  the  splenic  tumour 
was  first  noticed.  At  the  autopsy  the  spleen  weighed  fifty-two  ounces. 
There  was  found  a  very  great  degree  of  hyperplasia,  but  nothing  indicat- 
ing malignant  disease. 

Echinococcus  of  the  spleen  has  been  reported  in  Europe,  but  none,  so 
far  as  I  am  aware,  in  America,  among  children. 

*  Jahrbuch  fiir  Kinderheilkunde,  Bd.  xxxv,  H.  2. 


ACUTE  ARTHRITIS  OF  INFANTS.  835 

CHAPTER   IV. 

DISEASES  OF  THE  BONES  AND  JOINTS. 

ACUTE   ARTHRITIS   OF  INFANTS. 

The  term  acute  arthritis  of  infants  has  been  given  by  Thomas  Smith, 
Townsend,*  and  others,  to  a  form  of  joint  inflammation  which  is  peculiar 
to  infancy  and  not  very  rare  at  this  time.  It  has  been  described  under 
the  names  of  acute  purulent  synovitis  of  infants,  acute  epiphysitis, 
pymmia  of  done,  acute  osteo-myelitis,  etc.  The  disease  is  essentially  a 
form  of  pyaemia,  and  is  a  suppurative  process  almost  from  the  outset. 
It  may  begin  at  the  epiphyseal  Junction,  in  the  medullary  canal,  or  in 
the  joint ;  usually,  however,  the  Joint  is  invaded  secondarily,  the  disease 
sometimes  spreading  to  it  with  great  rapidity  from  the  bone.  It  may  also 
result  in  a  diffuse  osteo-myelitis  or  in  a  subperiosteal  abscess.  Secondary 
abscesses  may  form  in  the  viscera  or  in  distant  articulations.  As  a  con- 
sequence of  the  disease,  there  may  be  separation  of  the  epiphysis  from  the 
shaft,  sometimes  entire;  destruction  of  the  articular  extremities  of  the  bone 
or  articular  cartilages.  As  late  results  there  may  be  a  pathological  dislo- 
cation, or  a  "  flail  Joint "  ;  less  frequently  there  may  be  anchylosis.  The 
extent  of  the  ravages  in  the  joint  structures  depends  chiefly  upon  the 
duration  of  the  process.  Where  the  pus  is  evacuated  early,  recovery  may 
take  place  with  very  little  permanent  damage  ;  but  in  neglected  cases  com- 
plete destruction  of  the  Joint  often  occurs. 

Etiology. — Of  73  cases  collected  by  Townsend,  all  but  four  occurred 
during  the  first  year  of  life,  and  over  half  of  them  during  the  first  three 
months.  These  early  cases  have  already  been  mentioned  among  the 
Pyogenic  Diseases  of  the  Newly  Born  (page  82).  So  far  as  is  known,  the 
disease  has  no  relation  either  to  syphilis  or  tuberculosis.  There  is  in 
some  cases  a  history  of  traumatism,  but  this  can  only  play  the  role  of  an 
exciting  cause.  The  essential  cause  of  the  disease  is  the  entrance  of 
pyogenic  germs  into  the  circulation.  They  may  gain  admission  through 
the  umbilicus,  some  abrasion  of  the  skin,  or  the  conjunctiva  (pages  79, 
80).  Very  often  the  source  of  infection  cannot  be  discovered.  Cases 
occurring  later  than  the  first  few  months  of  life  have  sometimes  followed 
measles,  scarlet  fever,  or  empyema. 

Symptoms. — The  onset  is  often  sudden,  with  well-marked  local  and 
constitutional  symptoms.  The  disease  may  be  ushered  in  with  a  chill, 
followed  by  a  fever,  which  is  frequently  high,  fluctuates  widely,  and  is 
accompanied  by  general  prostration,  restlessness,  and  other  signs  of  pain. 

*  W.  R.  Townsend,  M.  D.,  American  Journal  of  the  Medical  Sciences,  January,  1890. 
Here  will  be  found  a  full  discussion  of  the  subject,  and  the  bibliography. 


836       DISEASES  OP  THE  BLOOD,  LYMPH   NODES,  BONES,  ETC. 

There  is  rapid  swelling  about  the  affected  joint,  which  is  usually  diffuse, 
as  the  lesion  is  deep-seated.  There  is  also  acute  tenderness,  and  usually 
deformity.  Later  there  are  redness,  oedema,  a  glazed  skin,  and  deep  fluc- 
tuation. In  some  cases  the  constitutional  symptoms  are  slight  or  wanting. 
After  pus  forms,  it  may  lead  to  rupture  of  the  capsule  and  infiltration  of 
all  the  tissues  about  the  joint,  often  burrowing  for  a  considerable  distance 
before  it  reaches  the  surface. 

When  its  progress  is  most  rapid,  death  may  occur  in  two  or  three  days, 
from  exhaustion  or  general  pya?mia.  The  lesions  in  such  cases  are  usually 
multiple.  The  usual  duration  is  from  one  to  two  weeks,  suppuration 
generally  being  evident  in  four  or  five  days.  In  Townsend's  collection  of 
cases  the  joints  were  affected  in  the  following  order :  hip,  in  38  cases ; 
knee,  in  27  ;  shoulder,  in  13  ;  wrist,  in  5  ;  elbow,  in  4 ;  ankle,  in  4 ;  fingers, 
in  2  ;  toes,  in  1 ;  sterno-clavicular,  in  1.  I  liave  met  with  one  case  in  which 
suppuration  occurred  in  the  temporo-maxillary  and  the  medio-sternal 
joints;  in  another,  in  the  temporo-maxillary  and  shoulder.  In  ?5  per 
cent  of  the  cases  collected  by  Townsend  only  one  joint  was  involved,  and 
of  these  two  thirds  recovered ;  in  the  remaining  25  per  cent,  with  multi- 
ple joint  lesions,  only  one  fourth  of  the  cases  recovered.  Of  those  who  sur- 
vive the  acute  period,  the  number  who  recover  with  perfect  joints  is  small. 

Diagnosis. — The  disease  is  not  usually  difficult  of  recognition,  from 
the  constitutional  symptoms,  the  marked  swelling,  tenderness,  and  de- 
formity, and  the  rapidity  with  which  suppuration  occurs.  It  has  been 
mistaken  for  rheumatism,  although  rheumatism  is  so  rare  in  infancy  that 
it  may  be  practically  ignored.  Syphilitic  epiphysitis  resembles  it  in  the 
localized  pain,  tenderness,  and  general  immobility,  but  lacks  the  rapid 
swelling,  fever,  and  severe  constitutional  symptoms,  and  its  course  is  more 
prolonged.  Acute  cellulitis  in  the  neighbourhood  of  the  joints  may 
resemble  it,  but  this  is  rare  except  from  traumatism.  The  disease  has 
little  in  common  with  tuberculous  bone  disease  of  later  childhood. 

Treatment. — The  general  treatment  is  to  be  directed  toward  the 
patient's  condition,  and  the  purpose  of  it  should  be  to  relieve  pain  and 
support  the  general  strength.  Suppuration  occurs  very  early,  and  no 
time  should  be  wasted  in  trying  to  allay  the  inflammation  by  local  appli- 
cations. The  best  results  are  obtained  by  early  incision,  free  drainage, 
and  thorough  antiseptic  treatment.  Fixation  of  the  joint  should  follow 
operation,  in  order  to  prevent  deformity. 

THE  TUBERCULOUS   DISEASES   OF  THE   BONES   AND  JOINTS. 

The  chronic  forms  of  tuberculous  bone-disease,  on  account  of  their 
insidious  onset  and  the  frequency  with  which  they  simulate  other  diseases, 
more  frequently  fall,  in  the  early  stage  at  least,  into  the  hands  of  the 
physician  than  into  those  of  the  general  or  orthopedic  surgeon.  All 
that  will  be  attempted  in  this  chapter  will  be  to  outline  in  a  general  way 


TUBERCULOUS   DISEASES  OF   THE   BONES   AND  JOINTS.        837 

the  most  important  forms — viz.,  disease  of  the  vertebra,  hip,  and  knee — 
dwelling  particularly  upon  the  early  symptoms  and  diagnosis.  For  their 
fuller  discussion,  particularly  as  to  the  details  of  treatment,  the  reader  is 
referred  to  text-books  on  general  or  orthopaedic  surgery.  The  causes  are 
the  same,  and  the  lesions  are  very  similar  in  all  forms,  and  will  therefore 
be  considered  together. 

Etiology. — The  age  at  which  tuberculosis  of  the  bones  most  frequently 
begins,  is  from  the  third  to  the  eighth  year,  it  being  comparatively  rare 
before  the  end  of  the  second  year.  The  sexes  are  affected  with  about 
equal  frequency.  Tuberculous  bone  disease  may  occur  in  a  child  who  has 
previously  been  in  apparent  health,  but  more  often  in  one  who  has  been 
reduced  by  some  previous  illness,  especially  the  infectious  diseases  of  child- 
hood ;  of  these,  it  most  frequently  follows  measles  and  whooping-cough. 

A  history  of  inherited  tuberculosis  is  present  in  a  large  number,  but 
by  no  means  in  a  majority  of  the  cases.  Like  tuberculosis  of  the  cervical 
glands,  it  is  rarely  preceded  by  other  tuberculous  processes,  although  it 
may  be  followed  by  them.  It  usually  appears  as  an  example  of  primary 
infection ;  but  it  seems  very  improbable  that  such  sliould  actually  be  the 
case.  It  is  more  likely  that  there  has  previously  been  a  latent  focus  of 
tuberculosis  elsewhere  in  the  body.  In  many  cases,  antecedent  disease  of 
the  bronchial  glands  has  been  demonstrated  by  autopsy.  Infection  from 
these  or  from  other  tuberculous  lymph  glands,  is  the  most  probable 
explanation  of  the  origin  of  infection  in  cases  of  bone  disease.  However, 
by  some  writers,  notably  Baumgarten,  tuberculous  disease  of  bone  is 
regarded  as  due  to  direct  inheritance,  and  is  to  be  compared  to  the  bone 
lesions  which  occur  as  late  manifestations  of  hereditary  syphilis. 

Traumatism  is  often  an  exciting  cause,  and  it  may  determine  the 
site  of  the  disease. 

Lesions. — The  tuberculous  joint  diseases  of  childhood  are,  as  a  rule, 
secondary  to  disease  of  the  bones.  Hip-joint  disease  usually  begins  in  the 
head  of  the  femur,  and  knee-joint  disease  in  one  of  the  condyles ;  ankle- 
joint  disease  in  the  lower  epiphysis  of  the  tibia,  etc. 

The  frequency  with  which  disease  is  seen  in  the  different  locations  is 
shown  by  the  following  table,  which  gives  the  number  of  cases  of  each 
form  applying  for  treatment  at  the  Hospital  for  Euptured  and  Crippled, 
New  York,  during  the  years  1884  to  1893  inclusive: 

Spine 2,145  cases,  or  37-5  per  cent. 

Hip 1,937  "  "34-0  " 

Knee 1.222  "  "  21-5  " 

Ankle  or  tarsus 255  "  "4-5  " 

Elbow 71  "  "     1-2  " 

Wrist 50  "  "     0-9  " 

Shoulder 24  "  "     0-4  "* 

Total 5,704  lOQ-O 


838       DISEASES   OP  THE   BLOOD,  LYMPH   NODES,   BONES,   ETC. 

The  character  of  the  bone  disease  upon  which  chronic  joint  disease  de- 
pends is  generally  a  primary  ostitis,  Avhich  affects  the  articular  extremities 
of  the  long  bones  usually  beginning  near  the  epiphyseal  line  ;  in  the  short 
bones  it  is  a  central  ostitis.  The  stages  in  the  process  are  first  congestion, 
swelling,  and  cell  infiltration,  followed  by  caseation,  and  frequently  by 
softening  and  suppuration.  In  the  early  stage,  the  bone  is  slightly  en- 
larged, and  on  section  one  or  more  yellowish  foci  of  disease  are  seen.  The 
disease  may  be  arrested  in  this  stage,  encapsulation  of  the  inflammatory 
products  taking  place ;  or  it  may  continue  until  there  is  a  more  or  less 
extensive  breaking  down  or  disintegration  of  the  affected  bone.  As  the 
disease  extends  there  are  involved,  the  periosteum,  the  articular  cartilage, 
and  finally  the  joint  itself.  Abscess  may  form  in  the  joint  or  in  the  soft 
parts  surrounding  the  bone.  The  process  is  quite  analogous  to  tuberculous 
disease  of  the  lung.  As  the  disease  advances  ligamentous  attachments  are 
loosened,  and  displacement  of  the  parts  occurs  with  the  production  of 
deformity,  due  partly  to  muscular  contraction  and  partly  to  the  weight  of 
the  body.  The  inflammatory  process  with  its  resulting  disintegration 
generally  goes  on  to  a  certain  point,  where  it  is  arrested.  Gradually  the 
broken-down  bone  substance  is  separated  and  thrown  off  in  small  particles 
in  the  discharge,  and  a  reparative  process  begins,  with  the  formation  of 
healthy  bone.  Where  joint  structures  have  been  destroyed,  cure  takes 
place  by  bony  anchylosis.  Sometimes  the  disease  finds  its  way  to  the 
surface  without  involving  the  joint ;  at  other  times  the  disease  may  be 
arrested,  and  its  products  become  encapsulated  within  the  bone.  Inflam- 
mation of  the  joint  may  occur  by  a  gradual  extension  of  the  inflammatory 
process,  or  by  a  sudden  perforation  of  the  articular  lamella.  As  a  result 
of  extensive  disease,  all  the  joint  structures  may  be  affected, — the  synovial 
membrane,  ligaments,  articular  cartilages,  and  the  cellular  tissue  surround- 
ing the  joint.  The  process  of  disintegration  and  that  of  repair  are  both 
very  chronic  and  measured  by  months  or  years.  The  entire  course  of  the 
disease  is  from  one  to  ten  years,  three  years  being  about  the  average  dura- 
tion. In  the  great  proportion  of  cases  but  one  joint  is  involved,  although 
it  is  not  infrequent  in  hospitals  to  see  two,  three,  and  sometimes  four  of 
the  large  joints  affected  in  the  same  patient. 

Secondary  lesions. — Abscesses  form  in  a  considerable  proportion  of 
the  cases,  and  often  burrow  a  long  distance  before  they  reach  the  surface. 
Amyloid  degeneration  of  the  liver,  spleen,  and  kidney,  and  sometimes  of 
the  villi  of  the  intestines,  occurs  as  the  result  of  the  prolonged  suppura- 
tion, chiefly  in  connection  with  disease  of  the  hip  or  spine,  occasionally 
with  that  of  the  knee.  General  or  localized  tuberculosis,  particularly 
tuberculous  meningitis,  may  develop  at  any  time  and  prove  fatal. 

Caries  of  the  Spine — Pott's  Disease. — This  consists  in  a  chronic 
inflammation  of  the  bodies  of  the  vertebrae,  usually  beginning  in  the  cen- 
tral portion  and  extending  to  the  periosteum,  ligaments,  cartilages,  and,. 


TUBERCULOUS  DISEASES  OP   THE  BONES  AND  JOINTS. 


839 


in  fact,  to  all  the  contiguous  structures.  It  frequently  involves  the  mem- 
branes of  the  cord,  the  roots  of  the  spinal  nerves,  and  even  the  cord  itself. 
The  number  of  vertebra;  usually  affected  is  from  two  to  five.  The  gross 
appearance  of  the  lesion  in  a  well-marked  case  is  shown  in  the  accompany- 
ing cut  (Fig.  144).  After  the  bodies  of  the  vertebra?  have  become  soft- 
ened and  partially  broken  down  by  disease,  the  pressure  from  the  super- 
incumbent weight  of  the  body  causes  them  to  fall  together  and  produces 
a  backward  displacement  of  the  spinous  processes,  giving  rise  to  the  de- 
formity known  as  kyphosis,  which  in  its  ex- 
treme form  is  popularly  known  as  "  hunch- 
back." 

Any  part  of  the  vertebral  column  may  be 
affected ;  but  the  disease  is  most  frequent  in 
the  dorsal  region,  as  shown  by  the  following 
statistics  from  the  Hospital  for  Ruptured  and 
Crippled :  of  2,143  cases,  72'5  per  cent  affected 
the  dorsal  region,  15 '3  per  cent  the  lumbar 
region,  and  12'2  per  cent  the  cervical  region. 

Symptoms. — The  onset  is  gradual,  often  in- 
sidious, and  the  early  symptoms  are  frequently 
overlooked  or  misinterpreted.  The  case  may 
go  on  for  weeks  or  even  months  before  the 
true  nature  of  the  disease  is  recognised,  which 
is  often  not  until  deformity  has  occurred.  In 
nearly  all  cases,  however,  the  early  symptoms 
are  sufficiently  characteristic  to  enable  a  care- 
ful observer  to  make  a  diagnosis  before  the 
stage  of  deformity. 

The  most  constant  early  symptoms  are  :  (1) 
pains  caused  by  the  irritation  of  the  nerve 
roots  and  referred  to  various  parts  of  the  body, 
following  the  distribution  of  the  spinal  nerves ; 
(2)  rigidity  of  the  spine  from  muscular  spasm, 
this  being  an  attempt  to  prevent  motion  at 

the  seat  of  disease ;  and  (3)  the  assumption  of  various  postures  calculated 
to  relieve  pressure  upon  the  diseased  vertebral  bodies.  Sometimes  the  first 
symptoms  are  those  of  pressure-paralysis  (page  768) ;  at  others  they  are 
the  local  signs  of  abscess.  In  addition  to  the  local  symptoms  mentioned, 
there  is  usually  disturbed  sleep,  often  accompanied  by  moaning. 

Cervical  disease. — The  pains  are  often  felt  above  the  point  of  disease, 
frequently  in  the  form  of  occipital  neuralgia ;  sometimes  they  are  referred 
to  the  front  or  the  side  of  the  neck.  They  may  be  so  frequent  and  so 
severe  that  the  face  assumes  a  constant  expression  of  anxiety  or  distress. 
In  other  cases  pain  is  excited  only  by  an  attempt  at  movement.     The 


Fig.  144. — Potfs  disease  of  the 
upper  dorsal  region  ;  a  ver- 
tical section  of  the  spine, 
showing  disintegration  of  the 
bodies  of  the  vertebra  and 
encroachment  upon  the  spinal 
canal.  ( From  a  patient  dying- 
in  the  Hospital  for  Kuptured 
and  Crippled.) 


840        DISEASES   OF  THE   BLOOD,   LYMPH   NODES,  BONES,   ETC. 

muscular  spasm  most  frequently  takes  the  form  of  slight  torticollis,  some- 
times of  slight  opisthotonus ;  sometimes  there  is  simply  a  fixation  of  the 
head  by  a  tonic  spasm  of  all  the  muscles  of  the  neck ;  both  active  and 
passive  motion  is  resisted,  and  any  movement  may  be  so  painful  that  the 
child  involuntarily  steadies  its  head  with  its  hands.  These  symptoms 
come  on  gradually  and  are  persistent.  Sometimes  they  are  overlooked,  and 
the  first  thing  to  attract  attention  is  a  progressive  weakness  in  the  lower 
extremities,  which  proves  the  beginning  of  paraplegia.  Occasionally  the 
first  marked  symptoms  are  those  due  to  the  formation  of  a  retro-pharyn- 
geal  or  a  retro-oesophageal  abscess  (page  276). 

The  deformity  from  cervical  disease  develops  much  later  than  when 
the  disease  is  located  elsewhere.  Usually  the  neck  appears  broadened  or 
thickened  in  a  nearly  uniform  way,  and  often  the  head  seems  to  have 
settled  downward  upon  the  shoulders.  In  the  lower  cervical  region,  a 
kyphosis  is  not  infrequent ;  but  in  the  middle  and  upper  regions  there  is 
more  often  an  anterior  prominence,  which  may  be  felt  in  the  posterior 
wall  of  the  pharynx. 

Dorsal  disease. — The  referred  pains  are  now  below  the  seat  of  disease, 
and  take  the  form  of  intercostal  neuralgia  or  pain  in  the  epigastrium  or  the 
abdomen.  They  are  often  ascribed  to  cold,  malaria,  indigestion,  or  worms. 
There  is  a  disposition  to  assume  the  prone  position  while  sleeping,  and 
also  to  lean  across  a  chair  or  the  lap  of  the  nurse.  The  child  walks  care- 
fully, holding  the  spine  erect  and  very  stiffly,  and  exhibits  great  caution 
in  getting  into  or  out  of  bed,  or  in  rising  from  a  recumbent  position.  In 
the  beginning  there  may  be  a  slight  lordosis,  or  forward  curve  at  the  seat 
of  disease,  instead  of  the  usual  kyphosis  or  backward  projection,  but  the 
latter  soon  takes  its  place,  and  with  it  is  seen  the  compensatory  lordosis  in 
the  lumbar  region. 

Lumbar  disease. — The  first  symptoms  here  are  often  pain  and  lame- 
ness, referred  to  one  of  the  lower  extremities.  This  frequently  leads  to 
the  suspicion  that  the  hip  is  the  seat  of  disease.  In  addition  to  the  lame- 
ness there  may  be  a  tilting  of  the  pelvis  to  one  side,  and  sometimes  quite 
a  distinct  lateral  curvature  of  the  spine.  Referred  pains  are  not  so  fre- 
quent nor  so  severe  as  when  the  upper  part  of  the  spine  is  affected ;  theyi 
may  be  felt  in  the  groin,  in  the  loin,  in  the  thigh,  in  the  buttock,  or  ini 
the  hypogastrium.  The  gait  and  attitude  are  very  characteristic  :  throw- 
ing the  shoulders  well  back,  the  patient  walks  stiffly  with  short  steps, 
holding  the  spine  with  the  greatest  care.  He  rises  from  the  floor  awk- 
wardly and  with  difficulty.  Deformity  is  not  usually  so  early  or  so 
marked  as  when  the  disease  is  dorsal,  and  often  before  it  is  visible  there 
are  symptoms  due  to  the  formation  of  psoas  abscess, — lameness,  flexion  of 
one  thigh,  and  a  tumour  may  be  found  deep  in  the  iliac  fossa  or  at  the 
upper  and  inner  aspect  of  the  thigh ;  in  both  locations  it  has  often  been 
mistaken  for  hernia. 


TUBERCULOUS   DISEASES  OP  THE   BONES   AND   JOINTS.        841 

Physical  examination. — Whenever  any  of  the  above  symptoms  are 
present,  the  child  should  be  stripped  and  submitted  to  a  thorough  exami- 
nation, the  purpose  of  which  should  be  to  determine,  first,  the  existence  of 
any  deformity ;  secondly,  the  mobility  of  the  spine ;  thirdly,  the  presence 
of  any  secondary  lesions,  such  as  abscesses  or  paralysis.  The  mobility  of 
the  spine  is  best  determined  by  studying  the  attitude,  gait,  and  posture  of 
the  child,  and  the  manner  of  stooping  or  rising  from  the  floor.  The  gait 
has  already  been  described  with  the  symptoms  of  lumbar  disease.  A.s  it 
has  been  tersely  put,  "  the  child  walks  with  its  legs  but  not  with  its  back." 
In  stooping,  the  same  disinclination  to  bend  or  move  the  spine  is  seen. 
It  is  often  impossible  to  induce  the  child  to  stoop  at  all,  and  when  it  does 
so,  to  pick  up  some  object,  there  is  acute  flexion  at  the  knee  and  hip,  but 
as  little  bending  of  the  spine  as  possible.  In  rising  from  the  recumbent 
position  the  same  thing  is  seen.  The  posture  and  attitude  of  the  child 
will  be  modified  by  the  position  of  the  disease,  and  somewhat  by  the  ac- 
tivity of  the  process  at  the  time ;  however,  by  comparing  the  movements 
referred  to  with  those  of  a  healthy  child,  the  great  difference  will  at  once 
be  apparent.  If  the  symptoms  point  to  cervical  disease,  a  digital  explora- 
tion of  the  pharynx  for  deformity  or  abscess  should  be  made,  and  the 
extremities  should  be  examined  for  paralysis.  If  the  disease  is  in  the 
lumbar  region,  deep  palpation  of  the  iliac  fossa  should  be  made  to  discover 
a  psoas  abscess,  and  the  passive  movements  of  the  thigh  should  be  carefully 
tested  to  determine  whether  there  is  any  resistance  to  extreme  extension, 
this  often  being  present  before  the  psoas  tumour.  No  matter  how  clearly 
the  lameness  may  be  at  the  hip,  it  should  be  remembered  that  this  often 
results  from  disease  of  the  lumbar  spine.  If  the  thigh  is  flexed  and  freely 
movable  except  in  extension,  the  symptoms  are  probably  the  result  of 
psoas  irritation,  for  in  hip-joint  disease  the  other  movements  of  the  joint 
are  also  resisted. 

The  deformity  of  Pott's  disease  is  often  spoken  of  as  "  angular  "  curva- 
ture of  the  spine.  While  this  is  a  true  description  of  the  disease  at  an 
advanced  stage,  there  is  often  in  the  early  stage  only  a  general  curve. 
Later  a  slight  knuckle  is  seen  from  the  unnatural  projection  of  a  single 
spinous  process.  This  deformity  may  increase  and  finally  involve  five  or 
six  vertebrse.  It  is  usually  greatest  in  the  upper  dorsal  region.  A  slight 
prominence,  which  does  not  disappear  on  suspending  the  patient,  is  always 
suspicious. 

Tenderness  upon  pressure  over  the  spinous  processes  and  increased 
sensitiveness  to  heat  and  cold,  are  rarely  present.  Pain  may  sometimes 
be  produced  by  downward  pressure  upon  the  head  or  shoulders  in  the  axis 
of  the  spine.  This  symptom  is  not  necessary  for  diagnosis,  and  the  at- 
tempt to  elicit  it  is  strongly  condemned  by  Gibney,  who  has  seen  serious 
harm  follow  such  a  test. 

Course  of  the  disease. — Caries  of  the  spine  is  a  very  chronic  disease,  its 


842       DISEASES  OP  THE   BLOOD,  LYMPH   NODES,   BONES,  ETC. 

course  being  measured  by  months  or  ^-ears,  but  marked,  as  in  all  clironic 
diseases,  by  periods  of  remission  and  exacerbation.  An  exacerbation  may 
follow  traumatism,  and  is  often  accompanied  by  the  formation  of  an  ab- 
scess. After  the  disease  has  lasted  from  one  to  three  years,  the  destructive 
inflammation  ceases  and  repair  begins,  a  cure  being  finally  effected  by  a 
process  of  consolidation  of  the  fragments  of  the  diseased  yertebrte,  and  the 
production  of  anchylosis.  Eelapses  are  easily  excited  by  traumatism,  by 
improper  treatment  or  by  discontinuing  the  use  of  mechanical  supports 
before  the  disease  is  arrested. 

Abscesses. — The  frequency  with  which  abscesses  occur  depends  some- 
what upon  the  treatment.  Townsend  states  that  of  380  cases,  abscess  was 
present  in  20  per  cent.  They  are  rarely  seen  earlier  than  three  or  four 
months  from  the  beginning  of  symptoms,  and  usually  belong  to  the  sec- 
ond year  of  the  disease.  They  sometimes  form  with  acute  symptoms,  but 
more  frequently  they  appear  as  typical  cold  abscesses.  Those  connected 
with  cervical  disease  are  retro-pharyngeal  or  retro-oesophageal,  or  they 
may  open  externally,  usually  just  above  the  clavicle,  in  front  of  the  sterno- 
mastoid  muscle.  Those  with  disease  of  the  lower  cervical  and  upper  dorsal 
vertebrae,  are  apt  to  burrow  along  the  spine,  appearing  in  the  lumbar  re- 
gion ;  rarely  they  may  rupture  into  the  oesophagus  or  the  pleural  cavity. 
Those  with  disease  of  the  lower  dorsal  or  lumbar  vertebras,  may  open  just 
above  the  iliac  crest  posteriorly,  or  burrow  anteriorly  between  the  abdomi- 
nal muscles,  but  the  usual  course  is  for  them  to  follow  the  psoas  muscle, 
appearing  in  the  groin  just  above  Poupart's  ligament  or  at  the  upper  and 
inner  aspect  of  the  thigh. 

Paralysis  occurs  in  about  one  half  the  cases  in  which  the  disease  affects 
the  lower  cervical  and  upper  dorsal  vertebrte,  but  it  is  rare  when  the  dis- 
ease is  below  the  middle  dorsal  region  (see  Compression  Myelitis,  page  7G8). 

Prognosis. — The  actual  mortality  of  Pott's  disease  is  difficult  to  state, 
so  many  of  the  consequences  of  the  disease  being  remote  and  not  fully 
appreciated  until  adult  life  is  reached.  The  general  mortality  from  all 
causes  is  from  ten  to  twenty  per  cent.  The  causes  of  death  are  exhaus- 
tion from  prolonged  suppuration,  amyloid  degeneration,  myelitis,  general 
tuberculosis,  and  tuberculous  meningitis.  Sudden  death  occasionally  oc- 
curs from  pressure  upon  the  cord  in  the  upper  cervical  region,  or  from  the 
pressure  effects  of  abscesses  in  the  posterior  pharynx  or  in  the  posterior 
mediastinum. 

The  prognosis  as  to  the  amount  of  permanent  deformity,  will  depend 
upon  the  seat  of  the  disease,  the  time  at  which  treatment  is  begun,  and 
upon  the  thoroughness  with  which  it  is  carried  out.  The  best  results  as 
to  deformity  are  obtained  when  the  disease  is  below  the  middle  dorsal  re- 
gion. With  improved  methods  of  treatment  begun  early,  a  large  number 
of  these  patients  recover  with  an  insignificant  amount  of  deformity,  and 
some  with  none  whatever. 


TUBERCULOUS   DISEASES   OP   THE   BONES  AND  JOINTS.        843 

Diagnosis. — The  spinal  deformity  resulting  from  Pott's  disease  may  be 
confounded  with  rachitic  kyphosis  or  with  rotary  lateral  curvature.  Rachitic 
curvatures  (page  225)  are  usually  seen  in  children  under  eighteen  months 
of  age,  a  time  when  Pott's  disease  is  rare  ;  there  are  other  signs  of  rickets 
present,  and  instead  of  rigidity  there  is  usually  undue  mobility  of  the  spine. 
What  is  true  of  rickets  may  be  said  of  all  curvatures  depending  upon  mal- 
nutrition. Rotary  lateral  curvature  is  seen  about  puberty,  rarely  in  young 
children  except  in  connection  with  rickets.  A  slight  lateral  deviation  of 
the  spine,  sometimes  seen  in  the  early  stage  of  caries,  may  resemble  a  case 
of  incipient  rotary  curvature.  The  latter  is  not  attended  by  pain  or  rigidity, 
and  is  most  frequent  in  young  girls  from  eleven  to  fourteen  years  of  age. 

Other  abscesses  may  be  mistaken  for  those  dependent  upon  vertebral 
caries.  This  difficulty  is  likely  to  exist  in  the  cases  attended  by  very 
little  spinal  deformity.  These  abscesses  are  most  frequently  in  the  iliac 
fossa  or  in  the  lumbar  region,  and  may  be  due  to  perinephritis  or  ap- 
pendicitis. The  latter  are  more  acute  than  those  depending  upon  bone 
disease  and  usually  accompanied  by  fever.  Tumours  of  the  vertebrae  or 
of  the  spinal  cord  may  give  rise  to  symptoms  almost  identical  with  those 
resulting  from  compression  myelitis  due  to  Pott's  disease,  but  both  of 
these  are  extremely  rare. 

Treatment. — The  treatment  of  Pott's  disease  is  both  general  and  local, 
and  neither  should  be  neglected.  The  constitutional  treatment  should  be 
similar  to  that  employed  in  other  forms  of  tuberculosis. 

The  indications  for  local  treatment  are  to  put  the  diseased  parts  at 
rest,  by  immobilizing  the  spine  and  removing  the  superincumbent  weight 
of  the  body.  With  the  great  advances  made  in  orthopaedic  surgery  it  is 
no  longer  necessary  to  confine  these  patients  in  bed,  as  was  formerly  prac- 
tised, to  secure  this  result.  It  may  be  accomplished  either  by  plaster-of- 
Paris,  or  some  other  form  of  jacket,  or  a  properly  fitting  steel  brace.  A 
head-support  should  be  attached  to  all  forms  of  apparatus,  if  the  disease 
is  above  the  middle  dorsal  region.  The  closest  attention  to  details  and 
much  experience  in  the  use  of  apparatus  are  required  to  secure  the  best 
results.  In  perhaps  no  class  of  cases  has  the  beneficial  results  of  mod- 
ern scientific  treatment  been  more  apparent  than  in  those  of  Pott's  dis- 
ease. For  the  details  in  regard  to  the  mechanical  treatment  and  the 
different  forms  of  apparatus,  the  reader  is  referred  to  works  on  general 
or  orthopaedic  surgery. 

Articular  Ostitis  of  the  Hip — Hip-Joixt  Disease — Morbus 
CoxARius. — In  early  childhood  this  generally  begins  as  a  chronic  ostitis 
in  the  head  of  the  femur,  starting  near  the  epiphyseal  line.  Exception- 
ally, and  according  to  Gibney,  oftener  in  older  children,  it  begins  in  the 
acetabulum.  The  pathological  process,  as  well  as  the  clinical  history,  is 
generally  described  as  consisting  of  three  stages.  In  the  first  stage — that 
of  ostitis — the  lesions  are  limited  to  the  bone ;  in  the  second  stage — that 


844        DISEASES   OF   THE   BLOOD,   LYMPH   NODES,   BONES,   ETC. 

of  arthritis — all  the  joint  structures  are  involved,  and  in  this  stage  suppu- 
ration usually  occurs ;  in  the  third  stage  there  are  breaking  down  and  ab- 
sorption of  the  head  and  sometimes  of  the  neck  of  the  femur,  which,  with 
destruction  of  the  ligaments,  lead  to  marked  displacement  of  the  parts 
from  muscular  contraction.  The  disease  may  be  arrested  in  the  first  or 
in  the  second  stage,  or  it  may  continue  through  all  three  stages. 

Symptoms. — Clinically,  the  usual  duration  of  the  first  stage  is  three  or 
four  months ;  it  may  last  only  for  a  few  weeks,  it  may  extend  over  two 
or  three  years,  and  the  disease  may  be  arrested  in  this  stage.  The  onset 
is  usually  very  gradual,  and  the  symptoms  are  often  considered  of  trivial 
importance  until  they  have  continued  for  some  weeks.  Generally  the  first 
thing  noticed  is  slight  lameness,  due  to  stiffness  of  the  joint.  In  the 
beginning  this  may  be  seen  only  in  the  morning,  wearing  off  during  the 
day.  It  may  be  accompanied  by  some  tenderness  about  the  hip  and  a  dis- 
inclination to  walk.  A  little  later  the  child  complains  of  pain,  which  is 
most  frequently  referred  to  the  front  of  the  knee  or  the  inner  aspect  of 
the  thigh,  but  only  in  rare  cases  to  the  hip  itself.  This  is  slight  at  first, 
but  gradually  increases  in  frequency  and  sevei'ity,  and  soon  there  are 
added  the  "  starting  pains  "  at  night,  which  are  one  of  the  most  character- 
istic features  of  early  hip-disease.  These  pains  are  produced  by  a  sudden 
spasm  of  the  muscles  during  sleep.  The  child  often  cries  out  sharply 
without  waking,  sometimes  wakes  with  a  cry ;  this  is  often  repeated  sev- 
eral times  during  the  night.  Soon  restlessness  and  fretfulness  during  the 
day  are  present.  The  lameness,  which  at  first  was  slight  and  occasional, 
or  noticed  only  in  the  morning,  comes  to  be  a  constant  symptom,  and 
week  by  week  increases  in  severity.  The  evolution  of  these  symptoms 
may  take  only  a  few  weeks,  but  sometimes  they  come  and  go  in  the  most 
inexplicable  manner'  during  a  period  of  several  months,  or  even  one  to 
two  years,  before  they  are  fully  developed. 

Physical  examination. — Every  child  with  a  suspicious  lameness,  or 
with  pains  like  those  mentioned,  should  be  stripped  and  submitted  to  a 
thorough  examination.  The  first  points  to  be  observed  on  inspection  re- 
late to  the  general  contour  of  the  hip ;  every  prominence  and  depression 
should  be  carefully  noted.  Then  the  attitude  and  gait  should  be  studied ; 
and  finally  all  the  functions  of  the  joint  should  be  carefully  tested,  and 
the  limbs  measured,  to  determine  the  existence  of  shortening  or  atrophy. 
At  every  step  a  comparison  should  be  made  with  the  sound  limb.  The 
contour  of  the  hip  is  changed  quite  uniformly  :  there  are  broadening  and 
fiattening  of  the  whole  gluteal  region ;  the  trochanter  is  unnaturally 
prominent;  the  gluteal  fold  is  shortened,  and  often  single  instead  of 
double.  There  is  no  characteristic  position  of  the  limb  in  this  stage. 
There  is  atrophy  of  the  thigh  and  often  of  the  calf.  In  Fig.  145  is  shown 
the  appearance  of  a  typical  case  in  the  full  development  of  the  first  stage. 
In  walking,  the  child  favours  the  diseased  side,  throwing  the  weight  as 


TUBERCULOUS   DISEASES  OP  THE   BONES  AND  JOINTS. 


845 


j%,. 


much  as  possible  upon  tlie  sound  limb  ;  but  all  these  symptoms  are  of 
much  less  importance  for  diagnosis  than  is  an  examination  of  the  func- 
tions of  tlie  joint. 

For  this  purpose  the  child  should  be  placed  upon  a  table  upon  its 
back,  and  the  various  movements  of  the  hip — abduction,  adduction,  flexion, 
extension,  and  rotation — should  be  executed,  first  with  the  sound  limb 
and  then  with  the  suspected  one,  the  two  being 
carefully  compared  at  every  point  to  determine 
the  degree  of  motion  allowed.  It  is  not  neces- 
sary that  force  should  be  employed  or  pain  in- 
flicted. If  the  symptoms  have  existed  for  some 
weeks,  there  is  generally  a  limitation  of  motion 
at  the  hip  in  all  directions,  but  first  usually  in 
abduction,  rotation,  or  extension.  In  more  ad- 
vanced cases,  no  motion  whatever  may  be  per- 
mitted at  the  joint,  the  pelvis  tilting  with  the 
slightest  movement  of  the  femur.  This  fixation 
of  the  hip  is  due  to  tonic  muscular  spasm. 
Crowding  the  articular  surfaces  together,  by 
pressure  upon  the  heel  or  trochanter,  produces 
pain,  which  is  usually  referred  to  the  joint. 
This  test  should  be  carefully  made,  lest  injury 
be  inflicted.  Gibney  cautions  against  examina- 
tions under  ether,  since  in  this  way  serious  in- 
jury may  be  done  unconsciously. 

Second  stage. — This  has  been  called  the  stage 
of  arthritis.  Its  existence  may  be  assumed  when 
the  limb  takes  the  position  of  marked  perma- 
nent deformity,  which  is  due  at  this  period  to 
muscular  action,  not  to  destructive  bone  changes. 
The  transition  from  the  first  to  the  second  stage 
is  in  most  cases  a  gradual  one,  and  the  line  be- 
tAveen  the  two  can  not  be  sharply  drawn.  Some- 
times, however,  it  is  rapid,  and  marked  by  a 
sharp  exacerbation  of  all  the  symptoms.  This 
may  indicate  a  sudden  perforation  of  the  joint, 

and  the  rapid  development  of  suppurative  arthritis.  Such  is  the  usual 
result  when  an  abscess  which  has  been  slowly  forming  in  the  bone,  opens 
into  the  joint ;  or  acute  joint  inflammation  may  be  lighted  up  without 
so  evident  a  cause.  Sometimes  the  pus  reaches  the  surface  below  the 
capsular  ligament,  and  the  joint  remains  intact.  An  acute  exacerba- 
tion is  indicated  by  increased  pain,  excessive  tenderness  about  the  hip, 
often  by  inability  to  walk,  or  even  to  bear  any  weight  upon  the  limb,  and 
frequently  by  fever.      The  position  assumed  by  the  limb  is  now  fairly 


Fig.  145. — lii[p-j(iuil  disease,  at 
the  end  of  the  first  stage, 
showing  muscular  atrophy, 
prominence  of  the  trochan- 
ter, flattening  of  the  gluteal 
region,  and  a  single  gluteal 
fold. 


846        DISEASES  OF  THE  BLOOD,   LYMPH   NODES,  BONES,  ETC. 

characteristic.  The  foot  is  generally  everted,  the  thigh  slightly  flexed  and 
rotated  outward,  and  the  limb  apj^arently  lengthened.  There  may  be 
infiltration  anywhere  about  the  hip,  due  to  the  formation  of  an  abscess. 
The  muscular  spasm  is  so  great  that  the  joint  is  locked, — no  motion 
whatever  being  allowed.  Abscesses  may  form  at  any  point  about  the 
hip ;  they  are  especially  frequent  at  the  upper  and  outer  aspect  of  the 
thigh,  and  may  buiTow  long  distances  before  reaching  the  surface.  The 
duration  of  the  second  stage  also  is  indefinite,  but  it  usually  lasts  from  a 
few  months  to  a  year,  or  the  disease  may  be  arrested  in  this  stage. 

Third  stage. — There  is  now  marked  deformity,  which  is  the  result  of 
muscular  contraction  after  absorption  of  the  head  and  sometimes  the 
neck  of  the  femur,  and  destruction  of  the  ligaments.  The  position  of 
the  limb  is  a  very  constant  one,  and  resembles  that  present  in  dislocation 
upon  the  dorsum  of  the  ilium.  There  is  shortening  of  from  one  to  four 
inches ;  the  thigh  is  strongly  flexed,  adducted,  and  rotated  inward,  and 
the  foot  is  inverted ;  the  trochanter  lies  against  the  outer  surface  of  the 
ilium,  and  is  above  Nelaton's  line.  In  this  position  the  joint  may  be- 
come anchylosed.  The  displacement  usually  comes  on  gradually,  but  it  is 
sometimes  so  sudden  as  to  be  mistaken  for  a  true  dislocation,  although 
the  latter  is  exceedingly  rare  in  the  course  of  hip-disease. 

There  is  now  marked  atrophy  of  all  the  muscles  of  the  limb,  and  the 
thigh  may  be  two  or  three  inches  smaller  than  its  fellow.  No  motion  at 
all  is  usually  allowed  at  the  hip,  but  this  is  compensated  for  to  some  degree, 
by  the  exaggerated  mobility  of  the  lumbar  spine.  The  spinal  curvature — 
lordosis — is  very  marked  both  upon  standing  and  walking.  The  duration 
of  this  stage  may  be  several  years.  From  time  to  time  exacerbations  oc- 
cur, often  excited  by  falls,  and  accompanied  by  the  formation  of  new  ab- 
scesses. In  protracted  cases,  all  the  soft  parts  about  the  hip  may  be  seamed 
with  cicatrices  from  old  sinuses.  After  the  disease  has  gone  on  to  the 
third  stage,  cure  can  take  place  only  by  anchylosis. 

Diagnosis. — The  important  point  in  the  early  diagnosis  of  ostitis  of 
the  hip,  is  the  gradual  evolution  of  the  symptoms,  the  most  characteristic 
of  which  are  lameness,  starting  pains  at  night,  and  impairment  of  all  the 
functions  of  the  joint.  Mistakes  in  diagnosis  most  frequently  arise  from 
a  failure  to  obtain  a  careful  history,  and  from  relying  too  much  upon  the 
symptoms  of  lameness  and  deformity.  The  essentially  chronic  character 
of  the  disease  should  constantly  be  borne  in  mind.  In  the  vast  majority 
of  cases,  with  a  careful  history,  and  a  thorough  examination,  there  can  be 
but  little  doubt  as  to  the  diagnosis  except  at  the  very  outset.  The  propor- 
tion of  obscure  and  irregular  cases  to  those  following  the  regular  course,  is 
small. 

In  the  early  stage,  hip- joint  disease  may  be  confounded  with  a  strain  of 
the  joint,  with  muscular  rheumatism,  poliomyelitis,  periostitis  of  the  shaft 
of  the  femur,  phlegmonous  inflammation  in  the  neighbourhood  of  the 


TUBERCULOUS  DISEASES  OF  THE  BONES  AND  JOINTS.        847 

joint,  or  with  caries  of  the  lumbar  spine.  In  the  second  stage  there  is 
even  less  difficulty  in  diagnosis,  although  abscesses  resulting  from  perine- 
phritis or  appendicitis  have  been  mistaken  for  those  arising  from  hip-dis- 
ease.    In  the  third  stage,  a  mistake  is  almost  impossible. 

Prognosis. — This  is  to  be  considered  both  with  reference  to  life  and 
limb.  The  records  of  the  Hospital  for  Ruptured  and  Crippled  show  the 
mortality  of  hospital  patients  with  hip-disease  to  be  nearly  25  per  cent. 
This  includes  deaths  directly  or  indirectly  traceable  to  the  disease.  The 
causes  are  nearly  the  same  as  in  caries  of  the  spine, — exhaustion  from  pro- 
longed suppuration,  amyloid  degeneration,  and  general  tuberculosis  or 
tuberculous  meningitis. 

Under  the  most  favourable  conditions,  the  disease  may  be  arrested  in 
the  first  stage,  and  recovery  occur  without  lameness  or  any  noticeable  im- 
pairment of  the  joint  functions.  This  result,  however,  is  not  often  ob- 
tained, because  the  disease  is  usually  well  advanced  before  it  is  recognised, 
or  because  of  the  difficulty  in  the  way  of  carrying  out  all  the  details  of 
treatment  in  the  best  possible  manner.  If  the  disease  has  advanced  to  the 
second  stage,  and  suppuration  has  occurred,  there  always  results  some  im- 
pairment of  the  joint  functions ;  usually  there  are  decided  lameness  and 
marked  muscular  atrophy,  but  very  little  shortening  or  deformity,  provided 
the  limb  has  been  kept  in  the  proper  position.  If  the  disease  has  ad- 
vanced to  the  third  stage,  there  are  always  marked  shortening,  deformity, 
and  lameness. 

Treatment. — The  indications  for  constitutional  treatment  are  the  same 
as  in  caries  of  the  spine.  The  purpose  of  local  treatment  is  to  secure  con- 
stant and  complete  rest  for  the  diseased  parts,  and  to  prevent  deformity. 
Rest  is  secured  by  overcoming  the  muscular  spasm  by  means  of  extension, 
by  immobilizing  the  joint,  and  by  transferring  the  weight  of  the  body,  in 
walking,  from  the  hip  to  the  perinaeum.  All  these  indications  are  now 
met,  while  the  patient  is  up  and  about,  by  the  use  of  the  most  approved 
apparatus.  Formerly,  rest  and  immobilization  could  be  secured  only  by 
keeping  the  patient  in  bed,  with  the  use  of  the  weight  and  pulley.  The 
general  opinion  of  orthopedic  surgeons  at  the  present  day  is  against 
excision,  except  in  cases  where,  in  spite  of  treatment  by  apparatus,  the 
disease  has  advanced  to  the  third  stage,  and  in  cases  where  life  is  threat- 
ened from  prolonged  suppuration  and  exhaustion.  Under  these  con- 
ditions, excision  should  be  performed ;  but  early  excision  gives  results 
very  much  inferior  to  those  obtained  by  mechanical  and  constitutional 
treatment. 

Articular  Ostitis  of  the  Knee — Knee-Joint  Disease — White 
Swelling — Ostitis  of  the  knee  usually  begins  in  one  of  the  condyles  of 
the  femur,  the  inner  much  oftener  than  the  outer  one ;  less  frequently  it 
begins  in  the  head  of  the  tibia.  The  pathological  process  is  very  much 
like  that  at  the  hip.     There  is  in  the  first  stage  a  central  ostitis  accom- 


848        DISEASES   OF  THE   BLOOD,   LYMPH   NODES,   BOXES,  ETC. 

panied  by  infiltration  and  expansion  of  the  part  of  the  bone  affected. 
The  disease  may  remain  limited  to  the  bone,  the  inflammatory  products 
becoming  encapsulated,  or  softening  and  breaking  down  may  occur,  with 
the  formation  of  an  abscess.  Gradually  the  process  extends  outward,  and 
the  periosteum  and  the  soft  parts  are  involved.  The  disease  may  invade 
the  joint  itself  in  a  destructive  inflammation,  or  pus  may  escape  externally 
without  seriously  involving  the  joint  structures.  The  degree  to  which  the 
joint  is  involved,  varies  much  in  different  cases ;  there  may  be  only  a  sim- 
ple synovitis,  a  suppurative  arthritis,  or  a  destruction  of  the  cartilages 
and  articular  ends  of  the  bones,  synovial  membrane,  and  ligaments,  so 
that  in  the  advanced  stage  all  traces  of  a  joint  structure  are  lost. 

If  the  process  remains  limited  to  the  bone,  recovery  may  take  place 
with  very  little  impairment  of  the  joint  functions.  If  suppuration  in  the 
joint  has  taken  place,  there  will  be  more  or  less  stiffness  and  fibrous  or 
bony  anchylosis.  When  there  is  destruction  of  the  ligaments  and  articular 
ends  of  the  bones,  the  limb  assumes  a  characteristic  position, — the  joint  is 
flexed,  the  tibia  is  displaced  backward  and  rotated  outward,  and  there  is 
marked  over-riding  of  the  femur.  Bony  anchylosis  in  this  j^osition  is 
often  seen. 

Symptoms. — The  earliest  symptoms  of  disease  at  the  knee  are  usually 
a  slight  stiffness  of  the  joint,  with  a  disposition  to  flexion  and  slight 
lameness.  At  first  these  symptoms  are  noticed  only  occasionally ;  finally 
they  become  constant  and  there  is  pain,  which  is  usually  referred  to  the 
knee.  In  some  cases  there  are  "starting  pains"  at  night,  although  these 
are  less  constant  and  less  severe  than  in  hip-disease.  Swelling  is  noticed 
early,  as  the  diseased  parts  are  so  superficial.  At  first  this  is  chiefly  of 
the  bone  itself ;  the  condyle,  usually  the  inner  one,  is  enlarged  and  elon- 
gated, often  to  a  marked  degree,  before  there  is  any  infiltration  of  the  soft 
parts.  Later  there  is  a  general  fusiform  swelling,  involving  the  entire 
joint  and  effacing  all  the  normal  outlines.  Some  tenderness  upon  pres- 
sure over  the  bone  affected  is  present  quite  early,  and  there  may  be  atrophy 
of  the  muscles  of  the  thigh  and  calf.  The  knee  is  flexed  and  slightly 
rotated  outward,  the  position  which  secures  the  most  complete  relaxation 
of  the  joint  structures.  In  some  cases  there  is  seen  the  characteristic 
swelling  due  to  distention  of  the  synovial  membrane.  Abscesses  may 
form  anywhere  about  the  joint ;  very  frequently  they  burrow  beneath  the 
tendon  of  the  quadriceps  extensor  as  far  as  the  middle  of  the  thigh. 
Gradually  the  deformity  increases  until  the  leg  may  be  flexed  at  a  right 
angle,  and  rotated  outward  over  an  arc  of  tvventy  or  thirty  degrees. 

The  course  of  the  disease  resembles  that  of  ostitis  of  the  hip  and  the 
spine.  During  periods  of  remission,  pain  and  tenderness  often  subside  for 
several  months  so  completely  as  to  lead  to  the  supposition  that  the  disease 
has  been  arrested.  An  exacerbation  is  often  excited  by  a  fall  or  a  strain 
of  the  joint,  or  it  may  follow  an  attack  of  acute  illness.     The  disease  may 


.    TUBERCULOUS   DISEASES  OP   THE   BONES   AND  JOINTS.        849 

then  progress  rapidly  and  abscess  after  abscess  form,  with  extensive  de- 
struction of  all  the  joint  structures  and  the  production  of  permanent 
deformity. 

Prognosis. — The  danger  to  life  is  considerably  less  than  in  disease  of 
the  hip  or  spine.  Death,  however,  results  from  the  same  causes — exhaus- 
tion, amyloid  degeneration,  and  general  tuberculosis  or  tuberculous  men- 
ingitis. 

With  an  early  diagnosis  and  proper  treatment  the  disease  ma}',  in  a 
considerable  proportion  of  cases,  remain  limited  to  the  bone,  and  the 
resulting  lameness  and  deformity  be  very  slight ;  but  otherwise  a  certain 
amount  of  lameness  results  from  the  stiffness  of  the  joint.  This  may  be 
due  either  to  fibrous  thickening  or  to  bony  anchylosis.  Xearly  all  patients 
are  able  to  walk  without  crutches,  and  if  proper  treatment  has  been  carried 
out  there  is  neither  marked  shortening  nor  deformity,  although  there  is 
always  great  muscular  atrophy. 

Diagnosis. — The  important  symptoms  for  diagnosis,  are  the  gradual 
onset,  the  early  swelling  which  is  due  to  etilargement  of  the  bone,  and  the 
constant  lameness  and  deformity.  The  disease  may  be  confounded  with 
rheumatism,  with  synovitis,  and  even  with  scurvy.  In  all  these  cases  the 
resemblance  exists  only  during  the  period  of  exacerbation.  A  careful  his- 
tory, however,  will  usually  clear  up  the  diagnosis. 

Treatment. — The  general  treatment  is  the  same  as  in  other  forms  of 
joint  disease.  The  indications  for  local  treatment  are  the  same  as  in  hip- 
disease, — viz.,  to  immobilize  the  affected  limb  and  prevent  deformity. 
This  is  accomplished  by  a  form  of  apparatus  which  transfers  the  weight 
of  the  body  from  the  joint  to  the  periuaeum,  and  which  overcomes  the 
muscular  spasm  which  produces  flexion  and  inward  rotation  of  the  joint. 
As  in  hip-disease,  the  results  of  mechanical  and  constitutional  treatment 
are  decidedly  better  than  early  operative  measures ;  but  late  operations 
are  indicated  under  the  same  conditions. 

Tl'Berculous  Osteo-Myelitis. — This  disease  is  rarely  seen  except  in 
the  short  tubular  bones,  most  frequently  those  of  the  hand  and  fingers. 
From  this  fact  it  is  often  called  scrofulous  or  tuberculous  dactylitis.  It 
is  described  by  niany  writers  under  the  name  of  spina  ventosa.  linger* 
gives  the  following  figures  showing  the  frequency  with  which  the  different 
bones  were  affected  :  fingers  in  43,  toes  in  3,  metacarpus  in  41,  metatarsus 
in  14,  radius  in  2,  ulna  in  2,  tibia  in  3,  jaw  in  3.  The  first  phalanx  of  the 
index  finger  is  the  bone  which  is  most  frequently  the  seat  of  disease.  In 
the  majority  of  cases  the  process  is  confined  to  a  single  bone,  although  it 
is  not  rare  to  see  five  or  six  affected.  In  such  cases  the  disease  is  seldom 
symmetrical.  The  process  is  a  chronic  inflammation,  beginning  in  the 
centre  of  the  bone  with  the  deposit  of  tuberculous  material.    The  swelling 

*  Arehiv  fur  Kinderheilkunde,  Bd.  ii,  233. 


850       DISEASES  OF  THE  BLOOD,   LYMPH  NODES,  BONES,  ETC. 

which  follows  causes  an  expansion  of  the  bone  and  thinning  of  the  shaft, 
until  a  mere  shell  may  remain.  The  later  changes  are,  inflammation  of 
the  periosteum  and  the  soft  parts,  the  formation  of  abscesses  and  sinuses, 
necrosis,  the  exfoliation  of  sequestra,  etc.  The  entire  disease  lasts  from 
one  to  three  years,  and  causes  in  most  cases  marked  deformity. 

Tuberculous  dactylitis  is  essentially  a  disease  of  early  childhood,  being 
seen  most  frequently  during  the  second  and  third  years.  In  a  considerable 
proportion  of  the  cases  there  is  a  history  of  inherited  tuberculosis.  It 
usually  exists  as  the  only  tuberculous  lesion  in  the  body,  but  occasionally 
it  is  associated  with  tuberculosis  of  the  hip,  knee,  ankle,  or  spine. 

Symptoms. — Tuberculous  dactylitis  usually  begins  as  a  painless  enlarge- 
ment of  one  of  the  phalanges,  most  frequently  the  first  one  of  the  index 
finger.     It  may  be  two  or  three  months  before  it  is  of  sufficient  size  to 


# 


first  phalanx  of  1 1 


attract  much  attention.  Exceptionally  the  inflammation  is  a  more  active 
one,  and  is  accompanied  by  both  pain  and  tenderness.  ■  The  swelling  is 
quite  characteristic;  it  is  smooth,  hard,  uniform,  and . generally  spindle- 
shaped,  involving  the  entire  phalanx  of  the  affected  finger.  The  appear- 
ance of  a  severe  typical  case  is  shown  in  Fig.  14G.  Later  there  is  discol- 
ouration of  the  skin,  and  usually  there  is  suppuration.  The  abscess 
generally  opens  at  the  side  of  the  finger,  and  a  curdy  pus  is  evacuated.  If 
the  opening  is  enlarged  by  an  incision  there  is  found  a  cavity  partly  filled 
with  caseous  matter,  and  dead  bone  is  felt,  and  perhaps  a  loose  sequestrum. 
The  cavity  is  surrounded  by  a  thin  shell  of  new  bone,  which  is  formed 
from  the  periosteum.  If  no  operation  is  done  the  discharge  continues  for 
weeks  or  months,  other  abscesses  often  form,  and  finally  several  small 


SYPHILITIC   DISEASES  OP  BONE.  851 

sequestra  are  exfoliated, — sometimes  a  single  large  one,  which  is  the  shell 
of  the  diseased  phalanx  almost  entire. 

In  some  cases  the  disease  is  arrested  before  necrosis  occurs,  but  in  the 
majority  this  is  not  so.  After  the  wounds  have  all  healed  the  finger 
remains  shortened,  deformed,  and  often  useless.  In  some  cases  the  disor- 
ganization is  so  extensive  that  amputation  is  necessary. 

Diagnosis. — The  recognition  of  dactylitis  is  usually  easy,  but  as  symp- 
toms identical  in  almost  every  particular  may  be  seen  in  a  syphilitic  in- 
flammation, it  is  often  difficult  to  tell  with  which  of  the  two  forms  one 
has  to  deal.  The  tuberculous  form  is  very  much  more  frequent ;  it  may 
occur  in  a  patient  with  tuberculous  antecedents,  or  it  may  be  associated 
with  other  tuberculous  lesions.  Syphilitic  cases  are  distinguished  by  the 
fact  that  the  lesion  is  more  frequently  multiple,  that  it  is  often  symmetri- 
cal, and  that  other  manifestations  of  syphilis  are  generally  present.  It  is 
affected  by  anti-syphilitic  remedies,  which  is  not  the  case  in  the  tubercu- 
lous variety. 

Treatment, — Painting  with  iodine  and  like  measures  are  useless.  The 
diseased  part  should  be  kept  at  rest, — if  a  finger,  by  the  application  of  a 
splint.  Every  means  should  be  taken  to  build  up  the  patient's  general 
health,  as  this  is  the  most  effective  way  to  influence  the  local  process.  The 
general  verdict  of  surgeons  is  against  early  excision  as  a  means  of  arresting 
the  disease.  Abscesses  should  be  opened  early  and  freely,  all  diseased 
bone  removed,  the  finger  kept  in  proper  position,  and  the  wound  treated 
according  to  general  surgical  principles.  Under  almost  any  treatment  the 
disease  is  a  protracted  one,  and  rarely  lasts  less  than  a  year. 

THE   SYPHILITIC   DISEASES   OF   BONE. 

The  bone  lesions  of  hereditary  syphilis  are  not  infrequent,  but  were 
long  unrecognised,  and  have  only  within  comparatively  recent  times  been 
fully  understood.*  They  may  be  divided  into  two  groups,— those  occur- 
ring with  the  early  symptoms,  and  those  which  belong  to  the  late  manifes- 
tations of  the  disease. 

Acute  Epiphysitis. — This  is  the  most  frequent  variety  of  bone  dis- 
ease in  early  hereditary  syphilis.  It  may  begin  even  in  intra-uterine  life, 
and  it  forms  one  of  the  most  characteristic  lesions  of  the  disease.  To  some 
degree  it  is  almost  invariably  present  in  syphilitic  foetuses  and  in  syphilitic 
infants  who  are  still-born.  . 

In  the  early  stage,  there  is  an  increase  in  the  cartilage  cells  and  delayed 
ossification.  Later,  a  line  of  softening  forms  at  the  epiphyseal  Junction, 
which  may  cause  loosening  of  the  cartilages  and  ultimately  complete 
separation  of  the  epiphysis  from  the  shaft,  by  the  formation  of  granula- 


*  See  Taylor,  Bone  Syphilis  in  Children,  New  York,  1875;  also  G.  Wegner,  Vir- 
chow's  Archives,  Bd.  1,  Heft  3. 


852       DISEASES  OF  THE   BLOOD,   LYMPH   NODES,   BONES,   ETC. 

tion  tissue  between  them.  In  cases  receiving  proper  treatment,  recovery 
may  take  place  with  good  union,  perfect, function,  and  without  any  de- 
formity. In  other  cases  degenerative  changes  continue,  and  infection 
with  pyogenic  germs  may  be  added.  The  periosteum  and  the  soft 
parts  in  the  neighbourhood  are  now  involved,  with  the  formation  of 
external  abscesses ;  or  the  disease  extends  to  the  medullary  cavity,  giving 
rise  to  acute  osteo-myelitis,  which  may  lead  to  necrosis;  or  the  contiguous 
joint  may  be  invaded,  causing  an  acute  suppurative  arthritis  (page  835). 
This  last  result  is  more  likely  to  occur  where  the  epiphysis  joins  the  shaft 
within  the  joint  cavity.     The  large  joints  are  usually  affected,  and  the 


Fig.  147. — Syphilitic  bone  disease  in  a  boy  four  years  old.  The  lower  end  of  the  radius  of  both 
arms  is  enlarged  as  a  result  of  former  epiphysitis  ;  there  are  sinuses  leading  to  dead  bone 
over  the  metacarpal  bone  of  the  right  thumb,  and  ovur  the  upper  extremity  of  the  left  ulna. 
The  last  two  are  recent  lesions. 

lesions  are  frequently  symmetrical.  Acute  suppurative  arthritis  may  oc- 
cur independently  of  changes  at  the  epiphysis ;  but  even  when  these  are 
seen  in  syphilitic  infants  they  are  to  be  regarded  as  of  pyajmic  rather 
than  of  syphilitic  origin.  Secondary  to  the  changes  at  the  epiphysis,  there 
are  periostitis  and  inflammation  of  the  soft  parts.  Periostitis  of  the  shaft 
is  rare  in  early  infancy. 

The  bones  most  frequently  the  seat  of  acute  epiphysitis  are  the 
humerus,  radius  and  ulna,  although  any  of  the  long  bones  may  be 
affected. 

Symptoms. — The  early  symptoms  are  usually  quite  acute,  and  appear 
during  the  first  six  weeks  of  life ;  they  may  precede  any  other  mani- 
festations of  syphilis.     In  some  cases  there  is  first  noticed  an  inability  on 


SYPHILITIC  DISEASES  OF   BOXE.  853 

the  part  of  the  child  to  move  the  limb,  which  may  easily,  be  mistaken  for 
paralysis.  It  is,  iu  fact,  often  described  as  "  syphilitic  pseudo-paralysis." 
The  limb  lies  perfectly  motionless,  and  any  attempt  at  passive  movement 
causes  evident  pain.  There  is  tenderness  on  pressure  and  soon  swelling  is 
seen,  both  being  most  marked  at  the  epiphyseal  line.  If  the  bone  affected 
is  superficially  situated,  as  the  lower  epiphysis  of  the  humerus,  radius,  or 
tibia,  swelling  is  very  apparent,  while  it  may  be  scarcely  perceptible  at  the 
upper  epiphysis  of  the  humerus.  The  swelling  is  usually  cylindrical  and 
moderate  in  degree,  being  limited  to  the  extremity  of  the  bone.  In  the 
more  severe  cases  it  may  involve  a  great  part  of  the  limb.  Abscess  may 
form  and  separation  of  the  epiphysis  take  place,  so  thnt  crepitation  may 
be  obtained  by  moving  the  limb.  Separation  of  the  epiphysis  not  infre- 
quently occurs  even  when  there  has  been  no  suppuration. 

In  the  milder  cases,  or  those  which  have  been  subjected  to  active 
treatment,  both  the  swelling  and  the  tenderness  subside  rapidly  without 
suppuration  ;  and  even  though  the  epi2)hysis  has  separated  from  the  shaft, 
it  speedily  unites.  Where  pseudo-paralysis  has  been  the  chief  symptom, 
very  rapid  improvement  occurs  under  treatment,  and  usually  complete 
recovery  of  function  in  two  or  three  weeks.  If  the  disease  extends  to  the 
joint,  or  if  osteo-myelitis  develops,  the  case  is  almost  certainly  fatal. 

Diagnosis. — This  is  usually  easy,  from  the  age  of  the  patient — gener- 
ally under  three  months — the  early  prominence  of  pain  and  apparent  loss 
of  power,  with  the  later  appearance  of  swelling  and  signs  of  inflamma- 
tion at  the  epiphyseal  junction.  In  all  these  respects  the  disease  closely 
resembles  scurvy ;  but  the  latter  is  rare  before  the  eighth  or  tenth  month, 
there  is  usually  a  history  of  the  long-continued  use  of  some  proprietary 
infant  food,  and  it  is  cured  by  dietetic  treatment  alone. 

The  apparent  loss  of  power  may  lead  to  the  diagnosis  of  birth  palsy, 
especially  of  the  upper-arm  type  (page  110).  The  presence  of  acute  pain 
and  tenderness,  the  absence  of  the  characteristic  deformity,  and  the  prompt 
recovery  under  constitutional  treatment,  usually  make  the  distinction  be- 
tween the  two  conditions  an  easy  one. 

Treatment. — This  is  the  same  as  in  all  early  syphilitic  manifestations, 
for  which  see  the  article  on  Syphilis.  Locally,  the  part  requires  in  the 
early  stage  only  protection  and  rest.  Should  suppuration  occur  in  the 
neighbouring  joint,  or  should  osteo-myelitis  develop,  these  conditions 
should  be  treated  surgically  as  they  are  when  due  to  other  causes. 

Chroxic  Osteo-Periostitis. — This  is  the  usual  form  of  bone  disease 
which  is  seen  in  late  hereditary  syphilis,  and  it  is  one  of  the  most  frequent 
and  most  characteristic  lesions  of  that  stage  of  the  disease.  Occurring 
in  adults,  this  would  be  classed  as  a  tertiary  symptom.  Chronic  syphilitic 
osteo-periostitis  is  rarely  seen  before  the  third  year,  and  most  of  the  cases 
occur  between  the  fifth  and  fourteenth  years.  The  most  frequent  seat  of 
disease  is  the  tibia,  and  next  to  this  the  bones  of  the  forearm  and  the 


854       DISEASES  OP  THE   BLOOD,   LYMPH  NODES,   BONES,  ETC. 

cranium.  The  following  is  the  frequency  with  which  the  different  bones 
were  affected  in  the  series  of  cases  reported  by  Fournier  :  *  tibia  in  91 
cases,  ulna  in  22,  radius  in  15,  cranium  in  16,  humerus  in  12,  all  others  in 
37.  The  process  may  result  either  in  a  diffuse  or  a  localized  hyperplasia 
of  bone  or  in  necrosis. 

The  typical  changes  are  seen  in  the  tibia.     The  shaft  of  the  bone  is 


Fig.  148. — Syphilitic  disease  of  the  tibia,  showing  tlie  sabre-like  deformity,  in  a  boy 


nine  years  old. 

principally  or  solely  affected.  There  is  often  produced  a  very  characteristic 
deformity,  consisting  of  a  forward  curve  of  the  anterior  border  of  the 
tibia,  which  has  been  compared  to  a  sabre  blade  (Fig.  148).  In  some 
cases  the  bone  is  bent  inward  at  its  lower  third,  resembling  somewhat  a 
rachitic  curvature  (Fig.  149).  Sometimes  the  entire  shaft  of  the  bone  is 
affected,  and  it  may  be  enlarged  to  nearly  twice  its  normal  dimensions. 


*  Syphilis  Hereditaire  Tardive,  Paris,  1886. 


SYPHILITIC   DISEASES  OP  BONE.  855 

At  other  times  the  swelling  is  chiefly  near  the  epiphysis,  where  large 
bosses  may  form  of  sufficient  size  to  interfere  with  the  functions  of  the 
joint.  Instead  of  affecting  the  bone  uniformly,  the  disease  often  affects 
only  certain  parts,  leading  to  the  formation  of  large  nodes  which  are  more 
likely  to  be  followed  by  necrosis  than  are  the  other  lesions.  In  most  of 
the  cases  the  process  is  purely  a  hyperplastic  one,  leaving  the  bone  per- 
manently enlarged.     Less  frequently,  there   occur   gummatous   deposits 


Fig.  149. — Syphilitic  disease  of  both  tibise.  The  left  shows  a  general  enlargement  of  the  bone, 
the  characteristic  curve  of  its  anterior  border,  with  ulcers  due  to  necrosis.  The  enlarge- 
ment of  the  right  tibia  is  less  marked,  and  there  is  a  pseudo-raehitic  curve  at  its  lower 
third.     Cicatrices  near  the  knee  mark  the  site  of  former  ulcers.     (After  Fournier. ) 

in  or  beneath  the  periosteum,  which  may  soften,  suppurate,  and  lead  to 
superficial  necrosis,  with  the  formation  of  sinuses  that  remain  open  until 
the  sequestrum  is  exfoliated  (Fig.  150).  Syphilitic  deposits  sometimes 
take  place  in  the  interior  of  the  bones,  generally  near  the  articular  ends ; 
these  may  soften  and  break  down  with  abscesses,  sinuses,  etc.,  very  much 
after  the  manner  of  a  tuberculous  inflammation  (Fig.  147). 

The  lesions  of  the  other  long  bones  are  essentially  the  same  as  of  the 
tibia.  They  are  nearly  always  symmetrical  and  often  multiple.  In  a  case 
recently  under  observation  in  a  boy  of  four  years,  the  disease  involved 
both  tibiae,  both  radii,  the  right  ulna,  the  left  metatarsus,  and  the  meta- 
carpal bone  of  the  left  thumb.     The  course  of  syphilitic  osteo-periostitis 


856       DISEASES  OF  THE   BLOOD,   LYMPH   NODES,   BONES,   ETC. 


is  very  chronic,  and  some  permanent  deformity  is  the  rule,  unless  cases 
come  very  early  under  treatment. 

When  affecting  the  bones  of  the  cranium  the  disease  usually  takes  the 
form  of  a  gummatous  periostitis,  which  leads  to  the  formation  of  large 
nodes.  These  may  remain  as  permanent  deformities,  or  they  may  break 
down  and  suppurate,  with  necrosis  of   one   or  both  tables  of  the  skull. 

This  may  be  followed  by  inflammation 
of  the  dura,  the  pia,  and  even  of  the 
brain  itself. 

Symptoms, — When  the  long  bones 
are  affected,  the  symptoms  are  pain, 
tenderness  and  deformity.  These  come 
on  very  gradually,  and  often  the  de- 
formity is  noticed  before  either  pain  or 
tenderness  is  sufficiently  marked  to  at- 
tract attention.  The  pain  is  regularly 
worse  at  night,  and  often  felt  only  at 
that  time  ;  it  may  be  mild  and  occa- 
sional, or  so  severe  as  virtually  to  pre- 
vent sleep.  There  is  tenderness  on 
pressure  over  the  bones  affected,  the 
acuteness  of  which  will  depend  upon 
the  activity  of  the  process.  When  sup- 
puration  occurs,  it  comes  very  slowly, 
and  never  with  symptoms  of  acute  in- 
flammation. Sinuses  usually  continue 
to  discharge  until  a  sequestrum  is  ex- 
foliated. The  course  of  the  disease  is 
very  tedious,  and  the  whole  duration  is 
usually  several  years. 

When  the  cranium  is  affected,  there 
are  seen  the  irregular  nodes,  especially 
upon  the  frontal  and  parietal  bones.  They  are  from  one  to  two  inches 
in  diameter,  and  project  from  one  eighth  to  one  fourth  of  an  inch  above 
the  general  outline  of  the  skull.  There  may  be  pain,  tenderness,  soften- 
ing, suppuration,  and  necrosis,  as  in  the  long  bones. 

Diagnosis. — It  is  so  very  rare  that  disease  of  the  bones  of  the  cranium 
is  due  in  childhood  to  any  other  cause  than  syphilis,  that  this  disease  may 
always  be  assumed  to  exist  if  traumatism  can  be  excluded.  The  bosses 
upon  the  cranium  in  rickets  (page  236)  are  always  large,  smooth,  and 
regular  in  position,  and  belong  to  infancy. 

Syphilitic  disease  of  the  long  bones  is  recognised  by  the  nocturnal 
pain,  the  tenderness  and  peculiar  deformity,  and  by  the  association  of 
other  late  manifestations  of  syphilis, — i.  e.,  the  peculiar  notched  teeth. 


Fig.  150. — Syphilitic  necrosis  of  the  tibia, 
showing  moderate  enlargement  of  the 
bone  and  a  sinus.  ( From  the  same  pa- 
tient as  Fig.  147.) 


SYPHILITIC  DISEASES  OF  BONE.  857 

the  interstitial  keratitis,  the  enlarged  epitroehlear  glands,  etc.  Tuber- 
culous disease  generally  aflFects  the  articular  ends  of  the  bones;  syiohilis 
nearly  always  the  shaft.  The  diffuse  hyperjilasia  of  the  tibia  and  the 
sabre-like  deformity  of  its  anterior  border,  are  rarely  if  ever  due  to  any 
other  cause  than  syphilis. 

The  deformities  of  the  long  bones  have  in  some  cases  a  certain  resem- 
blance to  those  due  to  rickets,  but  on  close  examination  there  are  seen 
striking  differences.  The  epiphyseal  enlargement  at  the  wrist  in  rickets 
affects  both  bones  (Plate  V,  page  222) ;  in  syphilis  it  is  usually  of  one 
bone  only  (Fig.  147).  The  differences  between  rachitic  curvatures  of  the 
tibia  and  the  deformities  from  syphilis  may  be  readily  seen  by  comparing 
Figs.  38,  39,  and  40  (pages  227  and  228)  with  Fig.  149. 


Fig.  151. — Multiple  syphilitic  dactylitis,  in  a  child  two  years  old.     The  disease  affects  the  first 
phalanges  of  both  thumbs,  both  little  fingers,  and  tlie  index  finger  of  the  left  hand. 

Treatment. — The  constitutional  treatment  of  these  lesions  is  the  same 
as  that  of  the  other  late  manifestations  of  syphilis, — mercury  and  the 
iodide  of  potassium ;  for  details,  see  the  chapter  on  Syphilis.  Surgical 
treatment  is  required  in  cases  which  terminate  in  necrosis,  whether  of  the 
cranium  or  the  extremities.  They  are  to  be  managed  like  the  same  con- 
ditions in  adults. 

Syphilitic  Dactylitis. — This  belongs  to  a  somewhat  earlier  period 
of  syi^hilis  than  the  disease  just  described,  and  is  usually  seen  in  children 
under  five  years  old.  It  is  not  a  frequent  manifestation  of  syphilis,  and 
as  compared  with  tuberculous  dactylitis  it  is  rare.  It  was  first  fully  de- 
scribed by  Taylor  (New  York).  The  symptoms  closely  resemble  the  tuber- 
culous form.  It  may  begin  as  a  periostitis  but  more  frequently  as  an 
osteo-myelitis.  Like  the  tuberculous  form  it  usually  goes  on  to  suppura- 
tion and  necrosis.  According  to  Taylor,  dactylitis  is  more  often  single 
than  multiple,  but  in  my  own  cases  several  phalanges  have  generally  been 


g58       DISEASES  OP  THE   BLOOD,   LYMPH  NODES,   BOXES,   ETC. 

involved,  and  the  lesions  have  often  been  symmetrical  (Fig.  151).  In  one 
case,  the  first  phalanx  of  every  finger  of  both  hands  was  affected.  This  oc- 
curred in  a  child  nine  months  old  who  was  under  observation  for  over  two 
years,  and  who  presented  during  this  period  almost  every  lesion  of  he- 
reditary syphilis. 

The  symptoms  and  course  of  syphilitic  dactylitis  are  essentially  the 
same  as  in  the  tuberculous  form.  The  differential  diagnosis  is  considered 
with  the  latter  disease  (page  851).  The  prognosis  is  much  the  same  in 
the  two  varieties,  with  the  exception  that  in  the  early  stage  the  syphilitic 
cases  may  often  be  arrested  by  constitutional  treatment.  This  is  the  same 
as  in  other  late  lesions  of  syphilis.  The  same  local  treatment  should  be 
employed  as  in  the  tuberculous  cases. 


CHAPTER  V. 

DISEASES  OF   TEE  SKIN. 

The  skin  at  birth  is  covered  with  a  whitish  sebaceous  secretion,  the 
vernix  caseosa.  The  skin  itself  is  of  a  deep  purplish  colour,  which  changes 
to  a  brio-ht  red  over  the  face  and  trunk  in  a  few  minutes,  with  the  estab- 
lishment of  normal  res]3iration,  and  in  a  few  hours  the  whole  body  has 
the  same  tint.  This  excessive  redness  slowly  fades  during  the  first  month, 
at  the  end  of  which  time  the  skin  has  assumed  the  pale  pink  of  infancy. 
On  the  third  or  fourth  day  there  are  usually  seen  the  first  signs  of  icterus ; 
this  generally  fades  by  the  end  of  the  second  week. 

The  epidermis  which  is  present  at  birth  soon  loosens  and  is  thrown 
off.  This  normal  desquamation  usually  begins  upon  the  fourth  or  fifth 
day,  and  is  completed  in  ten  days  or  two  weeks.  If  the  skin  is  frequently 
oiled  and  properly  bathed,  desquamation  is  scarcely  noticeable  unless  a 
close  examination  is  made.  In  some  infants,  especially  those  who  are  deli- 
cate and  cachectic,  it  is  very  much  more  marked,  and  closely  resembles 
that  seen  in  scarlet  fever.  Ritter  has  described  an  exfoliative  dermatitis 
of  the  newly  born,  appearing  generally  during  the  second  and  third  weeks, 
a  condition  which  is  regarded  by  Kaposi  as  simply  an  exaggeration  of 
normal  physiological  desquamation.  This  process  may  be  mistaken  for 
that  due  to  hereditary  syphilis ;  the  latter,  however',  is  rarely  general,  ap- 
pears later,  and  is  much  more  prolonged. 

Perspiration  is  rarely  present  before  the  end  of  the  fourth  month,  and 
is  then  seen  only  upon  the  forehead.  In  healthy  infants  it  is  scarcely 
noticeable  during  the  first  year.  Copious  perspiration  is  most  frequently 
a  symptom  of  rickets ;  less  marked  perspiration  may  occur  with  any  gen- 
eral weakness  or  during  acute  illness. 


CONGENITAL  ICHTHYOSIS. 


859 


CONGENITAL  ICHTHYOSIS. 

Congenital,  or  more  properly  foetal,  ichthyosis,  sometimes  known  also 
as  ditfuse  keratoma,  is  a  rare  disease,  characterized  by  the  formation,  usu- 
ally all  over  the  body,  of  a  thick,  horny  epidermis  resembling  parchment. 
This  is  divided  by  fissures  or  shallow  furrows  into  irregular  patches; 
sometimes  these  are  two  or  three  inches  wide,  at  others  as  small  as  a  pin's 
head.  The  disease  begins  in  the  early  months  of  foetal  life,  and  is  an 
abnormality  in  the  development  of  the  skin,  there  being  an  excessive  pro- 
liferation of  the  layers  of  the  epidermis. 

Symptoms. — In  the  gravest  form  of  the  disease  the  child  often  lives  but 


Fig.  1.52. — Congenital  ichthyosis  in  a  child  ten  months  old.  The  large  scaly  pate 
shown  on  the  lower  part  of  the  right  chest  and  abdomen,  and  the  constricting 
the  legs.     (From  a  photograph  by  Dr.  Cabot.) 


)aud; 


e  well 
,  upon 


a  few  hours,  and  rarely  more  than  a  week.  The  openings  of  the  nostrils 
and  the  ears  may  be  occluded  by  the  excessive  production  of  epithelial  cells. 
The  eyes  are  in  a  condition  of  ectropion,  and  there  are  often  deformities 
of  the  mouth  and  other  orifices  due  to  the  contractions  of  the  skin.  The 
nails  and  hair  are  usually  imperfectly  developed.  The  body  seems  in- 
cased in  a  hard,  horny  coverings  and  looks  as  if  it  had  been  varnished  or 
covered  with  collodion.  The  skin  cracks  or  splits  and  the  edges  curl  up, 
an  appearance  which  has  been  aptly  compared  to  the  skin  of  a  boiled 
potato. 

In  the  milder  form,  the  duration  of  life  is  indefinite,  depending  upon 


860   DISEASES  OP  THE  BLOOD,  LYMPH  NODES,  BONES,  ETC. 

the  degree  of  development  of  the  disease ;  but  even  in  such  cases  there 
are  frequently  seen  the  deformities  at  the  orifices  of  the  body,  and  there 
may  also  be  a  continued  exfoliation  of  the  epidermis  in  large  irregular 
patches.  After  this  has  separated,  the  skin  beneath  appears  red  and  moist, 
but  gradually  becomes  dry,  hard,  and  shining,  slowly  contracting  until  it 
splits  in  various  directions.  In  a  case  recently  under  observation  in  the 
Babies'  Hospital,*  a  picture  of  which  is  shown  in  the  accompanying  illus- 
tration (Fig.  152),  it  was  stated  by  the  mother  that  during  the  first  ten 
months  of  life  complete  exfoliation  of  the  skin  had  occurred  in  the  course 
of  every  two  or  three  months. 

The  outlook  is  bad  in  all  cases ;  in  most  of  the  severe  forms  death 
occurs  in  infancy,  but  in  some  of  the  milder  ones,  life  may  be  prolonged 
througliout  childhood.  The  "  alligator  boy  "  of  the  Dime  Museum  is  an 
example  of  this  class. 

Treatment. — The  indications  are  to  keep  the  skin  moist  and  soft  by 
the  use  of  oils,  continuous  baths,  etc.,  and  to  prevent  infection  by  perfect 
cleanliness.  Although  a  certain  amount  of  improvement  usually  follows 
these  measures,  a  cure  is  not  to  be  expected. 

MILIARIA. 

The  term  miliaria  is  applied  to  an  obstruction  of  the  sweat  glands, 
which  may  occur  either  with  or  without  inflammation.  The  non-inflam- 
matory form  is  known  as  sudaniitui,  the  inflammatory  forms  as  niiliaria 
rubra,  nuUdi'ia  vesiculosa,  and  miliaria  pajrulosa. 

Sudamina. — In  this  form  there  is  no  inflammation.  The  sweat  ducts, 
according  to  Crocker,  are  blocked  by  an  accumulation  of  epithelial  cells 
while  no  perspiration  is  going  on;  and  when  the  process  is  restored  the 
fluid,  being  unable  to  escape,  accumulates  in  the  form  of  tiny  vesicles. 
These  appear  like  small  pearly  bodies  very  closely  set,  and  disappear  in 
the  course  of  a  few  days  by  absor^ition.  Fresh  crops  may  appear  from  time 
to  time.  Sudamina  may  be  seen  in  any  of  the  continued  fevers  or  ex- 
hausting diseases.     It  requires  no  treatment. 

Miliaria  Rubra. — This  condition,  also  known  as  red  gum,  stropJiuhis, 
etc.,  is  a  sweat  rash,  usually  seen  in  young  infants  as  the  result  of  excess- 
ive clothing.  It  is  most  frequently  observed  upon  the  cheeks  and  neck, 
often  upon  the  side  of  the  face  upon  which  the  infant  sleeps,  or  the  side 
held  against  the  mother's  body  while  nursing,  if  this  is  done  upon  only 
one  breast.  The  eruption  consists  of  scattered  red  papules,  sometimes 
with  tiny  vesicles.      Miliaria  rubra  is  an  inflammation  about  the  sweat 

*  This  case  has  been  fully  reported  by  Cabot,  New  York  Medical  Recoi-d,  July  6, 
1895.  For  fuller  description  of  the  disease,  see  Ballantyne,  Diseases  of  the  Foetus,  vol. 
ii,  1895 ;  also  Archives  of  Paediatrics,  April  and  June,  1894. 


MILIARIA.  861 

glands,  the  result  of  which  is  a  retention  of  their  secretion.  There  is 
generally  little  or  no  itching.  The  treatment  consists  in  the  removal  of 
the  cause,  and  the  application  of  some  absorbent  powder,  such  as  boric 
acid  and  starch. 

Miliaria  Papulosa  (Lichen  Tropicus,  Prickly  Heat,  etc.). — This  is  the 
most  common  and  most  imj^ortant  variety  of  miliaria.  There  is  in  this 
disease  an  obstruction  of  the  sweat  glands  by  inflammatory  products.  The 
lesion  consists  in  the  formation  of  bright-red  papules,  which  are  very 
closely  set,  the  summits  of  some  of  them  being  surmounted  by  tiny  vesi- 
cles, and  here  and  there  in  severe  cases  even  small  pustules  may  be  seen. 
If  not  interfered  with  by  scratching,  the  vesicles  dry  up  without  rupture, 
and  are  followed  by  a  slight  desquamation.  Where  there  is  much  scratch-^ 
ing,  an  eczenuitous  condition  may  result.  Miliaria  papulosa  comes  out 
with  great  rapidity,  especially  upon  the  neck,  forehead,  back,  and  chest. 
It  is  accompanied  by  an  almost  intolerable  itching  and  stinging  sensa- 
tion. Over  other  parts  of  the  body  profuse  perspiration  occurs.  The 
disease  is  produced  by  very  hot  weather  and  excessive  clothing.  Although 
the  duration  of  a  single  attack  is  but  two  or  three  days,  in  susceptible 
patients  it  may  keep  recurring  for  weeks,  being  exceedingly  intractable. 
Where  there  is  much  scratching  the  resulting  eczema  is  very  troublesome. 
It  is  not  infrequently  followed  by  furunculosis. 

The  diagnosis  of  miliaria  rubra  and  miliaria  papulosa  is  usually  easy. 
They  are  distinguished  from  eczema  by  the  suddenness  with  which  they 
appear,  by  the  associated  sweating  of  other  parts  of  the  body,  by  the  tran- 
sitory character  of  the  eruption,  and  by  the  fact  that  the  rash  never  occurs 
in  circumscribed  patches.  Prickly  heat  sometimes  resembles  the  rash  of 
scarlet  fever,  but  the  fact  that  the  tiny  papules  are  in  some  j^laccs  crowned 
by  vesicles  and  that  constitutional  symptoms  are  absent,  usually  make  the 
distinction  an  easy  one. 

Treatment. — Prickly  heat  is  to  be  prevented  by  light  clothing,  fre- 
quent bathing,  and  the  plentiful  use  of  a  good  toilet  powder,  such  as  boric 
acid  and  starch.  During  an  attack,  the  bowels  should  be  freely  opened  by 
calomel  or  a  saline,  and  secretion  of  the  kidneys  stimulated  by  the  use  of 
nitrate  of  potassium  or  the  sweet  spirits  of  nitre.  The  skin  should  be 
protected  against  the  irritation  of  flannel  undergarments  by  the  interposi- 
tion of  silk  or  linen.  When  the  inflammation  is  at  its  height,  relief  is 
obtained  by  the  application  of  a  calamine  and  zinc  lotion  (page  869),  or  by 
a  dilute  solution  of  the  acetate  of  lead  ;  carbolic  acid  may  be  added  to 
either,  where  the  itching  is  intense.  In  some  cases  powders  are  preferable 
to  lotions.  One  of  the  best  is  the  stearate  or  the  oxide  of  zinc,  twelve 
parts ;  bismuth,  three  parts  ;  powdered  camphor,  one  part ;  or  equal  parts 
of  starch  and  boric  acid  may  be  used,  or  simply  rice  flour.  All  of  these 
must  be  very  freely  applied.  The  diet  should  be  light  and  fluid,  and  if 
milk  is  the  food  it  should  be  considerably  diluted. 


862       DISEASES  OF   THE   BLOOD,   LYMPH   NODES,   BONES,   ETC. 


SEBORRHCEA. 

Seborrhoea  is  considered  by  dermatologists  generally,  as  a  functional 
disease  of  the  sebaceous  glands  ;  although  Unna  regards  all  such  cases  as 
inflammatory,  and  classes  them  as  seborrhoeic  eczema,  which  is  of  para- 
sitic origin  (page  865).  The  disease  may  afl'ect  almost  any  part  of  the 
body,  and  children  of  any  age,  but  the  most  frequent  form  is  that  which 
is  seen  upon  the  scalp  in  young  infants.  This  is  the  most  important 
variety,  and  the  only  one  which  will  be  here  considered. 

Seborrhoea  of  the  scalp  is  characterized  by  the  formation  upon  the 
vertex,  of  dirty-yellow  crusts,  which  are  soft,  greasy,  and  friable.  They 
are  composed  of  epithelial  cells,  fat-globules,  and  granular  masses,  to  which 
is  always  added  dirt.  In  neglected  cases  the  hairy  scalp  is  nearly  covered 
by  a  dense  crust,  which  may  be  as  thick  as  heavy  pasteboard.  If  the 
crusts  are  removed  the  underlying  scalp  may  be  found  perfectly  healthy, 
but  more  frequently,  in  cases  of  long  standing,  it  is  eczematous.  The 
eczema  is  set  up  by  the  decomposition  of  the  exudation,  or  by  the  efforts 
to  remove  the  crusts  by  such  means  as  the  fine-toothed  comb,  commonly 
employed  in  domestic  practice.  There  is  little  tendency  to  spontaneous 
improvement  or  recovery,  and  the  condition  often  lasts  for  months.  Every 
seborrhcea  should  be  treated,  for  when  neglected  it  furnishes  a  favourable 
soil  for  the  development  of  eczema. 

Treatment. — Ouly  local  measures  are  required.  The  crusts  are  first  to 
be  softened  with  oil,  and  then  removed  by  washing  thoroughly  with  warm 
water  and  soap,  after  which  an  ointment  of  resorcin  (resorcin,  gr.  x  ;  ungt. 
aquae  rosae,  |  j)  or  sulphur  (precipitated  sulphur,  3  j ;  lanoline,  3  j) 
should  be  applied.  The  oil  and  soap  and  water  are  repeated  every  few  days, 
or  as  often  as  the  crusts  form.  In  the  meantime  the  scalp  is  kept  cov- 
ered with  the  ointment. 

ECZEMA. 

Eczema  may  be  defined  as  a  catarrhal  inflammation  of  the  skin.  It 
is  the  most  frequent  and  altogether  the  most  important  disease  of  the  skin 
in  early  life.  The  scope  of  the  present  work  permits  only  a  discussion  of 
such  features  and  varieties  as  are  peculiar  to  infants  and  young  children. 
The  eczema  of  older  children  does  not  differ  in  any  essential  points  from 
that  of  adults. 

Etiology. — The  conditions  in  infancy  which  predispose  to  eczema  are, 
first,  that  the  skin  is  extremely  delicate,  and  hence  more  easily  affected  by 
external  irritants  and  micro-organisms ;  secondly,  its  more  intense  glandu- 
lar activity.  While  all  children  are  susceptible,  there  are  certain  ones 
in  whom  the  susceptibility  is  very  marked,  and  in  them  the  slightest 
amount  of  external  irritation,  or  the  most  trivial  disturbance  of  diges- 
tion may  produce  a  severe  eruption.     It  was  formerly  the  fashion  to  class 


ECZEMA.  863 

eczema  of  the  face  and  scalp  among  the  manifestations  of  infantile 
"  scrofula."  It  is  true  that  certain  infants  are  prone  to  eczema,  as  others 
are  to  catarrhal  processes  of  the  mucous  membranes,  but  no  more  can 
be  positively  affirmed.  We  certainly  can  not  connect  eczema  with  any 
single  diathetic  condition ;  but  it  is  much  more  often  seen  in  children 
with  gouty  antecedents  than  in  others ;  or  to  state  it  differently,  the  most 
frequent  manifestation  of  gout  during  infancy  is  the  tendency  to  eczema. 
Children  of  rheumatic  families  are  also  prone  to  the  disease.  Eczema  of 
the  face  is  common  in  fat,  healthy-looking  infants,  and  is  seen  both  in 
those  who  are  nursing  and  in  those  who  are  artificially  fed.  It  also  occurs 
in  flabby,  poorly  nourished  children,  but  rarely  in  those  suffering  from 
marasmus. 

The  exciting  causes  of  eczema  may  be  external  or  internal.  Of  the 
former  the  most  important  are  heat,  cold  dry  air,  and  winds — as  in  the 
familiar  chapping  of  the  face — the  use  of  hard  water  or  of  strong  soaps 
in  bathing.  The  disease  may  be  due  to  the  irritation  of  clothing,  to  want 
of  cleanliness,  or  to  irritating  discharges  from  mucous  surfaces,  as  in  the 
eczema  of  the  upper  lip,  thighs,  or  buttocks.  It  accompanies  most  of  the 
parasitic  skin  diseases,  particularly  pediculosis,  scabies,  and  ring-worm.  It 
is  probable  that  in  many  forms  of  eczema  micro-organisms  play  an  impor- 
tant part ;  even  though  th£y  may  not  have  been  the  primary  factor  in 
causing  the  disease,  they  may  suffice  to  continue  the  inflammatory  process. 

T\]R  internal  causes  of  eczema  are  chiefly  associated  with  deficient 
elimination  from  the  kidneys  and  bowels,  and  digestive  disturbances.  It 
often  accompanies  chronic  constipation  where  there  is  intestinal  torpor 
and  the  white  stools  of  deficient  biliary  secretion  ;  and  it  is  seen  where  the 
urine  is  scanty  and  concentrated  because  children  partake  too  largely  of 
solid  food.     The  latter  is  true  both  in  the  first  and  second  years. 

Eczema  may  be  produced  by  any  form  of  digestive  disturbance,  but  it 
is  especially  frequent  in  the  intestinal  indigestion  which  results  from 
overfeeding,  or  the  too  early  or  excessive  use  of  farinaceous  food,  or  from 
breast  milk  in  which  the  percentage  of  fat  is  very  high.  From  personal 
experience  in  the  post-mortem  room,  I  can  confirm  the  observation  of 
Bohn  regarding  the  frequency  with  which  fatty  liver  occurs  in  very  fat 
infants.  Enlargement  of  the  liver  may  sometimes  be  made  out  during  life. 
It  is  highly  probable  that  the  interference  with  the  hepatic  functions  which 
accompanies  these  fatty  changes  has  much  to  do  with  the  production  of 
eczema  in  such  subjects.  In  children  fed  upon  cow's  milk  the  excessive 
fat  may  be  the  cause,  or  it  may  be  due  to  excessive  proteids.  Of  farina- 
ceous articles,  the  two  which  are  most  often  to  be  blamed  are  potato  and 
oatmeal.  Although  eczematous  patients  usually  appear  to  be  well  nour- 
ished, it  is  rare  that  some  symptoms  of  indigestion  are  not  present. 

Eczema  is  often  due  to  some  form  of  refiex  irritation.  Such  are  the 
cases  which  accompany  dentition,  and  the  rare  ones  due  to  genital  irrita- 
5a 


864       DISEASES  OP  THE  BLOOD,   LYMPH  NODES,  BONES,   ETC. 

tion.  By  many  writers  the  eczema  caused  by  disorders  of  the  stomach  or 
intestines  is  regarded  as  reflex.  The  stronger  the  predisposition,  the  more 
trivial  is  the  reflex  irritation  which  will  induce  an  eruption. 

Simple  Chronic  Eczema — Eczema  Rubrum. — This  is  the  most  frequent 
form  of  eczema  occurring  in  infants  and  young  children,  and  is  usually 
seen  upon  the  face.  It  affects  by  preference  the  cheeks,  forehead,  and 
scalp,  not  infrequently  the  ears  and  neck,  and  may  occur  upon  any  part 
of  the  body.  Upon  the  trunk  and  extremities  the  eruption  is  usually  in 
patches,  but  in  rare  cases  may  cover  nearly  the  entire  body.  The  disease 
generally  begins  upon  the  cheeks  with  the  formation  of  small  red  papules ; 
later  these  coalesce,  and  there  is  a  moist,  red  surface  exuding  serum  or 
sero-pus.  The  secretion  dries  and  forms  thick,  gummy  crusts,  which  may 
be  so  hard  as  to  form  a  mask  for  the  face.  From  the  scratching  caused 
by  the  almost  intolerable  itching,  the  surface  bleeds  freely,  and  the  dried 
blood  gives  to  the  crusts  a  dirty-brown  colour  and  adds  to  the  distressing 
appearance.  The  skin  is  often  much  swollen.  After  the  removal  of  the 
crusts  there  is  seen,  in  acute  cases,  a  red,  inflamed,  granular  surface,  dis- 
charging pus  or  serum  and  bleeding  readily.  When  the  process  is  less 
active,  there  are  redness,  thickening,  induration,  and  scaliness  of  the  skin, 
and  marked  itching.  In  the  same  case  these  stages  may  alternate,  exacer- 
bations occurring  whenever  the  exciting  cause  is  particularly  active. 
From  the  cheeks  the  disease  spreads  to  the  forehead,  ears,  and  scalp,  and 
here  similar  lesions  are  seen.  Upon  the  trunk  and  extremities  thic|(^crusts 
rarely  form,  but  the  skin  is  red,  thick,  and  scaly.  The  parts  most  often 
affected  are  the  forearms,  chest,  elbows,  knees,  abdomen,  and  back ;  occa- 
sionally the  eruption  is  general. 

Swelling  of  the  lymph  nodes  in  the  neighbourhood  of  the  eruption  is  a 
constant  feature  of  eczema  of  the  face  and  scalp ;  these  may  reach  the 
size  of  a  chestnut  or  walnut,  and  occasionally  they  suppurate.  Intense 
itching  is  a  characteristic  feature  of  all  cases  of  eczema  of  the  face  or 
scalp.  It  causes  restlessness  and  loss  of  sleep,  and  usually  it  is  only  in 
this  way  that  the  disease  affects  the  general  health  of  the  patient ;  but  in 
most  cases  the  health  remains  good.  With  eczema  of  the  occipital  region 
of  the  scalp,  pediculosis  is  usually  associated. 

Eczema  of  the  face  is  very  chronic,  easily  improved,  but  cured  only 
Avith  great  difficulty.  There  is  a  strong  tendency  to  relapses,  brought  on 
by  neglect  of  local  treatment  or  by  any  digestive  disturbance. 

The  predisposition  to  eczema  often  ceases  with  the  second  year ;  those 
who  have  suffered  from  it  almost  constantly  during  infancy  may  be  free 
from  it  during  the  remainder  of  childhood.  This  is  in  part  to  be  ex- 
plained by  the  loss  of  fat  in  consequence  of  more  active  exercise  and  a 
diet  which  is  more  largely  nitrogenous.  Where  the  disease  continues 
through  the  third  and  fourth  years,  tlie  associated  infantile  condition — 
obesity — is  not  infrequently  present. 


ECZEMA.  865 

Seborrhoeic  Eczema. — This  form  of  eczema  has  been  brought  into 
prominence  by  the  writings  of  Unna,  according  to  whom  not  only  are  all 
the  cases  usually  classed  as  seborrhoea  to  be  regarded  as  eczematous,  but 
also  many  others  classed  as  ordinary  eczema.  Instead  of  seborrhoeic 
eczema  being  a  form  of  disease  in  which  the  fat-producing  glands  are 
involved  in  the  inflammatory  process,  Unna  believes  it  to  be  parasitic  and 
due  to  a  certain  "  mulberry  coccus  "  which  he  has  described.  Although  his 
investigations  have  not  yet  been  corroborated,  there  are  many  arguments 
in  favour  of  the  pathology  which  he  has  advanced  for  this  disease.  Elliot, 
who  accepts  Unna's  views,  defines  seborrhoeic  eczema  as  follows  :  "  An 
inflammatory  disease  of  the  skin,  catarrhal  in  nature,  due  to  micro-organ- 
isms— a  parasitic  dermatitis — characterized  by  its  primary  seat  being  upon 
the  scalp,  whence  it  tends  to  spread  downward,  involving  by  preference 
the  middle  portion  of  the  face,  the  sternal  and  interscapular  spaces,  axilla, 
and  inguinal  regions,  but  may  affect  any  part  of  the  body."  *  The  lesions 
upon  the  scalp  may  be  of  the  nature  of  a  dry  seborrhoea  with  yellow 
greasy  crusts,  or  like  pityriasis.  Upon  the  body,  the  eruption  is  scaly,  with 
red  macules  or  papules,  or  it  may  be  accompanied  by  greasy  crusts  like 
those  seen  upon  the  scalp.  The  skin  is  not  usually  thickened  and  the 
lesions  are  not  elevated.  Itching  in  most  cases  is  only  moderate,  and  it 
may  be  absent ;  but  in  some  of  the  most  severe  cases  it  is  marked  and  ac- 
companied by  tingling.  An  extensive  weeping  surface  is  never  seen.  All 
the  crusts  are  soft  and  contain  fatty  matter.  The  lesions  are  not  deep, 
and  the  disease  frequently  shifts  from  one  part  of  the  body  to  another, 
often  coming  out  very  rapidly.  In  most  cases  the  patches  are  rather 
sharply  defined  and  have  rounded  borders. 

Pustular  Eczema  of  the  Scalp. — This  condition,  often  called  "simple 
impetigo,"  is  less  frequently  seen  in  infants  than  in  children  from  two  to 
five  years  old.  There  are  usually  present  from  half  a  dozen  to  fifty 
greenish-yellow  crusts,  matting  the  hair,  usually  discrete,  but  sometimes 
coalescing  to  form  a  mask  over  half  the  scalp.  There  is  very  little  itch- 
ing, in  some  cases  none  at  all.  The  lymph  glands  are  invariably  enlarged. 
There  is  frequently  continued  auto-infection,  and  in  this  way  the  disease 
may  be  prolonged  indefinitely.  It  is  possible,  too,  that  infection  may 
spread  to  other  children. 

Intertrigo. — This  term  is  rather  indiscriminately  applied  to  any  erup- 
tion which  develops  upon  two  moist  surfaces,  which  are  in  contact.  It 
is  often  regarded  as  a  form  of  eczema,  although,  as  Elliot  has  well 
pointed  out,  there  are  seen  several  processes  which  are  quite  distinct 
from  one  another.  The  most  frequent  is  a  simple  erythema ;  in  other 
cases  there  is  an  eczema  resulting  from  traumatism  or  the  decomposition 

*  Morrow's  System  of  Genito-Urinary  Diseases,  Syphilology,  and  Dermatology, 
vol.  iii,  D,  Appleton  &  Co.,  1895. 


866       DISEASES  OF  THE  BLOOD,  LYMPH  NODES,   BONES,  ETC. 

of  secretions,  or  a  seborrlioeic  inflammation.  Intertrigo  is  seen  in  the 
folds  of  the  groin,  between  the  scrotum  and  the  thighs,  between  the  but- 
tocks, about  the  anus,  in  the  axillae,  in  the  neck,  or  behind  the  ears.  Its 
essential  causes  are  moisture,  friction,  want  of  cleanliness,  and  sometimes 
infection.  The  disease  is  generally  seen  in  its  worst  form  about  the 
thighs,  genitals,  and  buttocks ;  it  sometimes  covers  the  sacrum  and  ex- 
tends down  to  the  middle  of  the  thighs.  There  is  an  intense  uniform 
redness,  and  in  some  cases  the  epidermis  is  denuded  over  large  areas,  and 
the  surface  is  moist.  There  is  no  thick  crusting  and  little  or  no  itching. 
Intertrigo  is  usually  easy  to  control  except  in  very  poorly  nourished  or 
marantic  children,  among  whom  it  is  especially  frequent. 

Diagnosis  of  Eczema. — This  is  usually  quite  an  easy  matter.  In  the 
majority  of  cases,  the  disease  affects  the  face  or  the  scalp,  and  its  appear- 
ances are  typical.  Eczema  of  the  body  or  extremities  may  be  confounded 
with  scabies  or  syphilis,  and  occasionally  with  other  forms  of  skin  disease. 
Scabies  resembles  eczema  in  its  intense  itching  and  multiform  lesions; 
but  in  the  former,  one  may  often  find  evidences  of  its  presence  in  other 
members  of  the  family ;  the  parts  most  frequently  affected  are  the  flexures 
of  the  wrists,  the  elbows,  the  skin  between  the  flngers,  the  margins  of  the 
axillte,  the  lower  part  of  the  abdomen  and  back,  and,  in  boys,  the  penis ; 
and  by  careful  examination  with  a  lens  some  of  the  characteristic  burrows 
are  certain  to  be  discovered. 

Syphilis  is  likely  to  be  confounded  with  papular  eczema  of  the  but- 
tocks. The  latter  affects  the  parts  near  the  anus,  and  the  irritation  may 
lead  to  the  development  of  spots  closely  resembling  mucous  patches.  The 
local  appearances  may  at  times  be  indistinguishable  from  syphilis,  and  the 
diagnosis  is  to  be  made  only  by  the  other  symptoms  present.  In  syphilis 
the  characteristic  eruption  is  seen  usually  upon  the  face,  hands,  legs,  and 
sometimes  the  palms  and  soles ;  there  is  no  itching  and  very  little  evi- 
dence of  inflammation ;  the  eruption  is  dark-coloured,  and  occurs  as  small 
circumscribed  spots;  there  are  usually  present  other  symptoms,  such  as 
the  coryza,  the  syphilitic  cachexia,  and  enlargement  of  the  spleen. 

The  diagnosis  from  pediculosis  and  ringworm  of  the  scalp,  rarely  pre- 
sents any  difficulties. 

Prognosis. — All  cases  of  chronic  eczema  are  tedious.  There  is  only  a 
slight  tendency  to  spontaneous  improvement,  and  very  little  to  spontane- 
ous recovery  during  infancy.  In  a  given  case,  the  prognosis  depends  upon 
the  duration  of  the  disease,  its  severity,  and  very  much  upon  the  co-opera- 
tion of  the  mother  or  nurse.  The  results  obtained  depend  not  only 
upon  the  particular  line  of  treatment  adopted,  but  upon  how  well  it  is  car- 
ried out.  Usually  it  must  be  continued  for  several  months.  Eczema  of 
the  face  is  especially  intractable  when  occurring  in  children  suffering  from 
chronic  indigestion  and  constipation,  for,  unless  these  conditions  can  be 
controlled  by  diet  and  general  management,  local  applications  give  but 


ECZEMA.  867 

temporary  relief.  Intertrigo  is  in  most  cases  easily  cured,  unless  the  pa- 
tient is  suffering  from  marasmus. 

Treatment. — It  is  never  dangerous  to  cure  an  eczema,  and  always  de- 
sirable to  do  so,  in  spite  of  the  strong  prejudice  to  the  contrary,  which 
still  exists  in  the  minds  of  the  laity  and  in  some  members  of  the  medical 
profession.  To  treat  eczema  successfully  there  is  required  a  careful  study 
of  the  exciting  cause,  for,  although  improvement  often  results  from  the 
use  of  local  measures  alone,  yet  in  the  great  majority  of  cases  this  is  only 
temporary.  A  permanent  cure  is  brought  about  only  by  the  removal  of 
the  cause.  The  physician  must  first  endeavour  to  decide  whether  the 
eczema  is  due  to  some  external  or  internal  cause,  or  to  both.  External 
causes  are  for  the  most  part  easily  discovered  by  carefully  questioning  the 
mother  and  observing  how  the  child  is  cared  for.  Internal  causes,  as 
before  stated,  usually  relate  to  the  digestive  tract  or  to  functional  disturb- 
ances of  the  kidneys. 

Diet. — A  thorough  investigation  into  the  food  is  necessary,  not  only  as 
to  its  character,  but  as  to  quantity  and  preparation,  the  manner  and  fre- 
quency of  feeding,  etc.  If  the  patient  is  a  nursing  infant,  an  examina- 
tion of  the  nurse's  milk  is  indispensable  to  intelligent  treatment.  If  the 
child  is  very  fat  and  well  nourished,  it  is  generally  the  case  that  the  fat  of 
the  milk  is  too  high  and  must  be  reduced  according  to  the  rules  given  else- 
where (page  1G4),  the  most  important  thing  being  to  exclude  from  the 
nurse's  diet  malt  liquors  and  alcohol  in  all  forms,  and  reduce  the  amount 
of  meat.  In  a  smaller  number  of  cases  the  trouble  is  with  the  proteids  of 
the  milk ;  there  will  then  be  other  signs  of  indigestion,  such  as  colic,  the 
appearance  of  curds  in  the  stools,  etc.  The  amount  of  food  should  be 
reduced  by  lengthening  the  period  between  the  nursings,  and  shortening 
the  time  which  the  child  is  allowed  to  remain  at  the  breast  at  one  nurs- 
ing. Plain  water,  or  better,  some  alkaline  water,  should  be  given  freely 
between  the  nursings.  In  children  fed  upon  cow's  milk,  the  trouble  is 
probably  more  often  with  the  proteids  than  with  the  fat.  The  physician 
should  try  the  effect,  first  of  giving  a  milk  which  is  low  in  proteids  and 
moderately  high  in  fat  (e.  g.,  formula  iii  or  iv,  page  175)  afterwards,  one  in 
which  both  fat  and  proteids  are  low  (e.  g.,  formula  xv  or  xvi,  page  176). 
These  and  other  changes  are  to  be  made  in  the  manner  described  in  the 
chapter  on  Infant  Feeding  (pages  175-182).  During  the  latter  part  of  the 
first  and  the  entire  second  year,  the  usual  error  is  that  of  overfeeding 
with  in  most  cases  an  excessive  use  of  solid  food,  especially  farinaceous 
articles.  The  diet  should  then  be  much  reduced,  and  the  amount  of  fari- 
naceous food  restricted,  potatoes  and  oatmeal  being  absolutely  prohibited. 
The  diet  which  suits  most  children  best  is  one  composed  of  milk,  beef 
juice,  broth,  fruit,  eggs,  and  a  little  red  meat,  with  the  addition  in  some 
cases  of  rice,  wheat,  or  barley.  In  severe  and  obstinate  cases,  however, 
all  cereals  and  even  meat  are  best  omitted  during  the  active  stage  of  the 


868        DISEASES  OP  THE   BLOOD,  LYMPH  NODES,   BONES,  ETC. 

disease.  The  form  of  indigestion  which  exists  is  to  be  managed  according 
to  the  special  indications  in  each  case. 

The  diet  of  older  children  needs  to  be  watched  no  less  closely  than 
that  of  infants.  The  general  rnles  laid  down  elsewhere  for  feeding  after 
the  second  year  (pages  188-190)  should  be  observed.  The  great  majority 
of  cases  do  best  upon  a  diet  which  is  largely  fluid,  and  composed  princi- 
pally of  milk  or  some  of  its  substitutes, — kumyss  or  matzoon. 

Elimination  by  the  kidneys  should  be  stimulated  by  the  very  free  use  of 
water,  to  which  it  is  well  to  add — especially  in  cases  with  a  gouty  tendency 
— the  citrate,*  or  acetate  of  potassium,  from  ten  to  twenty  grains  daily. 

Attention  to  the  condition  of  the  bowels  is  of  the  greatest  importance. 
To  overcome  the  tendency  to  constipation  is  in  many  cases  to  cure  the 
eczema.  Suggestions  under  this  head  will  be  found  in  the  chapter  on 
Chronic  Constipation  (page  374).  Special  importance  is  to  be  attached 
to  the  occasional  use  of  a  purge  of  calomel,  one  half  to  one  grain  being 
given  every  third  or  fourth  night.  The  best  eifects  from  this  are  seen  in 
over-fed  children.  It  has  a  favourable  effect  upon  the  kidneys  as  well  as 
upon  the  bowels.  The  bowels  must  not  only  be  opened,  they  must  be  kept 
freely  open  by  the  daily  use,  if  necessary,  of  some  of  the  milder  laxatives, 
such  as  phosphate  of  sodium,  rhubarb,  or  cascara.  Sometimes  nothing 
acts  so  well  as  castor  oil,  which  may  be  given  in  from  half  a  teaspoonful 
to  teaspoonful  doses  every  night  for  two  or  three  weeks  at  a  time.  It 
should  be  administered  in  emulsion. 

When  the  disease  occurs  in  flabby,  anaemic,  or  poorly-nourished  chil- 
dren, iron  and  bitter  tonics  are  required,  and  occasionally  alcohol  and  cod- 
liver  oil.  In  other  words,  the  child's  general  condition  should  be  treated 
just  as  if  no  eczema  existed.  Theoretically,  arsenic  is  indicated  when  the 
disease  is  in  a  chronic  stage  with  dry,  scaly  eruption,  but  its  effect  is  often 
disappointing  in  infancy.     It  is  in  no  sense  a  specific  remedy. 

The  general  management  of  cases  is  important.  The  skin  must  be 
carefully  protected  by  an  ointment  whenever  the  child  is  in  the  open  air ; 
if  the  weather  is  very  cold,  or  there  are  high  winds,  children  with  active 
eczema  should  not  go  out,  but  take  the  fresh  air  indoors.  Never  should 
an  eczematous  surface  be  washed  with  plain  water,  and  much  less  with 
castile  soap  and  water,  so  frequently  employed  by  the  ignorant.  Where 
washing  is  necessary,  it  may  be  done  with  bran  water,  milk  and  water, 
■or  starch  and  water,  to  which  borax  (a  teaspoonful  to  the  quart)  may  be 
added.  The  clothing  should  not  be  so  excessive  as  to  keep  the  child  con- 
stantly in  a  perspii'ation.  Napkins  should  not  be  washed  in  strong  soda 
solutions,  nor,  in  case  of  eczema  of  the  buttocks,  should  they  be  used  a 
second  time  after  being  simply  dried. 

*  While  the  citrate  can  not  be  depended  upon  as  a  diuretic,  unless  dispensed  from 
a  newly-opened  bottle,  it  is  generally  to  be  preferred,  as  being  more  easily  administered. 


ECZEMA.  869 

In  eczema  of  the  face  it  is  absolutely  necessary  to  prevent  the  child 
from  scratching  the  parts.  The  use  of  a  mask  is  not  always  sufficient, 
nor  the  wearing  of  mittens ;  nor  is  the  local  application  of  anti-pruritic 
lotions  or  ointments  invariably  successful.  In  severe  cases  mechanical 
restraint  is  absolutely  indispensable.  The  most  satisfactory  method  is  to 
surround  the  arms  at  the  elbows  by  pasteboard  splints,  and  hold  them  in 
place  by  bandages.  This  allows  free  use  of  the  hands,  but  makes  it  abso- 
lutely impossible  for  the  child  to  reach  the  face. 

Local  treatment. — Local  treatment  is  always  necessary,  for  not  only 
are  the  causes  sometimes  entirely  external,  but  the  condition  may  persist 
after  the  original  internal  cause  has  been  removed.  There  are  several 
indications  to  be  met  by  local  treatment  at  different  stages  in  the  disease : 
(1)  To  remove  crusts  and  other  inflammatory  products;  (2)  to  allay  con- 
gestion and  acute  inflammation  ;  (3)  to  relieve  itching ;  (4)  to  protect  the 
delicate  new  skin  which  is  forming ;  (5)  to  prevent  infection  ;  (6)  to  stimu- 
late the  skin  in  the  chronic  stages  of  the  disease. 

Preparatory  to  the  use  of  any  application,  the  scales,  crusts,  and  other 
products  of  inflammation  must  be  softened  and  removed  in  order  that  the 
diseased  surface  may  be  reached.  In  most  cases  it  is  sufficient  to  soften 
the  crusts  by  the  use  of  olive  oil  for  twelve  or  twenty-four  hours,  and  then 
remove  them  by  soap  and  warm  water.  If  the  crusts  are  very  hard  and 
thick,  they  can  be  softened  by  a  poultice.  During  the  stage  of  acute  in- 
flammation only  sedative  applications  should  be  used.  One  of  the  best  of 
these  is  a  lotion  of  zinc  and  calamine : 

5  Pill V.  calaminae  preparatae 3  ij 

Zinci  oxidi 1  ss. 

Glycerinae .' 1 .1 

Liquor  calcis 1  ij 

Aquae  rosae 1  viij, 

A  piece  of  muslin  should  be  dipped  in  this  solution,  and  applied  to 
the  affected  part,  being  kept  in  place  by  a  bandage.  If  there  is  much 
itching,  one  per  cent  of  carbolic  acid  may  be  added. 

Another  plan  of  treatment,  where  there  is  much  secretion,  is  to  keep 
the  surface  covered  with  equal  parts  of  boric  acid  and  starch  or  the 
stearate  of  zinc.  An  application  which  is  often  successful  in  allaying  the 
intense  burning  and  itching  is  black  wash.  This  is  applied  with  absorbent 
cotton  for  ten  or  fifteen  minutes  several  times  a  day,  and  allowed  to  dry 
on,  after  which  a  protective  ointment  is  used.  If  the  black  wash  in  full 
strength  is  painful,  it  may  be  diluted  with  water.  Ichthyol  may  be  used 
in  the  same  way,  but  only  in  dilute  solution — i.  e.,  from  one  half  to  one 
per  cent. 

As  a  simple  protective  ointment  to  follow  any  of  the  above,  one  con- 
taining starch,  zinc  oxide,  or  bismuth,  either  alone  or  in  combination,  may 
be  used.     An  excellent  formula  is  Lassar's  paste : 


8Y0       DISEASES  OF   THE   BLOOD,   LYMPH   NODES,   BONES,  ETC. 

]J   Acidi  salicyliei gr-  s 

Zinei  oxidi 3  ij 

Amyli 3  ij 

Vaseline §  J 

Later,  when  the  inflammation  is  less  acute  and  the  itching  severe, 
nothing  is  so  generally  useful  as  a  combination  of  tar  and  ziuc,  as  in 
the  following : 

5  Ungt.  picis  liquid* 3  iij 

Zinci  oxidi 3  iss. 

Ungt.  aquae  rosje 3  vi 

For  more  chronic  cases,  the  amount  of  tar  may  be  increased.  All 
ointments  used  should  be  spread  upon  muslin,  and  kept  in  close  contact 
with  the  inflamed  part  by  means  of  a  bandage  or  mask.  Little  or  noth- 
ing is  accomplished  by  simply  rubbing  the  ointment  upon  the  affected 
part.  Where  it  is  difficult  to  keep  a  mask  applied,  or  in  situations 
where  it  is  impossible  to  use  the  ointment,  Pick's  paste  may  be  tried : 

5   Pulv.  tragacanthse 3  j 

Glycerinse 3  iss. 

Aquae  rosa? 3  i^ 

To  this  may  be  added  zinc  oxide  gr.  xl  and  carbolic  acid  gr.  v,  or  tar  iU  x. 
A  similar  basis  for  ointments,  made  from  gum  tragacanth  has  been  sug- 
gested by  Elliot  and  is  known  as  bassorin  paste.  It  may  be  combined 
with  tar,  zinc,  salicylic  acid,  or  resorcin. 

The  methods  of  treatment  above  mentioned  are  especially  applicable 
to  eczema  of  the  face  and  scalp.  For  pustular  eczema  of  the  scalp  the 
best  application  is  the  white-precipitate  ointment,  which  should  be  com- 
bined with  three  or  four  parts  of  vaseline.  This  is  excellent  also  for  small 
eczematous  patches  upon  the  body,  but  it  is  not  to  be  used  over  a  large 
surface. 

In  intertrigo,  the  treatment  should  have  reference  to  the  j)athological 
condition  which  is  present.  Cases  of  simple  erythema  usually  yield 
promptly  to  cleanliness  and  the  free  use  of  absorbent  antiseptic  powders, 
such  as  boric  acid  and  starch  in  equal  parts.  If  there  is  an  acute  derma- 
titis, the  calamine  and  zinc  lotion  may  be  used,  and  later  some  protecting 
ointment.  When  infection  has  been  added,  lotions  of  resorcin  or  ich- 
thyol,  one  half  or  one  per  cent  strength,  should  first  be  applied,  and  the 
skin  then  covered  with  the  powder  mentioned ;  both  are  to  be  repeated  as 
often  as  the  parts  are  wet  by  urine  or  soiled  by  faeces.  It  is  important 
in  all  cases  that  the  diseased  surfaces  should  be  kept  separated,  which  is 
best  done  by  starch  and  absorbent  cotton.  All  napkins  should  be  imme- 
diately removed  when  soiled.  Other  useful  applications  are  Lassar's  paste 
and  Pick's  paste  combined  with  zinc  oxide. 

In  cases  of  chronic  eczema,  where  the  skin  remains  thickened,  red. 


FURUNCULOSIS.  871 

scaly,  and  itching,  stimulating  applications  are  to  be  used,  such  as  the 
tincture  of  green  soap  or  stronger  preparations  of  tar  than  those  men- 
tioned.    They  should  be  applied  every  three  or  four  days. 

In  the  seborrhceic  form  of  eczema,  whether  affecting  the  face,  scalp,  or 
body,  nothing  is  so  generally  useful  as  resorcin  : 

9  Resorcin gr.  x 

Ungt.  aquje  roste §  j 

This  may  also  be  advantageously  combined  with  bussorin  paste. 

FURUNCULOSIS. 

A  furuncle,  or  boil,  is  a  circumscribed  inflammation  of  the  subcuta- 
neous cellular  tissue,  beginning  in  a  hair  follicle,  sweat  gland,  or  sebaceous 
gland,  and  usually  ending  in  suppuration.  When  severe,  it  may  result  in 
necrosis  of  the  follicle,  which  forms  the  "  core,"  or  the  necrotic  process 
may  extend  to  the  surrounding  tissues  for  a  variable  distance.  The  ordi- 
nary boil  need  not  be  described,  as  it  presents  nothing  peculiar  in  early 
life.  The  condition,  however,  which  is  characteristic  of  young  children  is 
the  formation  of  small  ones  in  great  numbers.  It  is  to  this  more  espe- 
cially that  the  term  fiirimculosis  is  applied.  The  principal  seat  of  these 
small  abscesses  is,  in  nearly  all  cases,  the  scalp,  face,  and  shoulders,  al- 
though they  may  be  found  upon  any  part  of  the  body.  They  are  sometimes 
numbered  by  hundreds,  and  appear  in  crops  for  a  period  of  several  months. 
In  size,  they  usually  vary  from  a  pea  to  an  almond,  and  they  rarely  con- 
tain a  core.  Infants  are  much  more  often  the  subjects  of  this  disease 
than  are  those  who  have  passed  the  second  year.  In  the  great  majority 
of  cases  the  condition  is  not  serious,  yet,  occurring,  as  it  often  does,  in 
infants  who  are  already  suffering  from  extreme  malnutrition  or  marasmus, 
whose  tissues  possess  but  little  resistance,  the  process  may  develop  into  a 
gangrenous  dermatitis,  which  may  prove  fatal. 

Furunculosis  is  seen  in  children  who  are  in  other  respects  apparently 
healthy,  even  robust ;  but  the  majority  are  in  a  more  or  less  debilitated 
condition,  and  often  are  the  subjects  of  digestive  disturbances.  The  dis- 
ease is  quite  frequent  in  syphilitic  infants  ;  but  these  simple  abscesses  are 
to  be  sharply  distinguished  from  those  which  result  from  the  breaking 
down  of  gummata  of  the  skin.  Want  of  cleanliness  of  the  skin  is  a  factor 
of  some  importance  in  producing  the  disease.  Furunculosis  may  be  asso- 
ciated with  eczema.  The  exciting  cause  in  all  cases,  as  shown  by  the 
recent  investigations  of  Escherich  and  others,  is  the  entrance  of  pyogenic 
germs,  usually  the  staphylococcus  aureus,  into  the  follicles  of  the  skin. 

Treatment. — The  internal  treatment  is  to  be  directed  toward  any  dis- 
turbance of  digestion  or  general  nutrition  which  is  present.  General 
tonics  are  indicated  in  most  cases,  particularly  iron,  arsenic,  and  the  com- 
pound syrup  of  the  hypophosphites.     But  little  reliance  can  be  placed 


872       DISEASES  OP  THE  BLOOD,  LYMPH  NODES,  BONES,   ETC. 

upon  internal  remedies,  such  as  sulphide  of  calcium,  for  the  purpose  of 
arresting  this  disease.  Local  treatment  should  have  for  its  first  object 
thorough  cleanliness  of  the  skin.  This  is  best  secured  by  frequently  bath- 
ing the  parts  affected  with  a  saturated  solution  of  boric  acid.  Single 
furuncles  may  often  be  aborted  by  the  frequent  application  of  spirits  of 
camphor,  or  a  few  applications  of  tincture  of  iodine,  or  by  toixching  them 
with  pure  carbolic  acid.  The  last  mentioned,  although  efficient,  can  hardly 
be  intrusted  to  the  hands  of  a  mother  or  nurse.  A  remedy  which  has  been 
used  with  considerable  success  is  a  plaster  of  salicylic  acid.  In  ray  ex- 
perieuce  the  best  plan  of  treating  the  multiple  small  furuncles,  is  to  delay 
incision  until  they  have  pointed,  then  to  incise  freely  and  empty  the  follicle 
completely  by  compression.  It  is  then  washed  out  thoroughly  with  a 
solution  of  bichloride  (1  to  2,000),  and  small  pledget  of  absorbent  cotton 
applied  till  the  bleeding  has  ceased.  After  this  the  part  should  be  covered 
with  simple  collodion  or  that  in  which  iodoform  has  been  dissolved.  Where 
the  abscesses  are  of  large  size  and  upon  the  scalp,  it  is  wise  to  make  com- 
pression by  applying  a  snug  bandage  for  a  day.  It  is  very  exceptional  for 
abscesses  so  treated  to  refill.  When  the  suppuration  is  more  diffuse  and 
there  is  necrosis  of  the  cellular  tissue,  ichthyol,  either  in  the  form  of  an 
ointment  or  lotion  (one  to  five  per  cent  strength),  is  one  of  the  best  appli- 
cations.    Early  and  free  incisions  must  be  practised  in  all  such  cases. 


GANGRENOUS  DERMATITIS. 

This  is  not  a  frequent  disease,  and  is  seen  almost  exclusively  in  in- 
fancy. It  may  be  primary  or  it  may  follow  other  diseases,  and  hence  has 
been  described  under  many  different  names — viz.,  varicella  gangrenosa^ 
ecthyma  gangrenosa,  pemphigus  gangrenosa,  etc. 

The  lesion  consists  in  small,  discrete  areas  of  inflammation  of  the  skin, 
ending  in  necrosis.  In  the  jjrimary  cases  there  is  usually  first  seen  a  vesi- 
cle, about  as  large  as  a  pea,  with  a  dusky  areola ;  it  increases  in  size  and 
becomes  a  pustule.  Crusts  form  which  are  quite  adherent,  and  on  re- 
moving them  a  loss  of  tissue  is  seen.  The  ulcers  usually  have  sharp  but 
not  undermined  edges,  often  presenting  a  "  punched-out "  appearance. 
By  the  coalescence  of  several  small  ones,  ulcers  an  inch  or  more  in  diame- 
ter are  sometimes  formed. 

The  primary  form  of  gangrenous  dermatitis  occurs  in  wretched,  poorly- 
nourished  infants,  and,  according  to  Elliot,  is  most  often  seen  upon  the 
buttocks.  In  this  location  it  may  be  mistaken  for  syphilis.  The  second- 
ary form  is  more  common,  and  usually  follows  varicella,  less  frequently 
vaccinia,  measles,  or  pemphigus.  My  own  experience  with  this  disease  has 
been  confined  to  cases  following  varicella.  In  such,  the  lesion  is  usually 
seen  upon  the  upper  half  of  the  body,  especially  upon  the  neck  and  chest. 
It  follows  the  ordinary  lesions  of  varicella  and  continues  usually,  in  spite 


IMPETIGO  CONTAGIOSA.  873 

of  treatment,  from  one  to  four  weeks,  in  most  cases  ending  fatally.  The 
disease  always  occurs  in  infants  of  poor  vitality,  often  in  those  suffering 
from  marasmus,  and  is  seldom  seen  outside  of  institutions.  It  may  be 
accompanied  by  fever,  and  other  severe  constitutional  symptoms. 

For  the  production  of  the  disease,  two  factors  are  necessary :  first,  the 
constitutional  condition  referred  to ;  and,  secondly,  the  entrance  of  pyo- 
genic germs,  usually  the  streptococcus  pyogenes. 

Treatment. — Every  means  possible  should  be  employed  to  build  up  the 
general  health  of  the  infant  by  tonics,  fresh  air,  careful  feeding,  etc.  Lo- 
cally, strict  cleanliness  and  antiseptic  applications  are  necessary.  The  best 
application  is  a  solution  of  bichloride  (1  to  5,000),  or  an  ointment  of  ich- 
tliyol  or  iodoform. 

IMPETIGO    CONTAGIOSA. 

Impetigo  contagiosa  is  a  disease  characterized  by  the  formation  of  dis- 
crete vesiculo-pustules,  occurring  most  frequently  upon  the  hands  and 
face.  Cases  are  usually  seen  in  groups  affecting  several  children  in  one 
family  or  institution.  It  may  be  communicated  from  one  person  to 
another,  and  spread  by  auto-inoculation  from  one  part  of  tlie  body  to 
another. 

One  rarely  has  an  opportunity  to  see  the  disease  until  vesicles  have 
formed.  These  are  usually  from  one  fourth  to  one  half  an  inch  in  diame- 
ter, and  are  flaccid,  never  distended.  Later,  their  contents  become  slightly 
yellowish ;  then  they  rupture  and  dry,  forming  thick  yellow  crusts,  which 
have  the  appearance  of  being  "  stuck  on,"  the  surrounding  skin  being 
quite  healthy.  After  the  crusts  fall  off,  a  small  red  patch  remains,  which 
slowly  fades.  The  true  skin  is  not  involved,  except  in  poorly-nourished, 
cachectic  subjects,  as  a  result  of  continued  local  irritation,  like  scratching. 
Under  such  conditions  ulceration  may  occur.  Instead  of  the  small  vesic- 
ulo-pustules described,  bullae  from  one  to  two  inches  in  diameter  may 
form,  filled  first  with  serum,  afterward  with  sero-pus.  Very  little  inflam- 
mation is  seen  about  these  patches,  and  in  most  cases  the  intervening  skin 
is  normal. 

The  favourite  seat  of  the  eruption  is  the  face,  especially  about  the  chin, 
next  the  hands,  the  neck,  the  feet  and  legs,  the  forearms,  and  the  scalp ; 
it  is  rarely  seen  upon  the  abdomen,  and  never  upon  the  back.  There  may 
be  only  half  a  dozen  vesiculo-pustules,  or  from  thirty  to  forty  may  be 
present.  The  smaller  ones  sometimes  coalesce  and  form  others  of  consid- 
erable size.  Itching  is  never  a  prominent  symptom,  and  in  most  cases  it 
is  absent  altogether. 

The  usual  duration  of  impetigo  contagiosa  is  two  or  three  weeks ;  it, 
however,  runs  no  regular  course,  and  by  continued  auto-inoculation  may 
last  much  longer  than  this. 

The  disease  is  undoubtedly  due  to  some  form  of  local  bacterial  infection, 


874       DISEASES  OF  THE  BLOOD,  LYMPH  NODES,  BONES,  ETC. 

but  the  exact  nature  is  not  yet  determined.  It  may  occur  in  any  child, 
but  is  usually  seen  in  one  who  is  cachectic  and  poorly  nourished. 

The  diagnosis  is  not  often  difficult,  and  is  made  by  the  following  fea- 
tures— viz.,  the  occurrence  of  several  cases  together,  the  isolated  vesiculo- 
pustules  situated  upon  the  face  and  hands,  the  slight  itching,  and  the 
prompt  cure  by  local  measures  only.  The  bullous  form,  however,  is  some- 
times confounded  with  pemphigus,  and  there  are  cases  in  which  the  differ- 
ential diagnosis  may  be  quite  difficult. 

Treatment. — This  is  simple  and  usually  very  effective.  The  crusts  are 
to  be  softened  and  removed  by  thoroughly  washing  the  part  with  soap  and 
water  or  a  bichloride  solution,  after  which  the  white  precipitate  ointment, 
combined  with  three  parts  of  vaseline,  should  be  applied. 

URTICARIA. 

Urticaria  is  a  frequent  disease  in  early  life,  and  presents  some  features, 
particularly  in  infants  and  young  children,  which  are  quite  different  from 
those  seen  in  adults.  This  is  due  to  the  fact  that  papules  and  vesicles, 
and  occasionally  pustules,  are  associated  with  the  wheals.  As  the  wheals 
quickly  subside,  it  frequently  happens  that  the  other  lesions  mentioned 
are  the  only  ones  present.  This  fact  has  given  rise  to  considerable  con- 
fusion in  names,  and  the  urticaria  of  infancy  has  been  called  lichen 
urticatus^  urticaria  papulosa,  strophulus,  etc.  It  is  now  pretty  generally 
agreed  that  the  clinical  picture,  which  is  a  familiar  one,  belongs  to  a  single 
disease,  and  that  this  is  urticaria. 

The  initial  lesion  is  the  wheal,  but  on  account  of  the  extreme  suscepti- 
bility of  the  skin  in  young  children,  the  process  is  more  intense  than  in 
older  patients,  so  that  it  may  result  in  the  formation  of  an  inflammatory 
papule  or  a  vesicle.  In  a  few  hours  the  wheals  may  subside,  and  only  the 
papules  or  vesicles  remain,  and  without  a  good  history  the  disease  may  be 
a  very  obscure  one.  The  papules  and  vesicles  occur  with  greatest  fre- 
quency upon  the  hands  and  feet,  particularly  the  palms  and  soles.  The 
more  severe  form  of  the  disease  in  poorly  nourished  children  is  sometimes 
accompanied  by  a  pustular  eruption,  and  there  may  even  be  deep  ulcera- 
tion (ecthyma).  The  usual  appearance  of  the  eruption  is  a  number  of 
small  inflamed  red  papules  whose  tops  are  covered  with  scabs,  the  result  of 
scratching.  The  eruption  may  be  limited  to  the  extremities  or  it  may  be 
general.     It  is  as  a  rule  more  severe  in  regions  accessible  to  scratching. 

There  is  usually  severe  itching,  which  leads  to  loss  of  sleep,  and  often 
in  this  way  the  disease  affects  the  general  health  of  the  child.  The  urti- 
caria of  older  children  does  not  differ  essentially  from  the  same  disease  in 
adults. 

The  character  of  the  eruption  in  urticaria  and  even  its  distribution 
strongly  suggest  scabies ;  and  unless  one  has  had  an  opportunity  to  witness 
the  development  of  the  lesions,  a  differential  diagnosis  may  be  very  difficult, 


SCABIES.  875 

as  almost  every  lesion,  except  the  wheal,  may  be  identical  in  both  diseases. 
Other  cases  may  resemble  varicella. 

Urticaria  in  early  life  is  most  frequently  the  result  of  some  disturbance 
in  the  digestive  tract.  Almost  any  sort  of  derangement  may  produce  it, 
the  exciting  cause  varying  with  the  patient.  Exceptionally,  it  may  result 
from  other  forms  of  irritation,  such  as  dentition  or  intestinal  worms,  and 
it  has  been  ascribed  to  malarial  poisoning. 

Treatment. — The  milder  forms  of  urticaria  usually  respond  quickly  to 
treatment ;  but  when  it  is  severe  and  has  existed  for  several  weeks,  it  is 
one  of  the  most  troublesome  and  intractable  skin  diseases  of  childhood. 
The  treatment  is  to  be  directed  primarily  toward  the  condition  of  the 
digestive  organs.  Children  should  be  put  upon  a  milk  diet,  and  even 
milk  may  need  to  be  partially  peptonized.  The  bowels  should  be  kept 
freely  open  by  calomel,  a  nightly  dose  of  castor  oil,  or  a  morning  dose  of 
magnesia.  If  the  urine  is  excessively  acid  and  scanty,  alkaline  diuretics 
should  be  given.  The  drugs  most  useful  for  the  indigestion  with  which 
urticaria  is  associated  are  salicylate  of  soda  and  nitro-muriatic  acid,  each 
of  which  is  to  be  given  after  meals. 

All  local  causes  of  irritation,  such  as  rough  flannel  underclothing, 
should  be  removed.  The  sleep  may  be  so  much  disturbed  as  to  require 
the  use  of  trional  or  bromide  and  chloral.  The  two  remedies  which  are 
of  most  value  for  the  disease  itself  are  antipyrine  and  atropine ;  they  may 
be  used  separately  or  in  combination,  and  should  be  administered  in  mod- 
erately large  doses. 

The  local  irritation  and  itching  may  be  relieved  by  a  lotion  of  menthol 
(gr.  ij,  water  f  j),  by  a  very  dilute  solution  of  the  subacetate  of  lead  or 
carbolic  acid,  or  by  a  mixture  of  vinegar,  or  the  fluid  extract  of  hamamelis, 
and  water.  ^Yhere  pustules  are  present,  the  white-precipitate  ointment 
may  be  used,  combined  with  four  parts  of  vaseline ;  in  the  papular  and 
vesicular  forms,  an  ointment  of  ichthyol  or  naphthol,  one  per  cent  strength. 
In  many  cases  the  imiirovement  in  the  general  health  by  the  use  of  tonics, 
change  of  air,  etc.,  will  accomplish  more  than  any  measures  directed 
especially  to  the  relief  of  the  urticaria. 

SCABIES. 

Scabies  is  a  contagious  disease  due  to  the  burrowing  into  the  skin  of 
the  female  acarus,  with  secondary  lesions  which  result  from  scratching. 
This  disease  is  not  a  common  one  in  New  York,  even  among  dispensary 
patients,  while  among  the  better  classes  it  is  extremely  rare. 

The  burrowing  of  the  acarus  is  usually  where  the  skin  is  thinnest — 
viz.,  between  the  fingers,  on  the  flexor  surfaces  of  the  wrists,  the  axilljB, 
and,  in  males,  the  genitals.  It  is  not  seen  upon  the  face,  except  in  infancy, 
when  it  may  be  infected  by  contact  with  the  breasts  of  the  mother. 


876       DISEASES   OF   THE   BLOOD,   LYMPH   NODES,  BONES,   ETC. 

The  lesion  excited  by  the  acarus  is  iisually  a  papule  or  a  vesicle,  sometimes 
a  pustule.  Ill  some  cases  no  evidences  of  inflammation  are  present,  but 
in  infants  and  young  children  they  may  be  marked, — pustular  eruptions 
being  frequent  and  often  extensive,  especially  upon  the  hands  and  feet. 
The  characteristic  burrow  is  from  one  fourth  to  one  half  inch  in  length, 
and  appears  as  a  fine  brown  or  black  line,  at  the  end  of  which  the  acarus 
may  be  discovered  as  a  small  white  speck.  The  burrows  are  often  difficult 
to  find  in  infants.  They  are  generally  to  be  seen  along  the  inner  border 
of  the  hand  and  between  the  fingers.  The  intensity  of  the  inflammatory 
lesions  varies  greatly  in  different  cases ;  in  some  they  are  very  few,  while 
in  others,  particularly  in  delicate,  cachectic,  and  neglected  children,  they 
are  sometimes  very  severe,  so  that  the  skin  of  the  affected  part  is  nearly 
covered  with  pustules.  This  is  especially  true  of  the  hands,  where  a 
pustular  eruption  should  always  suggest  scabies.  The  lesions  which  result 
from  scratching  may  be  found  on  any  accessible  portion  of  the  body.  There 
are  usually  at  first  linear,  bloody  marks,  but  after  a  time  these  may  not 
be  visible,  and  there  may  be  only  a  traumatic  eczema.  In  little  children 
urticaria  is  often  associated. 

The  diagnosis  of  scabies  is  usually  quite  easy,  as  several  children  in  a 
family  are  likely  to  be  affected,  particularly  if  they  occupy  the  same  bed. 
The  diagnostic  features  of  the  eruption  are  the  presence  of  papules,  vesi- 
cles, or  pustules,  especially  upon  the  hands,  wrists,  and  genitals.  A  care- 
ful examination  with  a  lens  will  usually  disclose  some  of  the  character- 
istic burrows,  or  even  the  acarus.  In  infancy,  scabies  may  be  easily  con- 
founded with  the  vesicular  form  of  urticaria,  unless  the  development  of 
the  lesions  has  been  observed. 

Scabies  may  always  be  cured,  provided  sufficient  precautions  are  taken 
to  prevent  re-infection.  This  necessitates  boiling  or  baking,  not  only  the 
patient's  clothes,  but  all  the  bedding  as  well. 

Treatment. — This  should  always  be  begun  by  a  hot  bath,  in  order  to 
soften  the  epithelial  scales  about  the  burrows.  The  body  should  be  thor- 
oughly scrubbed  with  soap  and  water,  preferably  with  a  nail-brush,  the 
bath  being  continued  for  at  least  half  an  hour.  It  is  well  to  do  this  at 
night.  After  the  bath,  the  body  is  anointed  with  the  parasiticide,  which 
should  be  thoroughly  rubbed  into  the  skin,  clean  clothing  applied,  and 
the  child  put  into  a  perfectly  clean  bed.  In  the  morning  the  ointment 
may  be  washed  off,  but  none  of  the  clothing  previously  worn  should  be 
put  on.  This  treatment  is  to  be  repeated  on  two  or  three  successive 
nights,  and  if  thoroughly  done  it  will  effect  a  cure.  The  ordinary  sulphur 
ointment  is  too  irritating  for  use  in  little  children,  and  one  of  the  fol- 
lowing may  be  substituted  :  naphthol,  15  parts ;  creta  preparata,  10  parts ; 
vaseline,  100  j^arts  (Kaposi) ;  or,  precipitated  sulphur,  1  part ;  balsam  of 
Peru,  1  part ;  vaseline,  8  parts ;  or  the  simple  balsam  of  Peru  may  be  ap- 
plied without  dilution.     After  the  use  of  the  parasiticide  there  is  generally 


TINEA  TONSURANS.  877 

required  for  a  few  days,  some  soothing  application  like  those  mentioned 
in  the  chapter  upon  Eczema. 

TINEA  TONSURANS— RING-WORM  OF  THE  SCALP. 

Ringworm  of  the  scalp  is  a  very  frequent  disease  in  institutions  for 
children,  often  occurring  as  an  epidemic.  According  to  Crocker,  the 
primary  lesion  consists  in  a  red  papule  surrounding  a  hair,  which  soon 
increases  to  a  small  circular  patch ;  this  spreads  at  its  outer  margin, 
gradually  increasing  in  size  until  it  is  from  one  to  two  inches  in  diameter, 
but  rarely  larger  than  this.  Sometimes  several  of  the  patches  coalesce. 
These  affected  areas  always  have  rounded  borders,  and  are  sharply  out- 
lined. Here  the  hairs  are  very  brittle,  and  often  broken  off  close  to  the 
scalp,  so  that  it  may  appear  to  be  bald.  Where  they  have  not  fallen  off, 
the  hairs  have  lost  their  lustre.  The  stumps  of  the  broken  hairs  point  in 
all  directions. 

The  fungus  which  produces  the  disease  is  the  trichopliyton  tonsurans. 
It  penetrates  the  shaft  of  the  hair,  both  the  spores  and  the  mycelium 
being  se*en  under  the  microscope.  The  spores  are  present  in  great  num- 
bers in  the  hair,  but  the  mycelium  is  most  abundant  in  the  scales.  The 
amount  of  inflammation  found  in  the  diseased  areas  varies  much  in  the 
different  cases.  There  may  be  only  a  scaliness  of  the  scalp,  or  a  formation 
of  pustules  in  the  hair  follicles,  the  hairs  loosening  and  falling  out  in  con- 
sequence. In  young  infants  where  the  hair  is  scanty  and  thin,  the  dis- 
ease resembles  tinea  circinata — i.  e.,  it  is  superficial,  and  the  hair  follicles 
are  often  not  involved.  Children  of  all  ages  are  liable  to  tinea  ton- 
surans. It  flourishes  particularly  in  those  who  are  dirty  and  poorly 
cared  for. 

The  diagnostic  feature  of  the  disease  is  the  presence  of  scaly  patches, 
with  loss  of  hair.  The  patches  are  usually  circular,  and  by  examination 
with  a  lens  the  stumps  of  broken  hairs  are  seen  all  over  the  diseased 
area.  By  a  microscopical  examination  the  fungus  is  discovered.  In 
typical  cases  the  diagnosis  is  easy  if  the  process  is  at  all  advanced,  but 
there  are  many  atypical  forms  and  many  mild  cases  where  the  recogni- 
tion of  the  disease  is  difficult.  The  symptoms  are  often  masked  by  the 
inflammatory  conditions  present.  The  disease  may  be  confounded  with 
seborrha:>a ;  but  in  the  latter  the  lesion  is  diffuse,  never  sharply  defined ; 
there  is  general  thinning  of  hair  over  the  scalp,  and  never  the  stumpy, 
broken  hairs.  Psoriasis  has  points  of  resemblance,  but  it  is  usually  found 
on  other  parts  of  the  body,  especially  the  knees  and  elbows,  and  upon  the 
scalp  the  patches  are  more  numerous  and  smaller.  In  eczema  the  loss  of 
hair  in  circumscribed  patches  is  never  seen,  nor  are  the  broken  stumps. 

Tinea  tonsurans  is  always  curable,  provided  the  patient  can  be  kept 
under  close  surveillance,  and  treatment  thoroughly  carried  out.  There  is 
no  tendency  to  spontaneous  recovery.     In  a  recent  case,  treatment  must 


878       DISEASES  OF   THE  BLOOD,   LYMPH   NODES,   BONES,   ETC. 

usually  be  continued  for  one  or  two  months,  and  in  chronic  cases,  from 
six  months  to  one  year,  with  the  closest  watchfulness. 

Treatment. — The  great  difficulty  in  treatment  is  to  get  the  parasiticide 
deeply  enough  into  the  scalp  to  reach  the  fungus,  since  this  is  often  at  the 
very  bottom  of  the  hair  follicles.  As  a  first  step,  the  hair  should  be  cut 
short  all  over  the  patch  and  for  at  least  an  inch  beyond  it ;  this  is  neces- 
sary in  order  to  get  at  the  diseased  part  and  to  detect  new  foci  of  infection 
early — if  possible  before  the  fungus  has  extended  deeply  into  the  follicles. 
The  parasiticide  should  be  applied  not  only  upon  but  around  the  patch, 
and  the  entire  scalp  should  be  washed  thoroughly  two  or  three  times  a 
week.  To  prevent  the  disease  spreading,  all  the  scales  are  to  be  kept  soft- 
ened by  the  use  of  carbolic  soap.  The  hair  should  not  be  brushed,  as  this 
tends  to  scatter  the  spores  and  spread  the  disease.  All  patients  while 
under  treatment,  should  wear  a  cap  of  muslin  or  oiled-silk,  or  one  lined 
wuth  paper,  in  order  to  prevent  infecting  others.  In  institutions,  affected 
children  should  invariably  be  isolated. 

To  destroy  the  fungus  almost  every  germicide  on  the  list  has  been 
advocated  at  one  time  or  another,  which  proves  that  the  disease  is  a  very 
obstinate  one,  and  that  no  one  application  is  invariably  successful.  Those 
which  have  the  sanction  of  the  widest  use  are  the  tincture  of  iodine,  the 
bichloride,  white  precipitate,  and  oleate  of  mercury,  kerosene,  creosote, 
and  croton  oil.  As  a  vehicle  for  ointments,  lanoliue  is  greatly  to  be  pre- 
ferred to  vaseline  or  lard ;  according  to  Crocker,  the  addition  of  three 
parts  of  lanoline  to  one  part  of  olive  oil  is  much  better  than  lanoline 
alone.  Most  of  the  germicides  mentioned  are  used  in  the  strength  of  one 
to  five  per  cent,  according  to  the  age  of  the  child  and  the  irritability  of 
the  scalp.  In  an  epidemic  of  ring-worm  in  the  New  York  Infant  Asylum 
the  following  combination  of  bichloride  and  kerosene  proved  extremely 
satisfactory :  ten  grains  of  the  bichloride  were  dissolved  in  alcohol,  and 
to  this  were  added  two  and  a  half  ounces  each  of  olive  oil  and  kerosene. 
This  was  applied  every  day,  being  thoroughly  rubbed  into  the  diseased 
patches,  and  the  whole  scalp  saturated  with  it.  Considerable  irritation 
usually  resulted,  and  every  few  days  the  parasiticide  was  omitted  and  some 
simple  emollient  applied  until  the  irritation  had  in  a  measure  subsided. 
In  some  of  the  cases,  the  tincture  of  iodine  was  alternated  with  the  bichlo- 
ride and  kerosene.  Twenty-six  cases  were  treated  after  this  plan  and  all 
cured,  the  average  duration  of  treatment  being  eight  and  a  half  weeks.* 

Epilation  is  necessary  in  many  cases  as  an  accessory  to  the  application 
of  germicides,  particularly  in  older  children. 

*  A  full  report  of  these  cases  was  made  by  C.  Gr.  Kerley,  M.  D.,  in  the  New  York 
Medical  Journal,  October  10,  1891. 


ACUTE   OTITIS.  879 

CHAPTER  VI. 

ACUTE  OTITIS. 

Otitis  is  a  frequent  affection  during  infancy  and  early  childhood,  at- 
tacks usually  occurring  in  the  cold  season.  Of  all  the  inflammatory  con- 
ditions which  may  be  met  with  in  early  life,  there  is  perhaps  none  which 
more  frequently  gives  rise  to  obscure  febrile  symptoms  than  this. 

Etiology. — Acute  otitis,  as  a  rule,  is  a  secondary  disease,  and  is  generally 
preceded  by  some  infectious  process  in  the  rhino-pharynx.  The  usual 
avenue  of  infection  is  through  the  Eustachian  tube.  The  catarrh  of  the 
pharynx  may  be  a  simple  one,  the  ordinary  head-cold,  or  it  may  occur  as 
a  complication  of  the  acute  infectious  diseases.  Downie  gives  the  follow- 
ing statistics  of  501  cases  of  tympanic  involvement  treated  in  the  Chil- 
dren's Hospital  in  Glasgow : 

Originated  during  measles 131  cases,  or  26-1  percent. 

•'       scarlet  fever 63  "  "  12-6   " 

"               "      whooping-cough 15  "  "  3-0   "  " 

"                "       mumps 3  "  *'  .0-6   "  " 

"                "      simple  catarrh 147  "  "  29-4   " 

"      dentition 101  "  "  20-0   "  " 

Syphilitic 8  "  "  16   "  " 

Doubtful 33  "  "  6-7"  " 

501  100-0 

The  most  common  condition  preceding  severe  otitis  is  scarlet  fever, 
and  next  in  the  order  of  their  frequency,  epidemic  influenza,  simple  acute 
pharyngitis  or  tonsillitis,  measles,  diphtheria,  and  typhoid  fever.  Otitis 
when  following  simple  inflammations  of  the  throat  is  usually  much  less 
severe  than  when  it  complicates  scarlet  fever  or  diphtheria.  Cold  and 
exposure  frequently  play  the  role  of  exciting  causes.  In  a  few  cases  the 
disease  is  the  result  of  traumatism,  such  as  a  blow  or  traction  upon  the 
external  ear,  or  the  entrance  of  fluids  through  the  Eustachian  tube  from 
the  nasal  douche.  It  sometimes  results  as  an  extension  of  inflammation 
from  meningitis,  especially  the  cerebro-spinal  form.  When  seen  as  a  com- 
plication of  scarlet  fever,  measles,  or  diphtheria,  the  symptoms  are  usually 
manifested  from  the  sixth  to  the  tenth  day  of  the  disease. 

Lesions. — The  ordinary  course  of  events  in  the  pathological  process  is, 
first,  acute  hyperagmia  and  swelling  of  the  mucous  membrane  of  the 
rhino-pharynx,  which  extends  into  the  Eustachian  tube,  causing  ob- 
struction more  or  less  complete.  The  inflammatory  process  may  be  lim- 
ited to  the  tube,  or  it  may  extend  to  the  mucous  membrane  lining  the 
middle  ear. 

There  "are  two  varieties  of  acute  inflammation  of  the  middle  ear :  (1) 
57 


880       DISEASES   OF  THE   BLOOD,   LYMPH   NODES,   BONES,   ETC. 

The  catarrhal  form,  which  usually  accompanies  simple  catarrh  of  the 
rhino-pharynx  or  complicates  measles.  This  is  an  inflammation  of  the  mu- 
cous membrane  merely,  and  its  products  are  serum  and  mucus  ormuco-pus. 
It  is  not  usually  accompanied  by  great  pain  or  followed  by  serious  conse- 
quences. It  is  generally  confined  to  the  lower  part  of  the  tympanic  cav- 
ity, and  is  the  form  most  frequently  seen  in  infants.  (3)  The  phlegmonous 
form,  which  affects  older  children  principally.  This  is  a  much  more  se- 
rious inflammation,  and  is  often  excited  by  the  infectious  catarrh  of  scarlet 
fever,  diphtheria,  or  epidemic  influenza.  In  this  variety  micro-organisms 
find  their  way  into  the  middle  ear  in  great  numbers,  and  set  up  an  inflam- 
mation of  a  more  or  less  virulent  type,  which  may  involve  not  only  the 
mucous  membrane  lining  the  tympanum,  but  also  the  cellular  tissue  in 
the  upper  part  of  the  tympanic  cavity. 

The  catarrhal  form  of  inflammation  frequently  subsides  in  a  few  days 
with  proper  treatment,  the  only  result  being  a  slight  deafness,  which  is 
temporary.  The  phlegmonous  form  causes  a  stoppage  of  the  Eusta- 
chian tube,  rupture  or  sloughing  of  the  tympanic  membrane  and  dis- 
charge of  the  products  of  inflammation,  or  rarely  pus  finds  an  outlet  by 
burrowing  along  the  cartilages.  The  inflammatory  process  may  extend  to 
the  bones,  causing  necrosis  of  the  ossicles  or  the  bony  walls  of  the  tym- 
panum. The  remote  results  are  periostitis  and  necrosis  of  the  petrous 
bone,  pachymeningitis,  infectious  thrombosis  of  the  lateral  sinus,  general 
purulent  meningitis,  and  cerebral  abscess.  These  will  be  considered  under 
Complications. 

Symptoms. — These  are  usually  few  in  number,  but  present  great  varia- 
bility as  regards  their  combinations  and  intensity.  The  two  most  con- 
stant symptoms  are  pain  and  fever.  In  a  typical  case  in  an  infant,  there 
is  generally  at  the  beginning  some  discharge  from  the  nose,  slight  conges- 
tion of  the  pharynx  and  tonsils,  and  a  temperature  of  100°  to  102°  F. 
There  is  nothing  characteristic  about  this  catarrh.  After  two  or  three 
days  the  objective  symptoms  subside,  but  the  infant  continues  to  be  rest- 
less, worries  much  of  the  time,  wakes  frequently  at  night  with  a  start, 
nurses  poorly,  and  if  the  thermometer  is  used,  it  is  found  that  the  tempera- 
ture remains  elevated,  usually  from  99°  to  101°  F.  The  infant  seems  de- 
cidedly ill,  and  yet  no  very  definite  symptoms  are  present.  Sometimes 
there  is  marked  tenderness  about  the  ear,  and  the  child  refuses  to  lie  upon 
the  affected  side,  or  shows  signs  of  pain  when  the  ear  is  touched.  After  a 
week  or  ten  days  a  discharge  is  found  in  the  auditory  canal,  and  usually 
there  follows  a  rapid  subsidence  of  the  constitutional  symptoms.  In  some 
cases  there  is  seen  only  a  high  temperature,  ranging  from  101°  to  104°  F., 
which  persists  for  several  days  without  outward  evidences  of  pain  or  other 
signs  of  inflammation,  the  discharge  being  the  first  symptom  which  leads 
the  physician  to  suspect  disease  of  the  ear.  In  other  cases  there  are 
marked  dulness,  apathy,  anorexia,  and  sometimes  nausea  and  vomiting, 


ACUTE  OTITIS.  881 

but  for  several  days  no  evidence  of  pain ;  the  temperature  may  be  but 
little  elevated.  Thus,  in  most  of  the  attacks  seen  in  infancy,  pain  is  not 
very  marked,  and  it  is  this  which  so  often  leads  to  the  great  obscurity  of 
the  symptoms. 

In  older  children  the  symptoms  are  more  characteristic.  Pain  is  usu- 
ally sharp  and  severe,  and  is  complained  of  early  in  the  attack.  The 
temperature  is  nearly  always  elevated  two  or  three  degrees,  and  occa- 
sionally it  is  103°  or  104°  F.,  with  severe  headache,  extreme  restlessness, 
and  even  delirium  or  convulsions,  so  that  meningitis  may  be  suspected. 

The  inflammation  does  not  necessarily  go  on  to  suppuration  and  rup- 
ture. There  are  even  more  frequently  seen,  accompanying  ordinary  head- 
colds  or  mild  attacks  of  influenza,  cases  in  which  the  pain  is  quite  severe 
for  twenty-four  or  thirty-six  hours,  and  accompanied  even  by  a  moderate 
elevation  of  temperature,  and  yet  which  rapidly  subside  without  further 
symptoms.  In  these  cases  the  pain  is  too  constant  and  too  prolonged  to 
be  an  attack  of  neuralgia.  They  are  simply  cases  of  a  mild  form  of  in- 
flammation. 

In  infants  suffering  from  malnutrition  or  marasmus,  otitis  not  infre- 
quently comes  on  without  any  objective  symptoms,  the  first  thing  noticed 
being  the  discharge.  This  association  of  otitis  with  marasmus  is  to  be 
attributed  to  the  frequency  of  swelling  of  the  adenoid  tissue  in  the  phar- 
yngeal vault,  upon  which  the  catarrhal  process  depends. 

Of  the  individual  symptoms,  fever  is  the  most  constant,  and  is  present 
in  all  except  the  cases  of  marasmus  just  mentioned.  The  usual  range  of 
temperature  is  from  100°  to  102°  F. ;  exceptionally  it  may  be  from  103° 
to  105°  F.  The  course  of  the  temperature  is  irregular  and  remittent. 
After  spontaneous  rupture  or  incision  of  the  drum  membrane  the  tem- 
perature usually  falls,  but  often  not  immediately;  occasionally  it  con- 
tinues almost  as  high  as  before  for  twenty-four  hours.  Pain  is  more 
marked  in  older  children  than  in  infants :  first,  because  in  the  latter  the 
drum  membrane  is  not  so  firm,  yields  more  readily,  and  ruptures  earlier ; 
and,  secondly,  because  the  inflammation  is  usually  of  the  catarrhal  and  not 
the  phlegmonous  type.  Tenderness  is  sometimes  elicited  by  pressure  just 
in  front  of  the  external  auditory  meatus ;  there  may  be  increased  sensitive- 
ness of  all  parts  of  the  ear  and  even  of  the  whole  side  of  the  head.  Chil- 
dren not  infrequently  complain  of  noises  in  the  ear.  One  little  girl  with 
obscure  symptoms  and  high  temperature,  first  called  attention  to  her  ear 
by  the  remark,  that  she  "  heard  pussy  in  the  room."  A  sense  of  discom- 
fort resembling  that  which  is  felt  when  the  ears  are  stopped,  frequently 
leads  children  to  pick  at  them.  Cerebral  symptoms  are  infrequent,  and 
occur  chiefly  in  cases  not  receiving  proper  early  treatment ;  they  are  prac- 
tically limited  to  the  phlegmonous  form  of  inflammation,  and  they  may 
indicate  meningeal  congestion,  less  frequently  localized  meningitis  or 
thrombosis. 


882       DISEASES   OF   THE   BLOOD,   LYMPH   NODES,   BONES,   ETC. 

The  local  appearances  in  the  early  stage — provided  a  view  of  the 
tympanic  membrane  can  be  obtained — are  acute  redness  and  congestion ; 
later  there  is  distinct  bulging  of  the  membrane.  If  perforation  has  taken 
place,  its  site  may  or  may  not  be  visible,  but,  according  to  Pomeroy,  its 
existence  may  always  be  assumed,  if  there  is  pulsation  of  the  membrane, 
if  bubbles  of  air  are  seen  deep  in  the  canal,  if  the  perforation  whistle 
occurs  upon  blowing  the  nose  or  inflating  the  ear,  and,  finally,  if  much 
mucus  or  pus  is  present,  as  inflammation  of  the  external  canal  almost 
never  causes  much  discharge.  A  discharge  is  not  present  until  perfora- 
tion has  taken  place.  The  pus  in  rare  cases  may  burrow  along  the  car- 
tilages and  open  externally  behind  or  at  the  side  of  the  ear.  The  nature 
of  the  discharge  depends  upon  the  variety  of  the  disease ;  in  the  catarrhal 
form  it  is  at  first  sero-mucus,  whitish  in  colour,  rather  thick,  quite  profuse, 
and  usually  continues  when  once  established ;  later  it  is  usually  purulent. 
In  the  phlegmonous  form  it  is  always  purulent,  generally  less  abundant, 
and  liable  to  a  sudden  arrest  with  an  exacerbation  of  the  constitutional 
symptoms.  As  the  case  improves  the  discharge  diminishes  in  quantity 
and  gradually  assumes  a  serous  character. 

Diagnosis. — In  typical  cases  characterized  by  pain  and  temperature, 
this  is  usually  easy,  particularly  in  older  children.  Otitis  in  infancy  is 
frequently  obscure,  sometimes  because  the  patient  is  too  young  to  direct 
attention  to  the  seat  of  pain,  but  more  often  because  the  pain  is  slight  or 
entirely  absent.  The  temperature  is  almost  invariably  elevated,  and  the 
usual  problem  presented  to  the  physician  is  to  discover  a  cause  for  this 
fever.  In  the  absence  of  definite  otoscopic  signs,  one  must  rely  upon  the 
presence  of  faucial  congestion,  a  history  of  a  previous  acute  catarrh,  rest- 
lessness at  night,  and  the  absence  of  other  signs  in  the  throat,  lungs,  or 
digestive  tract,  which  might  explain  the  fever.  Local  tenderness,  deaf- 
ness, or  noises  in  the  ears  are  of  much  significance  when  present,  but  they 
are  very  often  wanting.  Otitis  is  so  common  a  cause  of  high  temperature 
in  infants  during  the  cold  season,  that  one  should  always  be  on  the  look- 
out for  it.  In  older  children  a  neuralgia  arising  from  a  carious  tooth  may 
give  rise  to  a  pain  resembling  that  of  otitis. 

Prognosis. — The  ordinary  catarrhal  form  of  acute  otitis  is  not  often 
followed  by  serious  consequences,  unless  there  are  repeated  attacks.  The 
phlegmonous  form,  especially  when  it  complicates  scarlet  fever,  is  always 
serious,  and  in  the  majority  of  cases  it  is  followed  by  some  degree  of  im- 
pairment of  the  sense  of  hearing. 

Complications  and  Sequelae.* — Remote  consequences  are  most  likely  to 
be  seen  in  cases  following  scarlet  fever,  probably  because  of  their  severity, 
particularly  when  early  treatment  has  been  neglected.  In  many  cases 
the  symptoms  are  obscure  because  the  discharge  from  the  ears  has  been 

*  See  Pitt's  Gulstonian  Lectures,  1890. 


ACUTE   OTITIS. 


883 


slight  or  wanting.  It  is  to  be  remembered  in  this  connection  that  the 
Eustachian  tube,  middle  ear,  and  antrum,  in  young  children  are  relatively 
large,  and  hence  easily  infected,  while  the  mastoid  cells  are  imperfectly 
developed.  These  anatomical  conditions  explain  the  greater  frequency 
of  extension  of  the  disease  to  the  petrous  bone  and  the  brain,  and,  as 
compared  with  adults,  the  infrequency  of  mastoid  complications. 

Meningitis. — This  may  be  a  cause  of  death  in  young  children.  There 
may  be  a  localized  pachymeningitis  with  the  formation  of  pus,  or  a  gen- 
eral purulent  meningitis.  It  may  be  secondary  to  other  lesions,  such  as 
thrombosis  of  the  lateral  sinus,  or  the  rupture  of  a  cerebral  abscess,  but 
is  usually  due  to  the  passage  of  pus  through  the  roof  of  the  tympanum, 
or  along  the  internal  auditory  meatus.  Meningitis  is  more  frequent  as  a 
complication  of  old  cases,  but  may  develop  soon  after  the  early  acute 
symptoms.  Its  onset  is  usually  sudden,  and  its  duration  rarely  more  than 
a  week. 

Cerebral  abscess. — This  is  due  to  a  direct  extension  of  the  infectious  pro- 
cess from  the  bone,  vein,  or  dura  mater.  In  about  two  thirds  of  the  cases 
the  abscess  is  in  the  temporo-sphenoidal  lobe.  The  next  most  frequent 
seat  is  the  lateral  lobe  of  the  cerebellnm.  Korner  states  that  disease  of 
the  mastoid  and  middle  ear  leads  to  cerebral  abscess,  and  disease  of  the 
labyrinth  to  cerebellar  abscess.  Abscesses  may  be  complicated  by  throm- 
bosis or  by  meningitis.  They  are  often  latent  until  just  before  death, 
which  more  frequently  occurs  from 
the  development  of  purulent  menin- 
gitis than  from  any  other  cause. 
They  are  rare  except  in  cases  of 
long  standing. 

Thrombosis  of  the  lateral  sinus 
occurs  as  a  condition  antecedent  to 
meniugitis  or  abscess,  or  without 
them.  It  usually  develops  suddenly, 
with  recurring  chills  and  a  high 
temperature,  which  is  subject  to 
sudden  and  wide  fluctuations. 

Mastoid  disease,  as  previously 
stated,  is  not  so  frequent  a  compli- 
cation of  otitis  in  children  as  in 
adults,  one  reason  being  that  the 
mastoid  process  contains  but  a  sin- 
gle cavity,  the  antrum,  whose  walls 
are  so  thin  that  spontaneous  rupture 
externally  readily  occurs,  while  the 

mastoid  cells  are  very  imperfectly  developed  until  after  puberty, 
disease  may  accompany  either  acute  or  chronic  otitis.     There 


Fig.  153. 


-Mastoid  abscess  lul 
otitis. 


Mastoid 
are  local 


884       DISEASES  OP  THE  BLOOD,   LYMPH  NODES,   BONES,   ETC. 

pain  and  tenderness  and  a  very  characteristic  swelling,  which  causes  the 
ear  to  stand  out  from  the  head  (Fig.  153).  Usually  the  process  ends  in 
suppuration,  with  the  symptoms  of  external  abscess,  but  resolution  some- 
times occurs.  This  may  often  be  promoted  by  the  early  application  of 
cold  either  in  the  form  of  an  ice  bag  or  a  coil. 

The  labyrintli  is  less  frequently  involved,  although  cases  are  recorded 
by  Pye,  Phillips,  and  others,  in  which  the  necrosis  and  discharge  of  the 
entire  labyrinth  has  occurred  after  scarlet  fever.  In  most  of  these  cases 
the  deafness  was  complete,  and  in  several  vertigo  was  present. 

Facial  paralysis  rarely  occurs  in  the  acute  cases,  but  accompanies  a 
considerable  proportion  of  the  chronic  ones.  It  is  due  to  an  extension  of 
the  inflammatory  process  from  the  bone  to  the  seventh  nerve,  where  it 
passes  through  the  canal.  The  symptoms  are  those  of  ordinary  peripheral 
facial  palsy. 

Treatment. — If  the  case  is  seen  in  the  early  stage,  the  inflammation 
may  not  infrequently  be  cut  short  by  local  blood-letting  and  the  use  of 
heat.  Blood-letting  is  not  to  be  advised  in  the  case  of  young  infants,  but 
may  be  used  in  children  over  two  years  old.  It  should  be  urged  in  spite 
of  its  obvious  disadvantages,  as  nothing  is  so  efficient.  Either  leeches  or 
wet  cups  may  be  employed.  They  should  be  applied  just  in  front  of  and 
close  to  the  tragus.  Dry  heat  is  to  be  preferred  to  moist  heat,  both  as  a 
means  of  arresting  inflammation  and  of  relieving  pain.  It  may  be  applied 
by  means  of  a  bag  of  hot  water,  salt,  or  bran,  or  by  a  hot  brick  or  soap- 
stone.  These  should  be  placed  beneath  a  thin  pillow,  upon  which  the 
child's  head  rests.  If  the  child  will  not  lie  upon  his  hot  pillow,  a  small 
bag  of  salt  or  hot  water  may  be  bound  over  the  ear,  which  has  been  first 
covered  by  cotton.  Perhaps  the  best  of  all  is  Bench's  device  of  filling  the 
tip  of  the  finger  of  a  kid  glove  with  salt,  and  inserting  this  into  the  canal 
after  heating ;  cotton  should  be  applied  over  it.  Hot  poultices  may  be 
used  for  a  short  time,  being  changed  frequently,  but  prolonged  or  con- 
tinuous poulticing  encourages  suppuration  and  should  never  be  allowed. 
On  no  account  should  oil,  or  oil  and  laudanum,  be  dropped  into  the  ear, 
as  is  so  often  done  in  domestic  practice.  If  the  child  is  not  comfortable 
in  the  course  of  a  couple  of  hours  after  the  blood-letting  or  dry  heat,  an 
opiate  should  be  given.  This  not  only  relieves  suffering,  but  has  a  favour- 
able influence  upon  the  inflammation. 

A  return  of  the  severe  pain  on  the  following  day,  or  its  continuance  in 
spite  of  ordinary  measures,  with  a  steadily  high  temperature,  are  indica- 
tions for  operative  interference.  If  to  the  above,  cerebral  symptoms  are 
added,  operation  is  imperative.  An  early  incision  of  the  drum  membrane 
is  usually  followed  by  a  discharge  of  blood  only ;  but  tension  is  relieved 
and  with  it  the  pain  disappears,  and  the  inflammation  often  quickly  sub- 
sides without  the  formation  of  pus.  Much  suffering  is  thereby  avoided, 
and,  as  the  wound  heals  quickly,  much  less  damage  is  done  than  by  allow- 


ACUTE   OTITIS.  885 

ing  the  disease  to  go  on  to  a  spontaneous  rnpture.  Later  operation  may 
be  required  either  for  the  relief  of  pain  or  the  evacuation  of  pus,  in  order, 
if  possible,  to  prevent  the  disease  from  spreading  to  the  bony  parts. 

After  incision  or  spontaneous  rupture  of  the  drum  membrane,  the  pain 
usually  ceases,  although  the  temperature  may  not  fall  to  normal  for  twenty- 
four  or  thirty-six  hours,  even  with  good  drainage.  The  discharge  is  now 
the  principal  object  of  treatment.  Nothing  else  is  necessary  than  to  keep 
the  ear  perfectly  clean.  The  canal  should  not  be  plugged  with  cotton, 
nor  should  it  be  stopped  by  the  insufflation  of  powders.  It  should  be 
syringed  with  a  solution  of  bichloride  (1  to  5,000),  or  a  saturated  solution 
of  boric  acid,  or  simply  with  boiled  water.  All  these  fluids  should  be 
used  warm,  and,  if  the  discharge  is  purulent  and  abundant,  as  often  as 
every  two  or  three  hours — in  all  cases  several  times  a  day.  A  bulb  ear- 
syringe  of  soft  rubber  is  the  most  satisfactory  instrument  for  general  use. 
It  is  a  mistake  to  keep  the  ears  covered  by  a  thick  mass  of  cotton  or  flan- 
nel, as  is  so  often  done.  In  the  house  no  protection  is  necessary.  A  sud- 
den rise  in  the  temperature  usually  means  that  drainage  is  imperfect;  if 
it  is  accompanied  by  pain,  a  second  incision  may  be  necessary.  If  the 
temperature  remains  high,  one  should  be  on  the  lookout  for  mastoid 
disease. 

In  most  cases  the  discharge  ceases  in  from  one  to  three  weeks  ;  should 
it  continue  longer,  some  measures  for  checking  it  may  be  used.  Dench 
advises  as  better  than  other  applications,  the  use  of  a  few  drops  of  a  satu- 
rated solution  of  boric  acid  in  alcohol  after  syringing.  It  should  be  ap- 
plied with  a  medicine  dropper.  Where  the  discharge  has  become  fetid, 
syringing  once  a  day  with  a  solution  of  peroxide  of  hydrogen  (1  to  4,  or 
even  stronger)  is  often  useful.  A  persistent  discharge  often  depends  upon 
the  fact  that  the  child's  general  condition  is  poor,  and  improvement 
in  this  will  do  more  to  stop  the  discharge  than  any  variation  in  local 
treatment. 

One  attack  of  otitis  is  frequently  the  precursor  of  many  others.  Chil- 
dren sometimes  have  one  or  more  attacks  every  winter  for  several  years. 
Such  children  are  usually  those  who  are  very  prone  to  catarrhal  colds,  and 
in  most  of  them  will  be  found  adenoid  vegetations  in  the  pharynx.  In 
order  to  get  rid  of  this  tendency  to  attacks  of  otitis,  such  growths  should 
be  removed  and  all  other  associated  pathological  conditions  treated.  The 
nose  should  be  kept  as  clean  as  possible  by  frequent  use  of  the  hand 
atomizer  with  some  mild  cleansing  solution,  such  as  Dobell's  or  Seller's. 
The  rhino-pharynx  may  be  touched  once  in  two  or  three  days  with  a  solu- 
tion of  nitrate  of  silver  (10  to  30  grains  to  the  ounce). 

Cold  sponging  about  the  neck  and  chest  should  be  employed,  as  well 
as  every  means  to  reduce  the  susceptibility  to  acute  catarrh.  The  remote 
dangers  from  these  recurring  attacks  are  often  overlooked.  They  may  be 
the  beginning  of  a  chronic  condition,  the  full  effects  of  which  are  not 


886        DISEASES  OP  THE  BLOOD,   LYMPH   NODES,   BONES,  ETC. 

seen  until  adult  life  is  reached,  both  the  physician  and  the  parents 
often  thinking  that  all  danger  has  passed  when  the  acute  symptoms  have 
subsided. 

The  treatment  of  chronic  otitis  and  of  the  associated  conditions  is 
largely  surgical,  and  belongs  to  the  specialist ;  but  it  is  extremely  impor- 
tant that  the  general  practitioner  should  be  familiar  with  their  symp- 
toms, and  realize  the  danger  from  these  neglected  cases,  not  only  to  the 
function  of  hearing,  but  also  to  life  itself.  The  essential  thing  in  treat- 
ment is  to  operate  sufficiently  to  secure  free  drainage,  and  to  permit  thor- 
ough cleansing  of  the  parts.  Too  much  can  not  be  said  against  the 
expectant  treatment  of  these  cases,  or  against  the  practice  of  prolonged 
poulticing. 


SECTION   IX. 
THE  SPECIFIC  INFECTIOUS  DISEASES. 

Accurate  classification  of  the  infectious  diseases  is  at  the  present 
time  impossible,  but  there  are  two  quite  distinct  groups  into  which,  with 
one  or  two  exceptions,  those  here  considered  may  be  placed. 

The  first  group  includes  scarlet  fever,  measles,  rubella,  varicella,  and 
pertussis.  The  nature  of  the  specific  poison  in  each  of  these  is  as  yet 
unknown.  They  are,  strictly  speaking,  contagious ;  for  it  is  practically 
certain  that  any  of  them  may  be  contracted  by  proximity  to  a  person 
suffering  from  the  disease,  without  actual  contact.  In  no  one  of  these 
diseases  is  the  poison  given  off  in  a  single  definite  discharge,  and  in  no 
one  is  there  a  characteristic  visceral  lesion.  Mumps  resembles  the  mem- 
bers of  this  group  in  all  points  except  the  one  last  mentioned.  These  pe- 
culiarities, together  with  the  fact  that  thus  far  the  poison  of  each  of  these 
diseases  has  resisted  all  attempts  at  isolation,  render  it  not  improbable  that 
these  poisons  are  some  other  variety  of  micro-organisms  than  bacteria. 

In  the  second  group  may  be  placed  diphtheria,  typhoid  fever,  and 
tuberculosis,  in  each  of  which  the  specific  poison  is  a  known  form  of 
bacteria.  Each  of  these  diseases  is  associated  with  definite  and  character- 
istic visceral  lesions.  The  poison  is  discharged  from  the  body  in  a  certain 
well-understood  manner  from  the  tissues  which  are  affected  by  the 
disease,  and  in  no  other  way.  These  diseases  can  not  be  contracted  by 
proximity  to  a  diseased  person,  but  only  by  receiving  into  the  body  the 
specific  germs,  either  by  contact  with  a  person  suffering  from  the  disease 
or  contact  with  something  upon  which  the  special  germs  of  the  disease 
have  been  discharged.  In  other  words,  though  communicable,  they  are 
not,  strictly  speaking,  contagious. 

Syphilis,  influenza,  and  malaria  have  not  been  included  in  either  of  the 
above  groups.  Syphilis  must  still  be  placed  in  the  doubtful  class,  although 
its  general  characteristics  ally  it  with  the  second  group.  The  fact  that  a 
certain  germ — Lustgarten's  bacillus — is  quite  uniformly  found  in  syphi- 
litic lesions  also  points  in  the  same  direction ;  the  evidence,  however, 
is  not  conclusive  that  this  bacillus  is  the  cause  of  the  disease.  In  its 
communicability,  influenza  resembles  the  first  group,  although  there  is 
now  little  doubt  that  it  is  due  to  a  form  of  bacteria — Pfeiffer's  bacillus. 

887 


ggg  THE   SPECIFIC   INFECTIOUS   DISEASES. 

Malaria  belongs  in  a  class  by  itself,  differing  in  nearly  all  its  essential 
features  from  the  other  diseases  of  this  general  group,  as  its  specific 
poison  is  known  to  be  a  form  of  protozoa. 


CHAPTER   I. 

SCARLET  FEVER. 
Synonym :  Scarlatina. 

Scarlet  fever  is  an  acute,  contagious,  self-limited  disease,  one  attack 
usually  protecting  the  individual  through  life.  The  period  of  incubation 
is  usually  from  two  to  six  days ;  that  of  invasion,  from  twelve  to  twenty- 
four  hours ;  that  of  eruption,  from  four  to  six  days ;  that  of  desquamation, 
from  three  to  six  weeks.  The  disease  may  be  communicated  at  any  time 
from  the  first  symptom  of  invasion  throughout  desquamation,  and  some- 
times even  during  the  existence  of  purulent  discharges  from  the  nose  or 
other  mucous  membranes.  It  is  usually  ushered  in  by  vomiting,  high 
fever,  and  sore  throat,  and  is  characterized  by  an  erythematous  rash  ap- 
pearing first  upon  the  neck  and  spreading  rapidly  over  the  entire  body. 
Its  chief  complications  are  otitis  and  membranous  inflammations  of  the 
pharynx,  which  frequently  extend  to  the  nose,  more  rarely  to  the  larynx. 
The  most  important  sequelae  are  deafness  and  nephritis. 

Etiology. — Analogy  leads  to  the  belief  that  scarlet  fever  is  due  to  a 
micro-organism,  but  as  yet  its  nature  has  not  been  discovered.  The  com- 
plications are  usually  associated  with  the  growth  of  the  streptococcus 
pyogenes.  Some  have  gone  so  far  as  to  claim  that  this  germ  is  the  cause 
of  the  disease.  From  present  knowledge,  however,  it  appears  rather  to 
play  the  role  of  a  secondary  or  accompanying  infection,  for  the  develop- 
ment of  which  the  mucous  membranes  of  a  person  suffering  from  scarlet 
fever  seem  to  afford  most  favourable  conditions.  To  the  streptococcus 
may  be  ascribed  the  membranous  inflammations  of  the  tonsils  and  pharynx, 
the  otitis,  the  inflammation  of  the  lymph  nodes  and  the  cellular  tissue  of 
the  neck,  and  probabl}^  also  the  nephritis,  pneumonia,  and  joint  lesions. 
In  many  of  the  above  conditions,  the  streptococcus  is  associated  with 
other  pyogenic  germs,  and  in  some  cases  with  the  diphtheria  bacillus. 

Predisposition. — The  susceptibility  of  children  to  the  scarlatinal  poison 
is  much  less  than  to  that  of  measles ;  still,  it  is  much  greater  than  that  of 
adults.  Billington  (New  York)  records  observations  made  in  twenty-six 
families  living  in  tenements  where  little  or  no  attempt  at  isolation  was  made. 
In  these  families  there  occurred  43  cases  of  scarlet  fever ;  but  47  other  chil- 
dren, although  unprotected  by  previous  attacks  and  constantly  exposed, 
did  not  contract  the  disease. 

Johannessen  reports  that  of  185  children  under  fifteen  years  who  were 


SCARLET   FEVER.  889 

exposed,  28  per  cent  contracted  the  disease ;  while  of  314  adults,  only  5  per 
cent  contracted  the  disease.  It  may  be  stated  that,  approximately,  not 
more  than  one  half  of  the  children  exposed  take  the  disease.  The  sus- 
ceptibility is  not  great  in  early  infancy,  but  it  increases  until  about  the 
fifth  year,  after  which  it  steadily  diminishes.  Both  sexes  are  equally 
liable  to  scarlet  fever.  Epidemics  are  more  frequent  in  the  fall  and  win- 
ter than  in  summer,  and  cases  occurring  in  the  cold  months  are  apt  to  be 
more  severe.  Whitelegge,  in  6,000  cases,  found  the  highest  mortality  in 
the  month  of  October ;  and  in  Caiger's  report  of  1,008  cases  this  was  also 
the  month  showing  the  greatest  mortality. 

Incubation. — Of  113  cases*  in  which  the  period  of  incubation  could 
be  accurately  determined,  it  was  as  follows : 


24  hours  or  less 6  cases. 

2  days 15  " 

3  "     28  " 

4  "     25  " 

5  "     G  '• 

6  "     15  " 

7  ••     8  " 


8  days 2  cases. 

9  •'      5     " 

11  ''      1  case. 

14  •'      1     " 

21  "      1     " 

113  cases. 


Thus  in  87  per  cent  of  these  it  was  between  two  and  six  days,  and  in 
66  per  cent  between  two  and  four  days.  The  incubation  is  rarely  over  a 
week ;  it  is  particularly  short  in  surgical  cases,  a  well-authenticated  in- 
stance being  on  record  in  which  it  was  but  six  hours.  Speaking  gener- 
ally, if,  after  exposure,  a  week  passes  without  symptoms,  the  chances  of 
infection  are  very  small.  A  short  incubation  is  more  frequently  seen  in 
severe  than  in  mild  cases. 

Mode  of  infection. — The  chief  source  of  infection  is  the  patient  him- 
self. It  is  somewhat  doubtful  whether  the  poison  of  scarlet  fever  can  be 
conveyed  by  the  breath,  but  it  may  be  by  discharges  from  the  mucous 
membranes  involved,  from  the  scales  during  desquamation,  and  probably 
from  all  the  excretions, — urine,  faeces,  and  perspiration  of  the  patient. 
Infection  often  takes  place  from  the  carpets  or  furniture  of  the  sick-room, 
and  from  the  clothing  of  the  patient.  In  a  city  the  bed-clothing,  while 
airing  in  the  window,  has  been  known  to  convey  the  disease  to  an  adjoin- 
ing house.  Instances  are  recorded  of  the  spread  of  scarlet  fever  by  the 
washing  of  infected  with  other  clothing.  Toys  or  books  may  be  carriers 
of  the  disease.  A  bouquet  of  flowers  sent  from  a  sick-room  to  an  institu- 
tion, in  one  instance  proved  a  vehicle  of  infection.  Cats,  dogs,  and  other 
domestic  animals  are  known  to  have  conveyed  the  disease.  Scarlet  fever 
is  sometimes  spread  by  food,  particularly  by  milk,  as  in  the  well-known 
epidemics  of  Hendon  and  Wimbledon  (England).     It  is  possible,  under 

*  Part  of  these  are  from  personal  observation,  but  the  great  majority  are  isolated 
cases  scattered  through  medical  literature,  occurring  under  circumstances  which  made 
it  possible  to  determine  the  exact  length  of  incubation. 


890  THE   SPECIFIC   INFECTIOUS  DISEASES. 

these  circumstances,  that  a  disease  resembling  scarlatina  existed  in  the 
cows ;  but  that  this  was  identical  with  scarlatina,  as  seen  in  man,  was  not 
demonstrated. 

The  transmission  of  the  disease  through  a  third  party  is  not  frequent, 
but  numerous  instances  of  it  are  on  record.  The  persons  most  likely  to 
carry  it  are  the  nurse  and  the  physician.  Physicians  have  in  many  cases 
carried  scarlatina  to  their  own  children,  but  only  when  there  had  been 
pretty  direct  contact  with  the  patient,  and  where  the  interval  before  seeing 
the  second  child  was  short.  The  clothing  of  the  nurse  may  be  almost  as 
infectious  as  that  of  the  patient.  The  transmission  of  the  disease  by  one 
who,  although  living  in  the  house,  does  not  come  in  contact  with  the 
patient  is  extremely  improbable.  I  can  find  no  instance  recorded  where 
scarlatina  has  been  transmitted  tliroagh  two  healthy  persons. 

Duration  of  the  infective  jyeriod. — There  is  no  evidence  to  show  that 
the  disease  is  cominunicable  during  the  period  of  incubation.  It,  how- 
ever, becomes  so  from  the  beginning  of  invasion,  even  before  the  rash 
appears.  Infection  is  doubtless  most  active  during  the  febrile  period — 
from  the  second  to  the  fifth  day— and,  next  to  this,  during  the  stage  of 
active  desquamation. 

In  simple  cases,  the  average  duration  of  the  contagious  period  may  be 
placed  at  six  weeks,  or  until  desquamation  is  complete.  However,  physi- 
cians generally  have  been  accustomed  to  place  too  much  stress  upon  the 
danger  from  the  scales,  and  too  little  upon  that  from  the  discharges  from 
the  mucous  membranes.  Early  infection  comes  chiefly  from  the  throat, 
nose,  or  possibly  the  breath.  Late  infection  may  arise  from  a  purulent 
otitis,  rhinitis,  chronic  pharyngitis,  suppurating  glands,  eczema,  empyema, 
and  possibly  also  from  the  urine  in  nephritis.  The  infectious  nature  of 
these  purulent  discharges  has  not  been  sufficiently  recognised.  It  is  pos- 
sible for  them  to  convey  the  disease  during  a  period  of  several  months. 
One  case  is  recorded  in  which  scarlatina  was  communicated  through  a 
purulent  nasal  discharge  after  eleven  weeks ;  another  in  which  the  open- 
ing of  a  post-scarlatinal  empyema  in  a  surgical  ward  was  followed  by  an 
outbreak  of  scarlet  fever. 

In  winter  especially,  a  chronic  pharyngeal  catarrh  may  long  contain 
the  germs  of  infection.  Ashby  found,  on  careful  investigation,  that  from 
two  to  four  per  cent  of  patients  discharged  from  a  scarlet-fever  hospital 
subsequently  conveyed  the  disease.  There  is  particular  danger  from  a 
child  who  has  recently  had  the  disease  sleeping  with  other  children. 
Line  records  a  case  in  which  this  was  the  means  of  conveying  the  disease 
after  fourteen  weeks,  and  when  the  patient  had  been  considered  perfectly 
well  for  three  weeks.  It  is  impossible  to  say  that  at  any  specified  time 
absolute  safety  exists.  All  patients  before  being  discharged  from  a  hospi- 
tal or  released  from  quarantine  in  private  practice,  should  be  carefully 
examined  as  to  the  condition  of  the  mucous  membranes,  and  quarantine 


SCARLET   FEVER.  39I 

continued  as  long  as  catarrhal  inflammations  are  present.  The  poison  of 
scarlatina  clings  more  tenaciously  to  clothing,  upholstery,  and  apartments 
than  that  of  any  other  contagious  disease,  possibly  excepting  tuberculosis. 
Authentic  cases  are  on  record  in  which  more  than  a  year  had  elapsed 
between  the  first  and  second  cases,  where  the  source  of  infection  seemed 
certain. 

Lesions. — The  only  essential  lesions  of  scarlet  fever  are  those  of  the 
skin  and  the  mucous  membrane  of  the  throat.  The  other  changes  occur- 
ring in  this  disease  are  considered  in  the  light  of  Complications,  under 
which  head  they  are  described. 

The  earliest  changes  in  the  skin  consist  in  an  intense  hyperaemia  with 
dilatation  of  all  the  small  blood-vessels ;  following  this,  there  is  an  exu- 
dation of  round  cells  into  the  rete  Malpighii,  and  considerable  swelling, 
due  partly  to  the  exudation  of  cells  and  partly  to  oedema.  There  are  also 
thickening  of  the  lining  membrane  of  the  sweat  ducts,  and  infiltration 
about  these  ducts  with  round  cells.  In  some  cases  there  is  destruction 
of  the  epithelium  lining  the  sweat  ducts,  and  the  lumen  of  the  duct  is 
filled  with  granular  detritus,  occasionally  with  blood.  The  local  process 
results  in  death  of  the  epidermis,  which  is  cast  off  during  desquamation. 
It  is  essentially  an  acute  dermatitis,  which  varies  in  intensity  with  the 
severity  of  the  attack.  The  only  constant  lesion  in  the  throat  is  an  ery- 
thematous pharyngitis,  with  the  usual  changes  of  a  catarrhal  inflammation. 

Symptoms. — Invasion. — As  a  rule,  the  invasion  of  scarlet  fever  is  ab- 
rupt, the  symptoms  at  the  onset  usually  being  directly  in  proportion  to 
the  severity  of  the  attack.  In  the  majority  of  cases  there  are  vomiting,  a 
rapid  rise  in  temperature,  and  soreness  of  the  throat.  Often  the  vomiting 
is  repeated ;  it  is  frequently  forcible,  and  without  nausea.  In  severe  cases 
the  rise  in  temperature  is  very  rapid,  to  104°  or  105°  F. ;  in  the  mildest 
cases  it  may  not  be  above  101°.  A  child  may  complain  of  soreness  of 
throat,  or  the  throat  symptoms  may  be  entirely  objective.  In  most  severe 
cases,  there  is  a  uniform  erythematous  blush  covering  the  pharynx,  tonsils, 
and  fauces,  but  on  the  hard  palate  consisting  of  minute  red  points.  The 
appearance  of  this  is  usually  coincident  with  the  rise  in  temperature. 
Occasionally  membranous  patches  may  be  seen  upon  the  tonsils  the  first 
day,  but  not  generally  before  the  third  or  fourth  day  In  mild  cases  the 
throat  shows  only  a  very  moderate  congestion,  and  in  some  presents  noth- 
ing abnormal.  Severe  cases  are  sometimes  ushered  in  by  convulsions, 
especially  in  very  young  children.  Diarrhoea  is  not  nncommon  in  sum- 
mer. There  is  general  prostration,  which  is  directly  proportionate  to  the 
height  of  the  fever. 

Eruption. — This  usually  appears  from  twelve  to  thirty-six  hours  after 
the  first  symptoms  of  invasion ;  exceptionally,  not  until  the  third  or  even 
the  fifth  day.  A  later  appearance  than  this  is  somewhat  doubtful,  for  the 
rash  not  infrequently  recedes  and  reappears,  having  been  overlooked  in 


892  THE   SPECIFIC   INFECTIOUS   DISEASES. 

the  first  instance.     In  108  cases  observed  in  the  New  York  Infant  Asylum, 
the  duration  of  the  rash  was  as  follows : 

Two  days  or  less 5  cases. 

Three  to  seven  days 81      '" 

Eight  to  eleven  days 16      " 

Over  eleven  days 4     " 

Recurring 2     " 

These  statistics  are  confirmed  by  the  observations  of  most  writers,  that 
the  rash  lasts  from  three  to  seven  days.  The  full  development  of  the  rash 
is  generally  seen  in  from  twelve  to  twenty-four  hours  from  its  first  appear- 
ance, and  not  infrequently  the  whole  body  is  covered  in  the  course  of 
four  or  five  hours.  Very  rarely  its  extension  is  so  slow  that  it  is  two  or 
three  days  before  the  body  is  covered.  Its  first  appearance  is  almost  in- 
variably upon  the  neck  and  chest.  Where  the  rash  is  faint,  it  is  some- 
times earliest  and  most  intense  over  the  sacrum,  buttocks,  and  back  of 
the  thighs.  In  the  cases  of  moderate  severity  the  typical  rash  is  seen.  It 
is  of  a  bright  scarlet  colour,  and  on  close  inspection  is  seen  to  be  made 
up  of  very  minute  points ;  it  covers  the  entire  body,  including  the  face. 
There  is  often  a  peculiar  pallor  about  the  mouth,  in  striking  contrast  with 
the  rest  of  the  face,  which  is  quite  characteristic  of  the  disease. 

Variations  in  the  eruption  are  very  frequent,  and  often  extremely  puz- 
zling. In  the  mild  cases  the  rash  is  not  seen  upon  the  face ;  it  is  often 
faint  upon  the  body,  and  may  be  present  only  upon  certain  parts ;  it  may 
last  only  one  day,  and  sometimes  may  be  so  slight  as  to  escape  notice 
altogether.  It  may  be  absent  in  some  very  mild  cases,  in  certain  others 
where  the  throat  symptoms  are  severe,  and  in  malignant  cases.  In  the 
very  severe  cases  many  irregularities  are  seen,  both  as  to  the  time  of  the 
appearance  of  the  eruption  and  its  character.  Sometimes  it  occurs  as 
large,  irregular  patches;  at  others  it  is  macular,  closely  resembling  the 
rash  of  measles ;  occasionally  it  is  of  a  dark  purplish  colour ;  and  vei-y 
rarely  it  is  haemorrhagic.  An  eruption  of  fine  miliary  vesicles  has  been 
observed  in  connection  with  a  fully- developed  rash.  Much  importance  is 
attached  by  the  laity  to  the  early  disappearance  of  the  rash,  an  especial 
danger  being  believed  to  exist  because  the  disease  has  "  struck  in."  A 
well-developed  bright  scarlet  rash  indicates  strong  heart  action,  and  a 
sudden  recession  of  the  rash  is  a  sign  of  heart  failure.  Often  a  rash  which 
is  faint  and  doubtful  in  character,  may  be  brought  out  fully  by  a  hot  bath. 

With  the  eruption  at  its  height,  there  is  intense  itching  or  burning  of 
the  skin,  and  in  severe  eases  considerable  swelling,  chiefiy  noticeable  upon 
the. hands  and  face.  All  the  constitutional  symptoms  increase  in  intensity 
as  the  rash  develops,  and  usually  diminish  gradually  as  it  fades. 

Desquamation. — Shortly  after  the  rash  has  faded  there  is  an  exfolia- 
tion of  the  dead  epidermis,  known  as  desquamation.  This  is  even  more 
characteristic  of  the  disease  than  the  rash.     It  is  usually  first  seen  upon 


SCARLET  FEVER. 


893 


the  neck  and  chest,  where  it  appears  as  fine  scales  or  small  patches. 
The  desquamation  of  the  trunk  is  completed  in  from  one  to  three  weeks. 
If  baths  and  inunctions  are  being  used,  it  is  scarcely  perceptible.  It 
continues  longest  where  the  epidermis  is  thickest — viz.,  upon  the  hands 
and  feet — and  here  it  lasts  from  three  to  six  weeks,  and  not  infrequently 
eight  weeks.  The  appearance  of  the  fingers  and  toes  during  desquama- 
tion is  characteristic.  The  finger  tips  usually  peel  first,  and  the  new 
epidermis  is  pink  and  fresh-looking,  while  that  which  has  not  yet  sepa- 
rated is  of  dull  gray  colour  and  loosened  at  the  margin.  Occasionally  the 
epidermis  of  a  considerable  part  of  a  finger  may  be  loosened  at  once,  so 
that  a  partial  cast  may  be  thrown  off  like  the  finger  of  a  glove.  Some- 
times the  patient  comes  under  observation  for  the  first  time  during  des- 
quamation, the  history  of  the  early 
symptoms  being  doubtful  or  ab- 
sent. Such  desquamation  as  has 
been  described,  occurring  both 
upon  the  hands  and  feet,  may  be 
regarded  as  conclusive  evidence 
of  scarlet  fever,  no  matter  what 
the  history  may  be. 

1.  The  mild  cases. — The  symp- 
toms may  be  so  slight  as  to  be 
entirely  overlooked,  nothing  be- 
ing noticed  until  desquamation 
occurs.  Usually,  however,  there 
is  a  rather  abrupt  invasion,  with 
vomiting  and  a  temperature  of 
100°  to  103°  F.  The  tonsils  and 
pharynx  are  congested,  while  the 
palate  shows  a  punctate  redness 
somewhat  like  the  cutaneous 
eruption.  Nearly  always  within 
twenty-four  hours  the  rash  makes  its  appearance,  generally  first  upon  the 
neck  and  chest.  Very  often  it  is  not  seen  upon  the  face,  but  the  rest  of 
the  body  is  usually  covered.  The  rash  fades  on  the  third  or  fourth  day, 
and  has  disappeared  by  the  fifth  day.  There  is  very  little  prostration,  the 
child  often  being  with  difficulty  kept  in  bed. 

The  highest  temperature  is  coincident  with  the  full  eruption,  and  is 
seen  during  the  first  thirty-six  hours  of  the  disease.  It  gradually  falls  to 
normal  by  the  fourth  or  fifth  day.  Its  typical  course  is  shown  in  Fig. 
154.  In  the  mildest  cases  the  temperature  may  never  be  above  100°  F., 
and  the  rash  may  last  but  one  day,  and  even  then  may  come  out  very 
imperfectly  and  over  only  a  portion  of  the  body — the  chest  or  the  loins. 

Desquamation  is  often  faint  over  the  body,  but  is  unmistakable  over 


DAY  OF 
DISEASE 

1 

2 

3 

4 

5 

6 

7 

3 

9 

.    E. 

M. 

E. 

M. 

E. 

m.Ie. 

M. 

E. 

H. 

E. 

M 

E. 

n,|e. 

m.;e. 

H.JE. 

104  °      - 

, 

k 

\ 

to 

^ 

H 

u 

A 

FAHR 

/' 

( 

/ 

I 

A 

100  °    - 

\ 

n 

,/ 

A 

/ 

\, 

;/ 

\ 

99  ° 

V 

^ 

V 

«^ 

'\ 

^ 

/ 

98  ° 

I 

Fig.  154. — Typical  temperature  curve  of  mild  scar- 
let fever ;  uncomplicated ;  in  a  child  three 
years  old. 


894 


THE  SPECIFIC   INFECTIOUS  DISEASES. 


the  hands  and  feet.  It  begins  about  the  end  of  the  first  week,  always 
being  most  marked  where  the  eruption  has  been  most  intense. 

The  mild  cases  are  usually  uncomplicated,  but  the  possibility  of  otitis 
and  of  late  nephritis  should  always  be  kept  in  mind,  as  these  may  occur 
even  with  the  mildest  attacks.  The  difficulties  in  diagnosis  in  mild  at- 
tacks of  scarlet  fever  are  often  great.  It  should  be  remembered  that  these 
cases  are  just  as  contagious  as  severe  ones,  and  that  from  a  mild  attack  a 
severe  one  is  often  contracted.  It  is  frequently  by  these  mild  cases  that 
this  disease  is  spread  in  schools.  In  dispensaries  I  have  often  seen  pa- 
tients desquamating  from  scarlet  fever,  who  had  been  attending  school 
regularly  up  to  the  time  when  they  were  brought  for  treatment  for  ne- 
phritis or  some  other  disease. 

2.  Cases  of  moderate  severity. — The  onset  is  sudden  with  vomiting, 
which  is  usually  repeated,  or  with  convulsions.      The  temperature  rises 


DAV 

1 

3 

4 

5 

C        7 

s 

9 

10 

11 

12 

13 

11 

15  1 

10 

17 

18 

, 

»    E 

M 

E 

M 

E 

M     E 

M    E    r 

E     M 

E 

M 

E 

M 

E 

M     E 

M    E 

M 

E 

M     E 

M     E 

M 

E   ^ 

E 

H 

E 

M    E 

I 
X 

< 

105°  - 
104°  - 
103°  - 

n 

/' 

; 

r~ 

; 

J 

t 

f 

1 

\        i 

\ 

/ 

u 

J 

1 

Ij 

Tj 

E 

vf 

S 

1 

|\ 

J 

\\ 

/ 



_ 

_ 

1 





-'V 

_ 

_ 





_ 





—i 

_ 

102°  - 

— 

— 

~1 

zp 

--^ 

— 

9 

t^ 

^ 

A 

— 

'— 

— r 

' 

-^ 

^ 

\ 

t 

101°  - 

\ 

V 

A 

1^ 

It 

; 

f 

\ 

/' 

/ 

.          1 

/ 

100°  - 

99°  - 
98°  - 

1 

1 

7 

\-^^ 

./ 

V 

V 

, 

i     / 

w 

■^ 

y 

t 

'^ 

V 

^ 

^ 













, 

1 









Fig.  155. — Moderately  severe  scarlet  fever,  running  a  prolonsed  course,  but  -svithout  complica- 
tions ;  the  patient,  a  boy  two  and  a  half  yeans  old. 

rapidly,  and  by  the  end  of  the  first  twenty-four  hours  has  reached  104°  or 
105°  F.  The  rash  usually  appears  within  the  first  twenty-four  hours,  and 
its  intensity  is  directly  proportionate  to  the  severity  of  the  attack.  Ap- 
pearing first  upon  the  neck  or  chest,  it  extends  rapidly,  covering  the  entire 
trunk,  extremities,  and  often  the  face  in  a  few  hours.  It  is  usually  typical 
in  appearance,  being  made  up  of  minute  points,  but  giving  the  appearance 
of  a  uniform  blush,  which  has  been  compared  to  a  boiled  lobster.  Little 
change  takes  place  in  the  rash  for  four  or  five  days.  After  this  it  fades 
quite  rapidly,  and  disappears  by  the  seventh  or  eighth  day. 

The  throat  resembles  that  of  the  mild  form,  except  that  the  redness  is 
more  intense  and  there  is  slight  swelling  of  the  tonsils,  fauces,  and  uvula, 


SCARLET  FEVER.  895 

and  often  pain  upon  swallowing.  Occasionally  small  yellowish  patches  are 
seen  upon  the  tonsils  by  the  second  or  third  day,  but  these  can  be  wiped 
off  and  are  not  distinctly  membranous.  There  is  usually  a  moderate 
discharge  of  a  sero-purulent  character  from  the  nose.  The  lymphatic 
glands  at  the  angle  of  the  jaw  are  swollen  and  quite  tender.  The  tongue 
shows  first  a  white,  frosty  coating,  and  after  a  few  days  may  clear  at  the 
border.  The  intense  redness  at  the  tip  and  margin  of  the  tongue,  with 
the  enlarged  papillae,  gives  rise  to  what  is  known  as  the  "  strawberry 
tongue,"  which,  though  not  peculiar  to  scarlet  fever,  is  a  very  frequent 
symptom. 

During  the  height  of  the  fever  there  are  restlessness,  thirst,  and  not 
infrequently  slight  delirium.  The  temperature  reaches  the  maximum  by 
the  second  or  third  day,  and  usually  falls  gradually  after  the  fourth  or 
fifth  day,  but  even  in  uncomplicated  cases  the  fever  often  lasts  from  ten 
to  fourteen  days  (Fig.  155).  The  pulse  in  the  early  part  of  the  disease  is 
rapid  and  full,  but  later  it  may  be  w^eak.  There  is  much  prostration,  fre- 
quently followed  by  quite  a  marked  degree  of  anaemia. 

This  form  of  the  disease  rarely  proves  fatal  apart  from  complications, 
but  it  may  do  so  in  very  young  infants.  The  complications  seen  most 
frequently  in  this  form  of  scarlet  fever  are  broncho-pneumonia  or  pleuro- 
pneumonia and  otitis,  the  latter  being  usually  double  and  occurring  be- 
tween the  sixth  and  the  fourteenth  days.  Nephritis  is  the  only  common 
sequel. 

3.  The  severe  cases. — The  severe  type  of  scarlet  fever  usually  declares 
itself  from  the  beginning.  The  incubation  is  short,  and  the  full  rash  may 
be  seen  within  a  few  hours  after  the  initial  symptoms.  It  covers  the  en- 
tire body,  including  the  face.  The  severity  of  the  infection  is  shown  by 
the  fact  that  the  temperature  is  higher  and  continues  for  a  longer  period, 
and  by  the  frequency  and  severity  of  the  complications,  particularly  those 
of  the  throat.  For  the  first  two  days  the  throat  presents  nothing  different 
from  what  is  seen  in  the  milder  cases.  By  the  third  or  fourth  day,  how- 
ever, membranous  patches  often  appear  on  the  tonsils,  and  spread  to  the 
soft  palate,  uvula,  and  pharynx,  sometimes  to  the  nose  and  through  the 
Eustachian  tube  to  the  ear,  rarely  to  the  larynx.  The  mucous  mem- 
brane of  the  mouth  is  intensely  congested,  and  often  partly  covered  by 
membrane ;  there  is  sordes  on  the  lips  and  teeth,  and  there  may  be  super- 
ficial ulcers,  which  bleed  readily.  The  glands  of  the  neck  swell  rapidly, 
often  to  a  great  size,  and  the  cellular  tissue  about  them  is  infiltrated.  The 
head  is  thrown  back  to  relieve  the  dyspnoea  which  the  pressure  from  this 
swelling  occasions.  There  is  an  abundant  discharge  from  the  nose  and 
mouth ;  the  breath  is  offensive,  often  fetid.  The  general  symptoms  are 
those  of  a  severe  septicaemia.  The  temperature  is  steadily  high,  usually 
between  103°  and  105°  F.,  the  fluctuations  being  usually  narrow  for  the 

first  week  or  ten  days.     In  cases  which  recover,  the  subsequent  course  is 
58 


896 


THE  SPECIFIC  INFECTIOUS  DISEASES. 


greatly  modified  by  the  presence  of  complications  (Fig.  loG).  The  fever 
generally  lasts  from  three  to  four  weeks.  In  fatal  cases  the  temperature 
may  be  steadily  high  till  death  (Fig.  157),  or  may  fluctuate  widely.  The 
pulse  is  rapid,  weak,  and  irregular.  There  is  complete  anorexia;  both 
food  and  stimulants  have  to  be  coaxed  or  forced  down.  There  is  low 
delirium  or  apathy,  and  sometimes  all  the  symptoms  of  the  typhoid  con- 
dition are  present. 

Signs  of  a  broncho-pneumonia  are  often  found  in  the  chest,  and  by  the 
end  of  the  first  week  or  early  in  the  second  the  ears  begin  to  discharge. 
The  urine  is  rarely  free  from  albnmih,  but  the  amount  present  is  not  usu- 
ally great ;  there  may  be  hyaline  and  epithelial  casts,  and  often  blood.  In 
some  cases  the  throat  symptoms  predominate ;  in  others,  those  of  general 
sepsis,  but  more  frequently  the  two  are  combined  and  are  directly  propor- 
tionate to  each  other.  In  still  other  cases,  instead  of  the  membranous  in- 
flammation, it  may  be  of  a  gangrenous  character,  and  extensive  sloughing 
may  take  place  in  the  throat,  and  even  in  the  cellular  tissue  of  the  neck. 

The  duration  of  the  symptoms  in  fatal  cases  is  from  six  to  fourteen 
days.  There  are  generally  increasing  prostration  and  finally  a  septic 
stupor,  with  death  from  exhaustion,  from  sudden  heart  failure,  or  from 
some  of  the  complications, — broncho-pneumonia,  pleurisy,  nephritis,  haem- 
orrhages following  sloughing,  laryngitis,  pericarditis,  or  endocarditis.  In 
cases  which  recover,  the  acute  symptoms  nearly  always  continue  for  a  full 


1        2        3    1    4        5        G        T        S        9       10      11       12      13      11      15      16       17      IS      I'J      20      21       22 

mIe    mIe   m|e|m|e    mIe    mIe    m|e  mIe   mIe   mIe   mIe   mIe   mIe  mIe   mIe   m|e   mIe    mIe   mIe   mIe   mIe    mIe 

t 
I 

z 

I 
< 

105 1 1 1 1    j    1    1    1 1 1— p-] L 

104°   ^-1 U^ 1 , 4-p-T \ ^-     1     1     1     ^h , 

I           t      ^                t- 

X     -      2        -.         -.3                                           =  = 

103^  — A~7\~A~^~"A~7rT^  v'^'^~rr — — n —  — — ^ 

T  .^    ^  .      ^V       F    ^n          ? 

c    ^^    SV    M     i    u          J                     zr                  = 

^"^  — V\  1^1  11  II      y  1 — T \ — \--h^ — ■ — -r^^ \ — 

tt                   t^-*      .    -ft    ,       5 

-^  ^  t  f   i       1 

'l       L    u     r?          F 

^      ^d    \i    i^ 

a    I    i 

100' ' 1 III! r-J i >— ' 1 1 

H=rrmT                             m 

99'                                                                                                                                                                   f                  FJ^'^^ 

\      i  "^  ^ 

Fig.  156. — Severe  scarlet  fever  complicated  by  double  otiti.s  and  nephritis ;  primary  fever  pro- 
longed ;  otitis  began  on  the  thirteenth  day  ;  nephritis  on  the  nineteenth  day  ;  recovery  ;  the 
patient  a  girl  twenty  months  old. 

month ;  and  after  escaping  the  dangers  of  sepsis  and  the  early  complica- 
tions, the  child  has  still  to  run  the  gantlet  of  all  the  late  complications — 
nephritis,  pneumonia,  endocarditis,  pyaemia,  etc.     A  case  may  prove  fatal 


SCARLET  FEVER. 


897 


as  late  as  the  end  of  the  seventh  week ;  nearly  all  such  results  are  due  to 
nephritis  or  to  its  complications. 

4.  Malignant  or  cerebral  cases. — These  are  rare  cases  which  are  more 
frequently  described  than  seen, 
and  in  which  death  takes  place 
usually  within  the  first  forty- 
eight  hours.  The  system  is  over- 
powered by  the  scarlatinal  poison. 
Such  cases  are  seen  only  in  severe 
epidemics.  Under  other  circum- 
stances, many  cases  of  unexpect- 
ed death  with  high  temperature 
are  diagnosticated  malignaut 
scarlet  fever  which  have  no  con- 
nection with  this  disease. 

The  onset  is  sudden  and  vio- 
lent, usually  with  convulsions, 
the  child  passing  in  a  few  hours 
into  a  condition  of  deep  stupor, 
with  great  prostration  and  hyper- 
pyrexia, the  temperature  ranging 
from  105°  to  107°  F.  The  rash 
appears  irregularly,  late,  or  not 
at  all.  There  are  frequently  re- 
peated convulsions,  cyanosis,  and 
invariably  a  fatal  termination. 
The  autopsy  often  gives  no  satis- 
factory explanation  of  these  cases.  Death  occurs  from  toxaBmia,  without 
any  characteristic  local  evidences  of  disease. 

5.  Surgical  scarlet  fever. — Patients  with  recent  wounds,  or  those  who 
have  been  subjected  to  surgical  operations,  are  peculiarly  susceptible  to  the 
scarlatinal  poison,  and  are  almost  certain  to  contract  the  disease  upon  ex- 
posure, unless  protected  by  a  previous  attack.  Whether  the  infection  takes 
place  directly  through  the  wound,  or  whether  the  susceptibility  depends 
upon  the  diminished  resistance  of  the  patient,  is  still  an  open  question. 
This  disease  doubtless  explains  some  of  the  unexpected  deaths  occurring 
after  minor  surgical  operations.  Scarlet  fever  may  occur  after  any  opera- 
tion, even  one  so  trivial  as  tenotomy  or  circumcision.  Patients  with 
burns  are  generally  believed  to  be  especially  susceptible.  The  effect  of 
scarlet  fever  upon  the  wound,  and  some  of  its  peculiar  clinical  features, 
are  illustrated  by  the  following  cases  from  "Walton  Browne  (Belfast) : 

A  healthy  child  was  operated  upon  for  hare-lip ;  sixteen  hours  after- 
ward it  became  seriously  ill,  the  skin  was  covered  with  a  dark  scarlatinal 
rash,  and  death  quickly  followed.     Another  patient  who,  it  was  afterward 


DISEASE 

1 

2 

3 

4 

6 

6 

7 

3 

9 

M. 

E. 

M.  E. 

M 

5 

M. 

E. 

mJe. 

M  !e. 

m.Ie. 

m.Ie. 

M.  E. 

M.  E. 

107° 
106° 

105° 
S    104° 

X 

I  103° 

< 

li. 

102° 
101° 
100° 

1 

1 

1  / 

\i 

h\ 

j\\ 

A 

ll 

h 

f\ 

l\ 

J 

1 

/  \l 

/i 

/I 

/ 

1 

r 

A 

1/ 

1 

A 

1 

1 

1 

1 

/ 

/ 

l\ 

\ 

\    1 

/ 

/ 

T~ 

1 

;  1 

1/ 

— 

/ 

/ 

1  1 

1 

/ 

■ 

/ 

/ 

j 

1 

/ 

1 

Ul 

• 

1 

1 

1 

1 

\ 

1  1 

^ 

1 

. 

1 

Fig.  157. — Severe  scarlet  fever,  septic  type  ;  double 
otitis,  severe  meiiihranous  angina;  death  on 
the  ninth  day ;  the  patient  a  girl  seven  years 
old. 


898  THE  SPECIFIC   INFECTIOUS  DISEASES. 

learned,  had  been  recently  exposed  directly  to  scarlatina,  was  circumcised 
for  congenital  phimosis.  In  thirty  hours  he  was  covered  with  a  scarla- 
tinal rash  and  had  a  temperature  of  104°  F.  In  forty  hours  the  wound 
became  gangrenous  and  the  patient  passed  into  a  condition  of  coma,  in 
which  he  died  in  seventy  hours.  A  child  admitted  to  the  hospital  with  a 
lacerated  wound  of  the  leg  was  accidentally  placed  in  a  bed  next  to  one 
in  which  was  a  patient  who  had  just  developed  scarlatina.  The  exposure 
lasted  less  than  an  hour,  but  in  six  hours  the  child  was  taken  with  vom- 
iting, high  fever  and  headache,  became  rapidly  comatose,  and  died  in 
fifteen  hours,  no  rash  having  appeared.  After  death,  however,  a  purpuric 
rash  could  be  seen  upon  the  skin. 

Surgical  scarlatina  is  nearly  always  irregular  in  its  symptoms ;  the 
incubation  is  very  short,  the  rash  usually  atypical,  and  the  general  symp- 
toms, particularly  those  relating  to  the  nervous  system,  especially  severe. 
There  may  or  may  not  be  throat  symptoms.  It  should  be  said  that  many 
writers  deny  that  surgical  scarlet  fever  is  anything  more  than  septicaemia 
with  an  erythematous  rash.  This  is  undoubtedly  true  of  some  of  those 
reported  as  surgical  scarlet  fever;  but  it  certainly  is  not  the  explanation 
of  all.  That  some  of  these  are  cases  of  genuine  scarlet  fever  is  shown  by 
the  fact  that  they  have  been  known  to  communicate  that  disease,  and  that 
they  are  often  followed  by  nephritis  and  usually  by  desquamation,  although 
the  latter  is  not  invariable.  But  in  the  absence  of  throat  symptoms,  des- 
quamation, and  contagion,  the  diagnosis  of  scarlatina  should  be  made  with 
extreme  caution.  Care  should  be  taken  to  exclude  erythematous  eruptions 
due  to  the  various  antiseptics  used  in  surgical  dressings. 

Relapses,  Recurrences,  and  Second  Attacks. — As  a  rule,  one  attack  of 
scarlatina  gives  immunity  through  life.  The  exceptions  are  very  few,  but 
some  of  them  are  well  authenticated.  Kinnicutt  (New  York)  observed 
two  attacks  within  eight  months  in  a  boy  of  five  years;  Pritchai-d  (Glas- 
gow) reports  the  case  of  a  patient  who  had  three  attacks  in  the  same 
hospital  within  two  years ;  such  cases  are  certainly  extremely  rare. 

Relapses  or  recurrences  within  a  brief  period  after  the  first  attack  are 
more  frequent.  There  are  to  be  excluded  the  cases  of  pseudo-relapses  in 
which  the  rash,  having  temporarily  subsided  for  two  or  three  days,  reap- 
pears ;  also  those  where  the  rash  varies  in  intensity  from  time  to  time ; 
and,  lastly,  the  cases  in  which,  occurring  late  in  the  disease,  it  is  due  to 
septicemia  or  pysemia.  True  relapses  are  usually  due  to  auto-infection, 
sometimes  to  a  new  accession  of  poison  from  without.  They  are  analo- 
gous to  the  relapses  of  typhoid  fever.  They  occur  most  frequently  during 
desquamation,  between  the  seventh  and  twenty-fourth  days.  There  may 
be  not  only  a  new  eruption  but  a  rise  of  temperature,  sore  throat,  and 
vomiting,  just  as  in  the  initial  attack.  These  recurrences  are  sometimes 
shorter  and  milder  than  the  first  attack,  but  this  is  by  no  means  uniform, 
since  Korner  mentions  eight  cases  where  the  second  attack  proved  fatal. 


SCARLET   FEVER.  899 

In  considering  the  subject  of  second  attacks,  the  liability  to  errors  in 
diagnosis  must  be  borne  in  mind  and  only  cases  included  which  have  pre- 
sented typical  symptoms. 

Complications  and  Sequelae. — Throat. — Three  distinct  forms  of  angina 
are  seen  in  scarlatina :  simple  or  erythematous,  membranous,  and  gan- 
grenous. 

1.  Erythematous  angina. — This  can  hardly  be  ranked  as  a  complica- 
tion, as  it  is  nearly  as  constant  as  the  scarlatinal  rash.  Usually  there  is 
only  the  general  blush  over  the  entire  pharynx  with  the  fine  red  points 
upon  the  hard  palate ;  but  there  may  be  seen  upon  the  tonsils  grayish- 
yellow  spots  resembling  those  of  follicular  tonsillitis,  which  can  be  wiped 
off,  leaving  a  clean  surface.  This  simple  angina  is  at  its  height  with  the 
maximum  temperature,  and  fades  as  the  temperature  falls.  It  does  not 
often  extend  to  adjacent  mucous  membranes. 

2.  Membranous  angina. — These  cases  were  formerly  classed  as  scarla- 
tinal diphtheria,  and  whether  this  process  was  identical  with  primary 
diphtheria  or  not,  was  for  a  long  time  a  subject  of  much  discussion.  This 
question  has,  however,  been  settled  by  bacteriology.  It  is  now  generally 
agreed  that  the  membranous  angina  which  occurs  early  in  scarlet  fever, 
and  that  which  develops  at  the  height  of  the  disease,  are  almost  invari- 
ably due  to  the  streptococcus,  the  diphtheria  bacillus  being  rarely  found  ; 
but  that  the  cases  which  develop  late  in  the  disease,  and  after  the  primary 
fever  has  subsided,  are  almost  invariably  true  diphtheria,  the  bacillus  being 
regularly  present.  The  latter  condition  is  to  be  regarded  as  scarlet  fever 
complicated  by  diphtheria. 

The  lesions  of  this  form  of  angina  are  considered  in  the  chapter  on 
Pseudo-Diphtheria.  Usually  on  the  second  or  third  day  of  the  disease  the 
membrane  appears  upon  the  tonsils,  and  in  the  milder  cases  it  covers 
only  the  tonsils.  In  the  most  severe  form  it  may  be  seen  within  twenty- 
four  hours  of  the  onset,  frequently  before  the  eruption  appears.  Be- 
ginning upon  the  tonsils,  the  membrane  rapidly  spreads  to  the  entire 
pharynx,  the  mucous  membrane  of  the  nose,  the  mouth,  the  Eustachian 
tube,  and  even  the  middle  ear.  In  colour  it  may  be  gray,  greenish,  or  almost 
black.  There  is  so  much  swelling  of  the  throat  that  swallowing  becomes 
difficult.  The  infiltration  of  the  cellular  tissue  of  the  neck  and  the  enlarged 
lymphatic  glands  produce  great  external  swelling,  which  may  extend  like 
a  collar  from  ear  to  ear.  The  breath  has  a  foul  odour,  the  nasal  discharge 
is  thin  and  fetid,  and  nasal  respiration  is  obstructed,  so  that  the  mouth 
is  open  constantly.  Occasionally  the  larynx  is  invaded,  with  the  usual 
symptoms  of  membranous  croup. 

These  local  changes  are  accompanied  by  constitutional  symptoms  of 
great  severity,  which  are  due  to  a  general  streptococcus  septicemia ; 
broncho-pneumonia  and  nephritis  are  very  frequent,  otitis  is  almost  con- 
stant, and  suppuration  of  the  lymphatic  glands  is  not  uncommon. 


900         *  THE  SPECIFIC  INFECTIOUS  DISEASES. 

As  the  eruption  in  these  cases  is  late  and  often  very  irregular  in  ap- 
pearance, the  diagnosis  from  true  diphtheria  is  often  a  matter  of  great 
difficulty,  and  a  positive  diagnosis  is  possible  only  by  making  cultures 
from  the  throat. 

3.  Gangrenous  angina. — This  is  seen  only  in  the  worst  cases  of  scarlet 
fever.  The  process  may  be  gangrenous  from  the  outset,  or  preceded  by  a 
membranous  inflammation.  It  is  sometimes  insidious  in  its  development. 
There  is  a  fetid  odour  to  the  breath,  irritating  discharges  from  the  nose 
and  mouth,  with  very  great  glandular  swelling.  The  tonsils  are  gray  or 
grayish-black  in  colour,  and  large  masses  of  necrotic  tissue  may  be  re- 
moved with  the  forceps  from  the  tonsils,  uvula,  fauces,  or  pharynx,  and 
sometimes  sloughing  occurs  in  the  cellular  tissue  of  the  neck.  Blood- 
vessels of  considerable  size  are  often  opened,  and  serious,  or  even  fatal 
haemorrhage  may  result.  Little  or  no  tendency  to  a  reparative  process  is 
seen.  The  constitutional  symptoms  are  those  of  great  asthenia,  prostration, 
and  profound  cachexia,  followed  almost  invariably  by  a  fatal  termination. 

Lymph  nodes. — These  are  swollen  in  all  cases  accompanied  by  severe 
angina.  The  inflammation  may  be  simply  an  acute  hyperplasia,  or  it  may 
go  on  to  suppuration.  Abscess  does  not  often  occur  at  the  height  of  the 
■  disease,  but  may  come  at  any  time  during  convalescence.  It  may  be  con- 
fined to  the  glands  or  be  complicated  by  suppuration  in  the  cellular  tissue 
of  the  neck.  Disease  of  these  glands  is  not  an  infrequent  cause  of  torti- 
collis. 

Cellulitis  of  the  neck. — This  usually  occurs  toward  the  end  of  the  first 
week,  and  is  associated  with  grave  throat  symptoms.  Rapid  and  extensive 
infiltration  occurs,  the  skin  becomes  tense  and  brawny,  the  head  is  held 
back,  and  there  may  be  considerable  dyspnoea.  The  infiltration  may  be 
only  in  the  neighbourhood  of  the  lymphatic  glands  or  it  may  be  diffuse. 
Unless  relieved  by  early  incision,  the  diffuse  form  may  result  in  suppuration 
and  extensive  sloughing,  which  may  be  deep  enough  to  lay  bare  the  large 
vessels  of  the  neck.  This  is  a  complication  of  the  gravest  possible  im- 
port. Death  may  occur  from  septicaemia  before  or  after  sloughing  or 
from  hgemorrhage  due  to  opening  by  ulceration  of  the  external  carotid  or 
some  of  its  branches ;  or  there  may  be  associated  thrombosis  of  the  jugu- 
lar vein,  leading  to  thrombosis  of  the  lateral  sinus,  meningitis,  or  pyaemia. 

Ears. — The  otitis  is  due  to  direct  extension  of  the  infection  from  the 
rhino-pharynx.  It  is  the  most  frequent  complication  of  scarlatina,  and  in 
doubtful  cases  may  have  some  diagnostic  importance.  As  a  rule,  the 
younger  the  child  the  greater  the  liability  to  otitis.  It  is  more  frequent 
in  winter  than  at  other  seasons.  Like  all  complications,  it  varies  greatly 
with  the  epidemic,  and  is  closely  connected  with  the  severity  of  the  throat 
symptoms.  In  an  epidemic  occurring  in  the  New  York  Infant  Asylum 
in  the  spring  and  summer  of  1889  there  were  73  cases  of  scarlatina  and 
not  one  of  otitis.     In  a  fall  and  winter  epidemic  in  the  same  institution 


SCARLET  FEVER.  '  901 

two  years  later,  of  43  cases  20  per  cent  had  otitis.  Of  4,397  cases  re- 
ported by  Fiulayson,  otitis  occurred  in  10  per  cent,  and  of  1,008  cases 
reported  by  Caiger,  in  13  per  cent.  In  Burkhardt's  statistics  the  propor- 
tion was  as  high  as  33  per  cent.  Of  cases  accompanied  by  severe  throat 
symptoms  otitis  is  present  in  fully  75  per  cent. 

As  a  rule,  both  ears  are  affected,  but  not  simultaneously,  or  at  least 
rupture  occurs  at  different  times.  This  is  most  frequent  early  in  the  sec- 
ond week,  but  may  occur  during  convalescence.  In  the  cases  where  otitis 
develops  at  the  height  of  the  disease  there  are  in  some  cases  no  new  symp- 
toms ;  in  others  there  are  pain  and  deafness.  If  it  develops  at  a  later 
period  there  is  usually  a  rise  in  the  tempei-ature,  which  falls  after  rupture 
of  the  drum  membrane  takes  place.  The  otitis  is  sometimes  overlooked 
until  symptoms  of  pyemia  or  meningitis  develop.  The  form  of  inflam- 
mation may  be  catarrhal  or  suppurative  (page  880),  the  latter  being  often 
accompanied  by  necrotic  changes. 

Bezold  makes  the  following  report  upon  185  cases  showing  the  results 
of  scarlatinal  otitis  :  "  In  30  there  Avas  entire  destruction  of  the  membrana 
tympani,  with  loss  of  one  or  more  bones ;  in  59  the  perforation  comprised 
two  thirds  or  more  of  the  membrane ;  in  13  there  were  smaller  perfora- 
tions; in  44  there  were  granulations  or  polypi;  in  15  there  was  total  loss 
of  hearing  on  one  side,  and  in  6  of  the  cases  upon  both  sides ;  in  77  of 
the  cases  the  hearing  distance  for  low  voice  was  less  than  twenty  inches." 

As  a  cause  of  permanent  deafness  and  deaf-mutism,  no  disease  of  child- 
hood compares  in  importance  with  scarlet  fever.  May  (New  York)  has 
collected  statistics  of  5,613  deaf-mutes,  of  whom  573  owed  their  condition 
to  otitis  following  scarlet  fever. 

Kidneys. — Albuminuria  accompanies  nearly  all  the  severe  cases  of 
scarlet  fever.  In  many  this  is  simply  the  ordinary  febrile  albuminuria 
due  to  acute  degeneration  of  the  kidneys  (page  612).  In  those  with 
severe  throat  comjilications,  and  in  nearly  all  the  septic  cases,  there  is  an 
acute  inflammation  of  the  kidney,  usually  of  the  variety  described  as  acute 
exudative  nephritis  (page  613).  This  occurs  at  the  height  of  the  febrile 
process  and  is  rarely  accompanied  by  dropsy  ;  but  albumin,  casts,  and  even 
blood  may  be  found  in  the  urine.  The  most  severe  and  the  most  charac- 
teristic renal  complication,  and  that  generally  designated  as  post-sca7-Ia- 
tinal  7iephritis,  is  a  diffuse  nephritis  which  in  most  cases  develops  during 
the  third  week  of  the  disease.  It  is  accompanied  by  general  dropsy ;  the 
urine  is  scanty  and  not  infrequently  suppressed,  and  it  contains  a  large 
amount  of  albumin  and  great  numbers  of  casts  of  all  varieties.  It  may 
cause  death  by  the  occurrence  of  acute  urtemia,  or  it  may  be  followed  by 
permanent  damage  to  the  kidneys.  It  is  more  fully  described  with  the 
Diseases  of  the  Kidney  (page  615). 

Joints. — Acute  articular  rheumatism  may  occur  coincidently  with  the 
development  of  tlie  scarlatinal  rash,  and  occasionally  during  convalescence 


902  THE  SPECIFIC   INFECTIOUS  DISEASES. 

in  patients  who  have  a  predisposition  to  that  disease.  Acute  swelling  of 
the  joints  is  sometimes  of  pyaemic  origin.  A  case  is  reported  by  Henoch 
in  which  this  was  due  to  an  infectious  thrombus  in  the  jugular  vein,  asso- 
ciated with  cellulitis  of  the  neck.  In  pyemic  arthritis  the  large  joints  are 
usually  involved  and  the  lesions  are  apt  to  be  multiple.  Joint  disease 
may  occur  as  a  sequel  of  scarlet  fever,  where  it  is  secondary  to  disease  of 
the  bone  or  to  periarticular  abscesses  opening  into  the  joint. 

The  foregoing  include  but  a  small  proportion  of  the  joint  complica- 
tions seen  in  scarlet  fever.  The  most  frequent  and  most  characteristic 
form  of  inflammation  is  scarlatiiial  synovitis^  or,  as  it  is  sometimes  called, 
scarlati7ial  rheumatism.  It  occurs  in  different  epidemics  with  varying 
frequency.  Carslaw  (Glasgow)  in  533  cases  of  scarlet  fever  met  with  syno- 
vitis in  60  patients.  It  is  seldom  seen  in  children  under  three  years  of  age, 
and  is  most  frequent  after  five  years.  It  may  occur  in  mild  as  well  as 
in  severe  cases.  According  to  Ashby,  it  is  more  frequent  when  the  febrile 
stage  is  prolonged,  owing  to  other  complications.  Synovitis  develops  quite 
uniformly  toward  the  end  of  the  first  or  the  beginning  of  the  second 
week.  The  symptoms  are  generally  mild,  and  are  followed  by  prompt 
recovery.  Suppuration  is  rare.  Any  of  the  joints  may  be  attacked,  but 
those  of  the  wrist  and  hand  are  most  frequently  and  often  the  only  ones 
affected.  Demme  (Berne)  has  reported  a  case  in  which  every  large  joint 
in  the  body  was  involved.  The  symptoms  are  redness,  moderate  pain, 
swelling,  which  is  usually  due  to  synovial  distention,  and  sometimes  a 
slight  rise  of  temperature.  The  duration  is  generally  but  three  or  four 
days,  and  in  most  cases  there  is  spontaneous  recovery.  This  disease  is  dis- 
tinguished from  rheumatism  by  several  points :  it  is  not  more  frequent 
in  rheumatic  patients;  cardiac  complications  are  rare  as  compared  with 
those  seen  in  patients  with  genuine  rheumatism  ;  in  some  epidemics  it  is 
very  common,  and  in  others  seldom  seen ;  there  is  little  or  no  tendency 
to  relapses ;  anti-rheumatic  remedies  are  without  striking  benefit ;  it  does 
not  skip  about  from  joint  to  joint,  and  usually  fewer  joints  are  in- 
volved. 

Lungs. — The  pulmonary  complications  of  scarlet  fever  are  neither  so 
frequent  nor  so  important  as  those  of  measles.  Broncho-pneumonia  is 
usually  found  at  autopsy  in  septic  cases  where  death  has  occurred  later 
than  the  third  or  fourth  day,  but  it  is  not  generally  recognisable  by  phys- 
ical signs. 

In  septic  cases  pleuro-pneumonia  sometimes  occurs  early  in  the  disease 
and  at  other  times  late,  generally  associated  with  nephritis,  but  occasion- 
ally without  it.  It  is  always  a  serious  condition  and  not  infrequently  a 
direct  cause  of  death.  Empyema  may  follow  pleuro-pneumonia  or  occur 
with  pyaemia  or  nephritis,  but  with  the  latter,  simple  serous  pleurisy  is 
more  common.  (Edema  of  the  lungs  occurs  chiefly  with  nephritis,  in 
which  it  is  the  most  common  cause  of  death. 


SCARLET  FEVER.  903 

Heart. — Abnormal  cardiac  sounds,  not  dependent  upon  organic  lesions, 
are  frequent  during  the  height  of  the  disease.  Endocarditis  and  pericar- 
ditis are  not  common.  They  are  occasionally  seen  in  septic  cases  and  in 
those  complicated  by  pyaemia,  but  principally  as  a  complication  of  post- 
scarlatinal nephritis  or  in  rheumatic  patients.  Endocarditis  may  be 
simple  or  malignant,  and  may  be  the  cause  of  embolism  and  hemiplegia 
during  convalescence. 

A  certain  degree  of  degenerative  change  in  the  cardiac  muscle  is  found 
in  nearly  every  fatal  case  that  has  lasted  over  four  days.  More  marked 
evidence  of  toxic  myocarditis  is  not  infrequent  in  the  prolonged  cases  and 
in  those  of  a  septic  type.  This  may  be  follovred  by  acute  dilatation  of  the 
left  ventricle  or  of  the  entire  heart,  and  it  may  be  a  cause  of  sudden  death. 

Digestive  system. — Functional  disturbances  are  very  frequent,  and,  in 
fact,  are  seen  in  most  of  the  cases,  but  organic  changes  are  rare.  Vomit- 
ing is  the  mode  of  onset  in  the  majority  of  cases,  but  rarely  continues 
through  the  attack.  Late  in  the  disease  it  is  a  frequent  symptom  of  urae- 
mia. Diarrhoea  may  be  associated  with  it  under  both  conditions.  The 
tongue  is  nearly  always  coated,  and  clears  off  in  quite  a  characteristic  way, 
wiiich,  with  the  prominent  papillae,  gives  rise  to  the  "strawberry"  ap- 
jiearance.  Catarrhal  stomatitis  is  a  very  frequent  complication,  and  in 
many  cases  of  severe  membranous  angina  the  same  j^rocess  is  seen  in  the 
buccal  cavity. 

Xervous  system. — Nervous  complications  and  sequelae  are  seen  less 
frequently  with  scarlatina  than  with  most  of  the  infectious  diseases  of 
such  severity.  Convulsions  are  frequent  at  the  outset,  and  generally  in- 
dicate a  severe  attack,  though  not  invariably  so.  Occurring  late  in  the 
disease,  they  are  usually  due  to  uremia,  and  may  be  a  cause  of  death. 
Meningitis  may  occur  as  a  complication  of  otitis,  in  pyaemic  cases,  and 
sometimes  with  post-scarlatinal  nephritis.  Paralysis  from  peripheral 
neuritis  is  rarely  seen.  Hemiplegia  sometimes  occurs  from  meningeal 
hemorrhage,  or  from  embolism  secondary  to  endocarditis  and  associated 
with  nephritis.  Chorea  was  noted  as  a  sequel  in  only  three  of  533  cases 
reported  by  Carlslaw.  In  a  report  of  187  cases  of  epilepsy,  Wildermuth 
states  that  it  followed  scarlet  fever  in  12  cases.  Insanity  has  been  occa- 
sionally observed,  the  usual  form  being  acute  mania,  with  complete  recov- 
ery in  a  few  weeks  or  months. 

Gangrene. — Cases  of  symmetrical  gangrene  after  scarlet  fever  have 
been  reported  by  Wilson  and  others.  The  parts  generally  affected  are 
the  buttocks,  thighs,  and  arms,  but  it  may  occur  almost  anywhere.  The 
pathology  of  these  cases  is  obscure.  The  process  usually  begins  in  sev- 
eral places  simultaneously,  or  in  rapid  succession,  and  advances  steadily 
till  death  occurs. 

Other  infectious  diseases. — Scarlet  fever  is  not  very  infrequently  com- 
plicated by  other  forms  of  infectious  disease.     It  is  seen  with  diphtheria, 


904  THE  SPECIFIC   INFECTIOUS  DISEASES. 

measles,  varicella,  erysipelas,  and  occasionally  with  variola  and  typhoid 
fever.  The  symptoms  are  an  irregular  commingling  of  those  belonging 
to  the  two  diseases.  They  may  begin  simultaneously,  or  more  frequently 
one  develops  as  the  other  is  subsiding. 

Diagnosis. — The  characteristic  symptoms  of  scarlet  fever  are  the  abrupt 
onset,  usually  with  vomiting,  the  marked  elevation  of  temperature,  the 
erythematous  condition  of  the  throat,  and  the  appearance  of  the  rash 
within  twenty-four  hours.  Before  the  eruption  it  can  not  be  diagnosti- 
cated from  tonsillitis  or  many  other  diseases.  The  difficulties  of  diagnosis 
usually  depend  upon  irregularities  in  the  eruption,  both  as  to  the  time  of 
its  appearance  and  its  character.  Tliese  variations  are  seen  in  the  mild- 
est, and  in  the  most  severe  cases.  In  the  former  the  temperature  may 
not  be  above  100-5°  F.,  the  rash  may  last  less  than  a  day,  and  may  be  seen 
only  upon  the  chest  and  neck,  or  there  and  upon  the  loins,  but  very  often 
it  does  not  cover  the  trunk  and  extremities.  Nothing  is  positively  diag- 
nostic about  these  symptoms,  even  when  associated  with  some  degree  of 
redness  of  the  throat,  which  is  by  no  means  constant.  But  the  appearance 
after  them  of  desquamation  is  usually  conclusive.  In  some  cases,  how- 
ever, this  is  of  so  uncertain  a  character  that,  even  after  the  entire  course 
of  the  disease,  the  diagnosis  may  remain  in  doubt.  A  history  of  an  un- 
doubted exposure  within  a  week  prior  to  the  onset,  or  the  fact  that  other 
cases  of  scarlet  fever  subsequently  develop  in  the  family  or  hospital,  great- 
ly strengthens  the  diagnosis. 

Cases  of  malignant  scarlet  fever  which  prove  fatal  before  a  character- 
istic eruption  appears,  can  not  be  diagnosticated  with  certainty  ;  but  when 
such  cases  are  preceded  or  followed  by  others  of  a  typical  character,  the 
diagnosis  can  be  made  with  a  strong  degree  of  probability. 

The  form  of  the  disease  in  which  the  throat  symptoms  are  of  great 
severity  and  appear  early,  are  often  difficult  to  distinguish  from  true  diph- 
theria. Here  the  only  reliable  ground  of  distinction  is  that  afforded  by 
the  bacteriological  examination.  There  are,  however,  points  in  the  local 
appearances  which  are  of  some  assistance  in  the  absence  of  the  culture 
test.     These  are  discussed  in  connection  with  the  Diagnosis  of  Diphtheria. 

The  eruption  of  scarlet  fever  may  be  confounded  with  that  of  measles, 
rubella,  urticaria,  and  various  forms  of  erythema.  The  typical  eruption 
of  measles  has  little  that  suggests  scarlet  fever,  appearing  as  it  does  first 
upon  the  face  and  spreading  slowly  over  the  body ;  but  in  irregular  cases 
the  eruption  may  resemble  neither  disease.  The  diagnosis  must  then  rest 
upon  the  other  symptoms :  the  sudden  onset  with  vomiting  in  scarlet 
fever,  or  the  gradual  onset  with  marked  catarrhal  symptoms  in  measles. 
The  eruption  of  rubella  is  more  difficult  to  distinguish.  In  this  disease 
the  important  thing  is  that,  although  the  rash  may  be  well  marked,  often 
covering  the  body,  the  constitutional  symptoms  are  few  or  entirely  ab- 
sent.    In  scarlet  fever  with  an  eruption  of  the  same  intensity  there  is  in- 


SCARLET  FEVER.  905 

variably  a  considerable  elevation  of  temperature,  usually  102°  to  103°  F., 
and  a  bright  red  throat. 

There  are  so  many  skin  eruptions  which  may  resemble  that  of  scarlet 
fever,  that  it  is  always  hazardous  to  make  the  diagnosis  of  this  disease 
from  the  eruption  alone.  This  is  especially  true  of  sporadic  cases  occur- 
ring in  infants ;  there  is  seen  at  this  age  a  great  variety  of  eruptions, 
usually  associated  with  digestive  disturbances,  which  closely  simulate  a 
scarlatinal  rash ;  but  most  of  them  are  of  short  duration.  A  scarlatini- 
form  erythema  is  occasionally  seen  in  diphtheria,  influenza,  typhoid  fever, 
and  varicella,  which  may  cause  them  to  be  mistaken  for  scarlet  fever,  or 
may  lead  to  the  diagnosis  that  both  diseases  are  present.  The  same  is 
the  case  with  the  septic  erythema  occurring  in  surgical  patients.  Bella- 
donna, quinine,  and  occasionally  antipyrine,  may  produce  eruptions  more 
or  less  closely  resembling  that  of  scarlet  fever.  This  is  also  true  of  some 
cases  of  urticaria,  and  of  several  other  forms  of  skin  disease.  There  is 
little  doubt  that  many  of  the  cases  reported  as  relapsing  scarlatina  are 
really  examples  of  recurring  erythema,  particularly  as  some  of  the  latter 
are  followed  by  a  desquamation  which  is  very  similar  to  that  after  scar- 
latina. In  all  doubtful  conditions  great  importance  is  to  be  attached  to 
the  constitutional  symptoms. 

Prognosis. — The  mortality  of  scarlet  fever  varies  much  in  different 
epidemics.  In  some,  nearly  all  the  cases  are  of  a  mild  type,  and  the 
mortality  may  be  as  low  as  3  or  4  per  cent ;  in  others,  a  severe  or  malig- 
nant type  prevails,  and  it  may  be  as  high  as  40  per  cent.  The  disease  is, 
as  a  rule,  more  fatal  in  the  youngest  infants,  becoming  less  so  as  age  ad- 
vances. This  is  well  shown  in  two  recent  epidemics  in  the  New  York 
Infant  Asylum.     There  were — 

Under  one  year 29  cases  ;  mortality,  55  per  cent. 

From  one  to  two  years 37      "  "  22 

"      two  «  three  "    28     "  "  7       " 

Over  three  years 23     *'  "  0 

In  the  first  epidemic  the  general  mortality  was  12-5  per  cent;  in  the 
second  it  was  33  per  cent,  in  the  same  class  of  children. 

The  following  are  the  mortality  records  from  various  European 
sources : 

Ashby,  Manchester  Hospital 681  cases ;  mortality,  12  2  per  cent. 

Koren,  a  single  epidemic 426     "  "  14 '0 

Bendz,  Copenhagen 22,036     "  "  12-2       " 

OUivier,  three  Paris  hospitals  for  five  years       893     "  "  14*5       " 

Fleischmann,  five  epidemics 1,356     "  "10  0 

The  general  mortality  of  the  disease  may  therefore  be  assumed  to  be 
from  12  to  14  per  cent ;  it  is,  however,  much  higher  than  this  among 
young  children,  as  shown  by  the  following  figures : 


906  THE   SPECIFIC   INFECTIOUS  DISEASES. 

New  York  Infant  Asylum ...  116  cases  under  5  years ;  mortality,  20  per  cent. 
Ashby,  Manchester  Hospital .  259     "        "      5     "  "  23       " 

Bendz not  stated   "      5     "  "  13       " 

Heubner 136  cases     "      7     "  '•  30       " 

Fleischmann not  stated   "      4     "  "  43       " 

Under  five  years  of  age  the  average  mortality  from  scarlet  fever  is, 
therefore,  between  20  and  30  per  cent. 

The  fatal  cases  may  be  grouped  in  three  classes  :  first,  those  due  to 
late  nephritis,  in  which  the  early  symptoms  of  the  disease  are  of  moder- 
ate severity  or  even  mild  ;  secondly,  the  septic  cases,  usually  associated 
with  severe  throat  symptoms  and  dying  most  frequently  in  the  second 
week  from  exhaustion,  or  from  some  local  complication,  such  as  laryngitis, 
pneumonia,  pleurisy,  meningitis,  or  nephritis ;  thirdly,  the  malignant 
cases,  which  are  overpowered  by  the  poison  of  the  disease  in  the  first  two 
or  three  days  of  the  attack. 

Prophylaxis. — Even  the  mildest  cases  should  be  isolated  for  six  weeks, 
or  until  desquamation  is  completed.  If  complications  exist,  such  as  otitis, 
rhinitis,  pharyngitis,  empyema,  or  suppurating  glands,  the  quarantine 
should  be  continued  imtil  these  conditions  are  cured.  Patients  should  not 
be  allowed  to  mingle  with  other  children  for  at  least  a  month  after  all 
symptoms  have  subsided,  and  should  be  forbidden  to  sleep  with  other 
children  for  three  months.  Children  in  the  house  who  have  not  been 
exposed  to  the  disease  should  be  immediately  sent  away ;  and  those  who 
have  been  exposed,  separately  quarantined  for  at  least  a  week.  After 
recovery,'the  patient,  before  mingling  with  other  children,  should  have  at 
least  two  disinfectant  baths,  the  entire  body  being  scrubbed  with  soap  and 
water  and  then  washed  in  a  solution  of  carbolic  acid  (1  to  50)  or  bichloride 
(1  to  5,000),  and  every  particle  of  clothing  changed.  The  hair,  if  long, 
should  be  cut  short,  and  the  scalp  thoroughly  washed  and  disinfected. 

The  nurse  should  be  quarantined  with  the  patient,  and  should  not 
mingle  with  other  members  of  the  family  until  a  complete  change  of 
clothing  has  been  made,  and  hands  and  face  thoroughly  disinfected.  The 
nurse  and  all  others  in  close  contact  with  a  severe  case  should  use  an  anti- 
septic gargle  four  or  five  times  a  day  and  a  nasal  spray  at  least  twice  a  day. 

The  room  should  be  in  that  part  of  the  house  most  easily  quarantined, 
usually  on  the  top  floor ;  during  the  attack  it  should  be  stripped  of  up- 
holstery, hangings,  and  carpet,  should  be  freely  ventilated,  and  kept  as 
clean  as  possible,  the  floor  being  frequently  sprinkled  with  a  bichloride 
solution  (1  to  1,000).  The  presence  in  the  room  of  vessels  filled  with 
antiseptic  fluids  is  of  no  practical  value,  and  often  harmful,  in  that  it  cre- 
ates a  false  sense  of  security.  The  same  may  be  said  of  sheets  wet  in  car- 
bolic or  other  solutions  and  hung  about  the  room.  Carbolic-acid  poisoning 
has  been  known  to  result  from  this  practice.  After  an  attack  it  should 
be  remembered  that  the  room  is  probably  a  greater  source  of  danger  than 


SCARLET  FEVER.  907 

the  patient.  Smooth  walls  should  be  wiped  with  damp  cloths  wrung  out 
of  a  bichloride  solution  (1  to  2,000),  or  should  be  rubbed  down  very  care- 
fully with  bread.  The  wood-work  should  be  washed  in  the  same  solution 
and  the  floor  thoroughly  scrubbed  with  it.  After  a  severe  case,  the  walls 
should  be  painted  or  whitewashed,  or  if  papered,  the  wall-paper  should 
invariably  be  renewed  and  the  wood-work  repainted.  Simply  airing  a 
room  after  an  attack  is  of  little  or  no  benefit.  An  instance  is  on  record  of 
a  patient  contracting  the  disease  in  a  room  in  which  the  windows  had 
been  open  constantly  for  three  months.  The  carpets,  bedding,  hangings, 
and  upholstery  are  best  disinfected  by  steam.  Where  this  is  impossible, 
after  a  severe  case  they  should  be  burned  ;  after  milder  cases,  articles  which 
can  be  boiled  should  be  treated  in  this  manner,  and  others  exposed  to  sun- 
light for  a  long  time  out  of  doors,  or,  after  having  been  moistened,  should 
be  fumigated  with  sulphur  in  the  sick-room.  The  mattress  should  be 
burned.  As  ordinarily  employed,  sulphur  fumigation  is  of  very  doubtful 
efficacy,  and  should  never  be  alone  depended  upon. 

The  bedclothes,  linen,  and  clothing  removed  from  the  patient  during 
an  attack,  should  be  put  at  once  into  a  solution  composed  of  zinc  sul- 
phate, four  ounces,  common  salt,  two  ounces,  and  water,  one  gallon,  and 
afterward  boiled  at  least  two  hours  in  the  same  solution.  Instead  of 
handkerchiefs,  pieces  of  old  muslin,  surgeon's  gauze,  or  absorbent  cotton, 
should  be  used  for  cleansing  the  nose  and  mouth  of  the  patient  and 
burned  immediately. 

The  physician  in  attendance  upon  a  case  should  leave  his  coat  and 
overcoat  in  an  anteroom,  and  put  on  a  long  gown  or  rubber  coat,  button- 
ing tightly  at  the  neck  and  sufficiently  large  to  cover  all  his  clothing. 
This  should  always  be  worn  in  the  sick-room,  and  boiled  or  disinfected 
when  the  case  is  finished.  The  physician's  visit  should  not  be  unduly 
prolonged,  and  a  stethoscope  should  be  used  for  examining  the  chest. 
For  a  single  visit  the  overcoat  may  be  worn  in  the  room,  but  the  clothing 
should  be  changed  before  visits  to  other  children  are  made.  After  every 
visit  the  physician's  hands  and  face  should  be  thoroughly  washed  with 
soap  and  then  with  a  disinfectant  solution. 

A  physician  in  attendance  upon  scarlatinal  patients  should  not  attend 
obstetric  cases  or  otl\er  patients  with  recent  wounds.  The  great  liability 
of  such  cases  to  contract  scarlatina  should  never  be  forgotten.  If,  in 
emergencies,  it  becomes  necessary  to  attend  such  patients,  the  physician 
should  change  all  his  clothing  and  disinfect  his  hands,  face,  hair,  and 
beard,  with  the  greatest  thoroughness. 

Schools  are  the  hot-beds  for  the  spread  of  scarlet  fever.  The  greatest 
sources  of  danger  are  the  mild  or  walking  cases  in  which  the  disease  has 
not  been  recognised,  and  the  clothing  of  patients  who  have  had  a  severe 
form  of  the  disease.  As  a  rule,  a  child  should  be  kept  from  school  six 
weeks  from  the  beginning  of  the  attack,  and  the  certificate  of  a  physician 


908  THE  SPECIFIC  INFECTIOUS   DISEASES. 

should  be  required  before  re-admission,  stating  not  only  that  the  desqua- 
mation is  complete,  but  also  that  the  child  is  suffering  from  no  sequelee. 
Other  children  in  the  household  should  not  be  allowed  to  attend  schools 
of  any  kind  during  the  period  of  active  symptoms  ;  they  should  be  kept 
at  home  on  the  average  for  a  month.  This  precaution  is  necessary,  first, 
because  they  might  carry  the  disease  from  the  child  at  home ;  secondly, 
because  otherwise  they  might  themselves  attend  school  while  suffering 
from  the  disease  in  a  very  mild  form  or  during  the  period  of  invasion. 
Where  the  sick  child  is  completely  isolated,  the  danger  from  the  first 
source  is  very  slight.  During  severe  epidemics  it  frequently  becomes 
necessary  to  close  all  schools. 

During  desquamation  the  spread  of  the  disease  may  be  in  a  measure 
prevented  by  the  free  use  of  inunctions  and  warm  baths.  The  bath 
water  should  always  be  disinfected.  All  the  excreta  from  the  patient 
should  be  disinfected  throughout  the  disease,  best  by  a  carbolic  solution 
(1  to  20).  If  cases  of  scarlet  fever  are  to  be  transported,  this  should 
be  done  only  in  a  vehicle  w^hich  can  be  easily  disinfected.  Under  all  cir- 
cumstances as  few  persons  as  possible  should  come  in  contact  with  the 
patient. 

In  general,  it  is  to  be  remembered  that  the  danger  is  first  from  the 
patient,  secondly  from  the  room,  and  thirdly  from  the  nurse.  Special  at- 
tention should  always  be  given  to  the  complete  and  immediate  isolation  of 
the  first  case  which  appears  in  an  institution  or  community,  which  should 
apply  to  mild  as  well  as  the  severe  forms  of  the  disease. 

Treatment. — There  is  as  yet  no  specific  for  scarlet  fever,  so  that  the 
treatment  is  one  of  symptoms  and  complications.  Mild  attacks  require 
no  medicine  whatever.  Children  should  be  kept  in  bed  for  at  least  a 
week  after  the  fever  has  subsided,  and  upon  fluid  diet  for  a  period  of  three 
weeks.  This  is  an  important  matter  in  the  prevention  of  nephritis  (page 
618).  During  the  height  of  the  eruption,  the  intense  itching  of  the  skin 
may  be  allayed  by  sponging  with  a  weak  carbolic-acid  solution,  or  by  in- 
unctions with  vaseline,  or  by  the  free  use  of  rice  powder.  Plenty  of  fresh 
air  should  ahvays  be  secured  in  the  sick-room.  As  soon  as  the  fever  and 
rash  have  disappeared,  daily  warm  baths  with  soap  and  water  should  be 
used,  after  which  the  entire  body  should  be  anointed  with  carbolized  vase- 
line or  a  one-per-cent  ichthyol  ointment,  or  boric  acid  and  vaseline,  five 
per  cent  strength,  with  the  two-fold  purpose  of  facilitating  desquamation 
and  disinfecting  the  scales.  In  case  the  skin  becomes  irritated  by  this 
treatment,  bran  baths  may  be  substituted  for  soap  and  water.  The  diet 
requires  careful  attention  in  all  cases.  With  the  exception  mentioned 
above,  it  should  be  regulated  as  in  other  forms  of  severe  illness  (page  191). 

The  temperature  does  not  usually  require  interference  when  it  only  oc- 
casionally rises  to  104°  or  104-5°  F.  But  if  there  is  hyperpyrexia,  or  a  tem- 
perature which  ranges  from  103°  to  105°  F.  or  over,  antipyretic  measures 


SCARLET   FEVER,  909 

are  called  for.  Cold  is  much  safer  and  more  certain  than  drugs.  Some- 
times cold  sponging  is  sufficient,  but  in  the  great  proportion  of  cases  the 
cold  pack  or  the  cold  bath  (pages  47, 48)  is  required.  The  pack  is  almost 
as  efficient  as  the  bath,  and  usually  meets  with  less  opposition  on  the  part 
of  the  parents.  The  use  of  cold  in  the  reduction  of  temperature  is  espe- 
cially indicated  in  septic  cases  with  typhoid  symptoms,  and  in  those  with 
pronounced  cerebral  symptoms.  Where  these  are  severe  the  bath  should 
always  be  used,  and  repeated  with  sufficient  frequency  to  keep  the  tem- 
perature below  103°  F. 

The  nervous  symptoms  are  frequently  better  controlled  by  ice  to  the 
head  and  by  cold  sponging  than  by  medication.  Antipyretic  drugs  may 
be  relied  upon  to  control  restlessness  and  promote  sleep,  and  in  mild  cases 
to  effect  a  moderate  reduction  in  temperature  when  this  is  accompanied 
by  great  discomfort.  Phenacetine  is  usually  to  be  preferred.  For  the 
nervous  symptoms  occurring  in  nephritis,  as  stated  elsewhere,  opium  is  to 
be  used. 

As  soon  as  the  pulse  becomes  weak  or  rapid  and  irregular,  with  a 
feeble  first  sound  of  the  heart,  stimulants  should  be  given,  no  matter  at 
what  stage  of  the  disease.  In  mild  or  moderately  severe  cases  they  are 
not  generally  required.  In  septic,  or  malignant  cases,  or  in  those  ac- 
companied by  severe  angina,  adenitis,  or  cellulitis,  alcoholic  stimulants 
must  be  used  fearlessly — carried  even  to  the  full  toleration  of  the  patient 
(page  49).  Digitalis  is  next  in  value  to  alcohol,  and  is  especially  indi- 
cated where  the  pulse  is  weak  and  soft,  with  a  low  tension.  The  fluid 
extract  may  be  given  to  a  child  five  years  old  in  minim  doses,  four  times 
a  day  in  the  beginning,  and  later,  if  necessary,  with  greater  frequency. 
Strychnine  is  also  useful,  and  may  be  combined  with  digitalis  or  given 
separately,  the  usual  initial  dose  being  gr.  ^Aq  to  a  child  of  five  years. 

The  erythematous  sore  throat  requires  no  treatment  except  the  use  of 
a  mild  antiseptic  gargle.  If  there  is  profuse  nasal  discharge,  nasal  syring- 
ing (page  oC)  with  a  warm  saline  or  boric-acid  solution  may  be  used  with 
the  hope  of  preventing  infection  of  the  middle  ear.  The  local  treatment 
of  the  membranous  angina  is  the  same  as  that  of  other  cases  of  pseudo- 
diphtheria.  Gangrenous  inflammation  of  the  tonsils  br  palate  is  some- 
times benefited  by  injections  of  a  10-per-cent  solution  of  carbolic  acid  in 
glycerin,  but  most  such  cases  prove  fatal,  no  matter  what  the  treatment. 

]\[ilder  forms  of  adenitis  require  no  local  treatment.  When  severe,  an 
ice-bag  should  be  applied  in  the  case  of  older  children.  If  this  is  not 
well  borne,  for  young  children  a  hot  poultice  may  be  used  for  a  short  time 
for  the  relief  of  pain.  Prolonged  poulticing,  however,  almost  invariably 
does  more  harm  than  good,  and  favours  suppuration.  If  abscess  forms, 
early  incision  should  be  practised. 

it  is  doubtful  if  otitis  can  be  prevented  by  any  form  of  local  treat- 
ment.    My  experience  has  been  that  it  rarely  occurs  in  cases  with  mild 


910  THE  SPECIFIC   INFECTIOUS  DISEASES. 

throat  symptoms,  but  that  where  these  are  severe  it  almost  invariably 
follows,  whatever  the  treatment  employed.  The  indications,  however,  ai-e 
to  keep  the  rhino-pharynx  as  clean  as  possible  by  syringing  the  mouth 
and  nose.  The  indications  for  paracentesis  of  the  drum  membrane  are 
the  same  as  in  other  severe  forms  of  otitis  (page  884).  The  treatment  of 
scarlatinal  nephritis  has  been  considered  in  the  chapter  devoted  to  Diseases 
of  the  Kidney  (page  618).  Diif use  cellulitis  of  the  neck  calls  for  free  in- 
cisions early  as  the  only  means  of  preventing  extensive  sloughing. 

During  convalescence,  tonics,  particularly  iron  and  digitalis,  are  called 
for.  The  urine  should  be  frequently  examined  for  a  long  time ;  antisep- 
tic gargles  and  a  nasal  spray  or  syringe  should  be  used  as  long  as  a  puru- 
lent discharge  from  the  nose  or  pharynx  continues. 


CHAPTER   II. 

MEASLES. 

Synonyms:  Rubeola,  Morbilli. 

Measles  is  an  epidemic  contagious  disease,  more  widely  prevalent 
than  any  other  eruptive  fever ;  very  few  persons  reach  adult  life  without 
contracting  it.  One  attack  usually  confers  immunity.  It  is  highly  con- 
tagious even  from  the  beginning  of  the  invasion,  and  spreads  with  great 
rapidity  from  the  patient  to  all  susceptible  persons  exposed.  The  poison, 
however,  does  not  cling  so  long  to  clothing  or  apartments  as  does  that  of 
scarlet  fever.  Measles  has  a  period  of  incubation  of  from  eleven  to  four- 
teen days;  a  gradual  invasion  of  three  or  four  days  with  symptoms  of 
an  acute  coryza ;  a  maculo-papular  eruption  which  appears  first  upon  the 
face  and  spreads  slowly  over  the  body,  and  which  lasts  from  four  to  six 
days.  This  is  followed  by  a  fine  bran-like  desquamation,  which  is  com- 
pleted in  about  a  week.  The  mortality  is  low,  except  among  infants  and 
delicate  children,  where  it  may  reach  30  or  even  40  per  cent.  In  institu- 
tions for  infants  and  young  children  no  disease  is  more  to  be  dreaded 
than  measles,  not  only  on  account  of  its  severity,  but  the  frequency 
with  which,  in  such  subjects,  it  is  complicated  by  broncho-pneumonia. 

Etiology. — The  essential  cause  of  measles  is  as  yet  unknown.  It  is 
generally  believed  to  be  due  to  a  micro-organism,  but,  as  in  the  case  of 
scarlatina,  all  attempts  to  isolate  it  have  thus  far  been  unsuccessful.  The 
poison  is  one  which  possesses  remarkable  powers  of  diffusion,  but  whose 
viability  is  much  less  than  that  of  most  of  the  pathogenic  germs  which 
are  known.  Only  a  short  exposure  is  required  to  communicate  the  dis- 
ease, and  even  close  proximity  to  a  patient  does  not  seem  necessary.  One 
instance  has  come  under  my  own  observation  where  measles  was  appar- 


MEASLES.  911 

ently  conveyed  by  an  exposure  of  half  an  hour  across  a  hospital  ward,  a 
distance  of  at  least  fifteen  feet. 

Predispositioyi. — With  the  exception  of  young  infants,  children  of  all 
ages  are  extremely  susceptible  to  measles.  The  disease  broke  out  in  a  cot- 
tage of  the  Kew  York  Infant  Asylum  which  was  occupied  by  twenty-three 
children,  nearly  all  of  them  being  under  two  years  old ;  only  four 
escaped,  all  these  being  under  five  months  old.  In  an  epidemic  reported 
by  Smith  and  Dabney,  110  unprotected  children,  between  the  ages  of 
eight  and  eighteen  years,  were  exposed  and  only  two  escaped.  In  the 
Nursery  and  Child's  Hospital,  during  the  epidemic  of  1892,  there  were 
62  children  over  two  years  of  age ;  five  were  protected  by  a  previous 
attack  and  escaped;  of  the  remaining  57  children,  55  took  the  disease. 
There  were  also  in  the  institution  113  children  under  two  years  old;  of 
this  number  78  per  cent  took  the  disease  ;  but  although  many  were  exposed, 
not  one  child  under  six  months  old  contracted  measles.  The  age  of  the 
persons  affected  depends  much  upon  the  length  of  time  since  the  last 
outbreak  of  the  disease.  In  an  epidemic  occurring  in  the  Island  of 
Guernsey,  where  the  disease  had  not  prevailed  for  many  years,  all  ages 
were  affected,  the  youngest  being  twelve  days  old,  and  the  oldest,  a  man 
and  wife,  each  aged  eighty  years.  Somer  has  rejiorted  an  instance  of  an 
eruption  of  measles  appearing  in  a  child  twelve  hours  after  birth ;  the 
mother  was  suffering  from  the  disease  at  the  time.  Gautier  has  col- 
lected six  additional  cases,  where  measles  either  existed  at  the  time  of 
birth  or  developed  within  a  few  hours  after  it. 

Except,  then,  in  early  infancy,  the  probabilities  are  very  strong  that 
every  child  exposed  to  measles  will  contract  the  disease.  Occasionally, 
however,  one  is  seen  who  seems  insusceptible  to  the  poison,  no  matter  how 
close  the  exposure. 

Epidemics  of  measles  are  more  frequent  and  more  severe  during  the 
spring  months.  They  are  least  frequent  and  mildest  during  the  autumn 
months. 

Incubation. — In  144  cases,*  where  the  period  of  incubation  could  be 
definitely  traced,  it  was  as  follows  : 

Incubation  of  less  than  nine  days 3  cases. 

"  "  nine  or  ten  days 22    " 

"  "  eleven  to  fourteen  days 95     " 

*•  "  fifteen  to  seventeen  days 19    " 

"  "  eighteen  to  twenty-two  days 5    " 

Thus  in  66  per  cent  of  the  cases  the  incubation  was  between  eleven  and 
fourteen  days,  and  in  only  one  case  was  it  less  than  a  week.    The  constancy 

*  About  twenty-five  of  these  are  taken  from  my  own  recordG ;  the  remainder  are 
mainly  isolated  cases,  scattered  through  medical  literature.     The  incubation  is  reck- 
oned from  the  time  of  exposure  to  the  beginning  of  the  catarrh. 
69 


912  THE  SPECIFIC   INFECTIOUS   DISEASES. 

of  the  incubation  period  is  strikingly  shown  in  some  epidemics.  Thus 
in  the  one  reported  by  Smith  and  Dabney  in  an  institution  in  Virginia, 
exactly  eleven  days  after  the  rash  appeared  in  the  first  case,  the  disease 
developed  in  twenty  children  —  no  cases  having  occurred  in  the  in- 
terval. 

Duration  of  the  infective  j^eriod. — This  is  much  shorter  than  in 
scarlet  fever,  and  the  average  duration  may  be  placed  at  four  weeks. 
Haig-Browu  discharged  fifty-eight  cases  on  or  before  the  twenty-ninth 
day  of  the  disease,  and  in  no  instance  was  measles  spread  by  these  chil- 
dren. Eansom,  however,  records  one  instance  in  which  it  was  communi- 
cated thirty-one  days  after  the  appearance  of  the  rash. 

Measles  is  highly  contagious  from  the  beginning  of  the  catarrhal 
symptoms,  A  case  occurred  in  the  Babies'  Hospital  under  my  own  ob- 
servation, in  which  a  child  conveyed  the  disease  four  days  before  the  rash 
appeared.  Eansom  reports  another  precisely  similar.  An  instance  has 
been  related  to  me  by  Dr.  S.  W.  Lambert,  where,  of  thirteen  little  girls 
who  were  at  a  children's  party,  only  one  escaped  measles,  the  source  of  in- 
fection being  a  child  who  showed  no  rash  until  the  following  day ;  the 
child  who  escaped  had  previously  had  measles.  The  period  of  greatest 
contagion  is  still  a  matter  of  dispute,  the  general  belief  being  that  it  is 
coincident  with  the  highest  temperature,  the  full  eruption,  and  the  most 
severe  catarrhal  symptoms. 

With  the  fading  of  the  eruption  and  the  subsidence  of  the  catarrh,  the 
communicability  of  measles  diminishes  rapidly.  It  is  relatively  feeble 
during  desquamation,  and  soon  after  this  period  it  usually  ceases  alto- 
gether. It  is  generally  proportionate  to  the  severity  of  the  catarrhal 
symptoms,  and  where  these  are  protracted  it  is  probable  that  the  disease 
may  be  communicated  for  a  much  longer  period  than  that  mentioned. 

Mode  of  infection. — Measles  is  usually  spread  by  direct  contagion,  very 
infreqiiently  through  the  medium  of  clothing,  furniture,  or  a  third  person. 
Townsend  (Boston)  records  an  instance  in  which  one  family  moved  into 
a  tenement  house  on  the  same  day  on  which  it  was  vacated  by  another 
family  in  which  two  children  had  suffered  from  measles,  one  of  them 
fourteen  and  the  other  eighteen  days  previously.  The  apartments  were 
not  fumigated  nor  disinfected,  and,  although  there  were  two  susceptible 
children  in  the  incoming  family,  they  did  not  contract  the  disease. 
Measles  rarely  if  ever  clings  to  apartments  for  weeks  or  months,  as  does 
scarlet  fever.  Many  instances  are  on  record  in  which  the  disease  has  been 
carried  by  a  third  party  ;  but,  after  all,  this  rarely  happens,  unless  the  con- 
tact both  with  the  sick  and  the  well  child  is  very  close  and  the  interval 
short.  It  is  very  seldom  that  measles  is  carried  by  a  physician  who  takes 
even  the  ordinary  precautions.  In  a  case  reported  by  Girom,  the  clothing 
of  a  patient  is  stated  to  have  conveyed  the  disease  nineteen  days  after  an 
attack,  but  this  must  be  regarded  as  very  exceptional. 


MEASLES.  913 

Lesions. — The  only  constant  lesions  of  measles  are  those  of  the  skin 
and  the  mucous  membranes,  chiefly  of  the  respiratory  tract.  According 
to  Xeumann,  the  process  in  the  skin  is  of  an  inflammatory  character,  but 
is  more  superficial  than  in  scarlet  fever.  There  is  congestion,  accom- 
panied by  an  exudation  of  round  cells  about  the  small  blood-vessels,  and 
also  about  the  sweat  and  sebaceous  glands,  and  the  papillae.  To  this 
exudation  and  the  oedema,  the  swelling  of  the  skin  is  due.  It  occurs 
everywhere,  but  is  especially  noticeable  upon  the  face. 

The  changes  in  the  mucous  membranes  are  quite  as  much  a  part  of 
the  disease  as  are  those  of  the  skin.  There  is  a  catarrhal  inflammation 
affecting  the  conjunctivse,  nose,  pharynx,  larynx,  trachea,  and  large 
bronchi,  which  varies  in  intensity  with  the  severity  of  the  attack.  In  the 
most  severe  forms  in  infants  and  in  young  children,  this  inflammation 
extends  witli  great  uniformity  to  the  small  bronchi,  and  usually  to  the 
air  vesicles,  causing  broncho-pneumonia.  In  severe  cases,  the  lesion  in 
the  pharynx  and  larynx  also,  instead  of  being  catarrhal,  may  be  mem- 
branous ;  the  larynx  being  much  more  frequently  involved,  and  the  ears 
much  less  so,  than  in  scarlet  fever.  The  lesions  of  the  lungs  and  of  other 
organs  will  be  more  fully  considered  under  Complications. 

The  bacteria  which  are  associated  with  the  lesions  of  the  respiratory 
tract  are,  in  the  milder  cases,  usually  the  staphylococcus,  and  in  the  more 
severe  ones  the  streptococcus,  although  this  is  sometimes  reversed.  They 
may  be  found  separately  or  together,  and  either  form  may  be  associated 
with  the  pneumococcus  (see  Bacteriology  of  Broncho-Pneumonia,  page 
482).  The  poison  of  measles  produces  conditions  in  the  mucous  mem- 
branes of  the  respiratory  tract  which  are  especially  favourable  for  the 
development  of  these  bacteria,  which  at  such  times  are  always  present  in 
the  mouth  in  large  numbers.  Many  of  the  other  complications  besides 
pneumonia  are  due  to  infection  with  these  germs.  Associated  with  the 
lesions  of  the  mucous  membranes,  are  found  changes  in  the  lymphatic 
glands  with  which  they  are  connected  ;  they  may  be  of  a  hyiDerjDlastic  or 
of  a  suppurative  character. 

Symptoms. — Invasion. — As  a  rule,  the  invasion  of  measles  is  gradual, 
both  the  fever  and  catarrhal  symptoms  increasing  steadily  up  to  the  appear- 
ance of  the  eruption.  The  characteristic  symptoms  of  the  invasion  are 
those  of  a  severe  coryza, — suffusion  of  the  eyes,  increased. lachrymation, 
photophobia,  sneezing,  and  a  discharge  from  the  nose.  The  hoarse,  hard 
cough  indicates  that  the  catarrhal  process  has  involved  the  larynx  and 
trachea,  as  well  as  the  visible  mucous  membranes.  Frequently  the  patient 
complains  of  some  soreness  of  the  throat,  and  on  inspection  there  is  seen 
moderate  congestion  of  the  tonsils,  fauces,  and  pharynx.  On  the  hard 
palate  are  frequently  seen  on  the  second  or  third  day  small  red  spots,  from 
the  size  of  a  pin's  head  to  that  of  a  pea.  This  is  sometimes  spoken  of  as 
the  eruption  upon  the  mucous  membrane.     The  constitutional  symptoms 


914 


THE  SPECIFIC  INFECTIOUS  DISEASES. 


are  indefinite,  and  may  be  met  with  in  almost  any  disease.  There  are 
dulness,  headache,  pains  in  tlie  back,  and  the  usual  symptoms  of  malaise; 
there  is  rarely  vomiting  or  diarrhoea.  Drowsiness  is  a  frequent  symptom, 
and  is  regarded  by  the  laity  as  characteristic. 

The  exceptional  cases  in  which  the  invasion  is  abrupt  are  puzzling. 
There  may  be  a  sudden  accession  of  fever  with  vomiting,  and  even  con- 
vulsions, as  in  a  case  lately  under  my  observation.  Not  infrequently,  when 
the  disease  prevails  epidemically,  the  invasion  is  sudden,  with  high  fever 
and  pulmonary  symptoms  which  are  so  severe  as  to  mask  everything  else 
until  the  rash  makes  its  appearance,  the  case  up  to  that  time  being  often 
regarded  as  one  of  primary  pneumonia  or  of  influenza.  The  duration  of 
the  stage  of  invasion— i.  e.,  from  the  beginning  of  the  catarrh  until  the 
eruption— in  370  cases  of  which  I  have  notes,  was  as  follows : 

6  davs 20  cases. 

7  "*  6      " 

8  "    2       " 


1  day  or  less 35  cases. 

2  days 47      " 

3  "     64      " 

4  "    64      " 

5  "     29       " 


9    "    2       " 

10    "    1  case. 


From  this  table  it  will  be  seen  that  the  length  of  the  period  of  invasion 
varies  considerably, — more,  1  think,  in  infants  and  very  young  children 
(most  of  these  were  under  three  years  old)  than  in  those  who  are  older. 
In  the  greater  number  of  cases  it  lasts  from  two  to  four  days. 

Eruption. — The  rash  usually  appears  on  the  third,  fourth,  or  fifth  day 
of  the  disease — in  the  largest  number  upon  the  fourth  day.  As  a  rule,  it 
is  first  seen  behind  the  ears,  on  the  neck,  or  at  the  roots  of  the  hair  over 
the  forehead.  It  appears  as  small,  dark-red  spots,  which  are  at  first  few, 
scattered,  and  not  elevated,  resembling  flea-bites.  In  twenty-four  hours 
the  macules  are  much  more  numerous,  and  many  of  them  have  become 
papules.  They  frequently  group  themselves  in  crescentic  forms.  They 
are  usually  separated  by  areas  of  normal  skin,  but  where  the  rash  is  intense 
they  are  frequently  coalescent.  From  the  time  of  its  first  appearance  to 
the  full  development  of  the  rash  on  the  face,  is  usually  about  thirty-six 
hours,  but  may  be  from  one  to  three  days.  With  a  full  eruption  there  is 
considerable  swelling  of  the  face,  especially  about  the  eyes,  and  the  features 
are  sometimes  scarcely  recognisable.  On  the  second  day  of  the  rash  it 
begins  to  appear  upon  the  neck  beneath  the  chin,  the  upper  part  of  the 
chest  and  back ;  on  the  third  day  the  trunk  is  covered,  and  scattered  spots 
are  seen  upon  the  extremities.  The  rash  appears  last  upon  the  lower  ex- 
tremities, and  by  the  time  it  is  fully  out  upon  them  it  has  usually  begun 
to  fade  from  the  face.  In  mild  cases  it  remains  discrete,  but  in  severe 
ones  it  is  frequently  confluent  upon  the  face  and  upon  the  extensor  surface 
of  the  extremities.  As  a  rule,  it  covers  the  entire  body,  even  the  palms 
and  soles. 

The  eruption  fades  slowly  in  the  order  of  its  appearance,  and  there  is 


MEASLES.  915 

left  behind,  in  typical  cases,  a  slight  brownish  staining  of  the  skin,  which 
often  remains  for  nearly  a  week.  The  duration  of  the  rash  is  from  one  to 
six  days,  the  average  being  four  days. 

There  are  many  cases  in  which  the  rash  does  not  follow  the  typical 
course  described  :  (1)  Instead  of  spreading  gradually,  the  entire  body 
may  be  covered  in  a  few  hours.  (2)  The  rash  may  be  hemorrhagic. 
This  condition  was  present  in  about  five  per  cent  of  my  cases.  Tlie 
whole  eruption  may  be  hcemorrhagic,  or  it  may  be  so  only  upon  certain 
parts — usually  the  abdomen  or  extremities.  Under  such  circumstances 
small  petechial  spots  take  the  place  of  the  macules.  This  is  the  "  black 
measles"  of  the  older  writers.  It  is  in  most  cases  a  bad,  but  by  no 
means  a  fatal  symptom.  I  have  seen  it  in  several  cases  that  were  not 
especially  severe.  (3)  The  rash  may  be  very  faint,  and  of  short  duration, 
being  scarcely  elevated  at  all.  (4)  It  may  consist  of  very  minute  papules, 
closely  resembling  the  rash  of  scarlet  fever.  It  is  to  be  remembered,  how- 
ever, that  the  irregular  eruptions  of  scarlet  fever  much  more  frequently 
resemble  measles  than  vice  versa.  (5)  It  may  be  very  scanty,  and  late  in 
its  appearance  ;  particularly  in  cases  of  great  severity  and  hyperpyrexia — 
the  so-called  malignant  cases.  (G)  Temporary  recession  of  the  eruption 
may  occur  at  any  time  during  the  height  of  the  disease,  and  is  usually 
due  to  heart  failure.  A  recurrence  of  the  eruption  after  it  has  run  its 
usual  course  is  something  which  I  have  never  seen ;  although  such  cases 
have  been  reported,  I  believe  them  to  be  very  exceptional. 

During  the  first  two  days  of  the  eruption,  the  local  and  constitutional 
symptoms  increase  in  severity,  both  usually  reaching  their  maximum  at 
the  time  of  the  full  development  of  the  rash  upon  the  face.  The  skin 
is  swollen,  and  the  seat  of  intense  itching  and  burning.  The  eyes  are 
very  red  and  sensitive  to  light,  and  there  is  swelling  of  the  conjunctiva 
with  an  abundant  production  of  mucus  or  muco-pus,  causing  the  lids  to 
adhere.  There  is  pain  on  swallowing,  also  swelling  of  the  glands  at  tlie 
angle  of  the  jaw  or  in  the  post-cervical  region.  The  cough  is  frequent 
and  very  annoying.  There  is  complete  anorexia,  and  often  diarrhwa. 
The  tongue  is  coated,  and  may  show  at  its  margin  enlarged  papilla, 
resembling  the  "  strawberry  "  appearance  of  scarlet  fever.  As  the  rash 
fades  the  temperature  declines  rapidly,  often  reacliing  the  normal  in  two 
or  three  days.  The  catarrhal  symptoms  now  subside,  and  soon  the  patient 
is  convalescent.  Within  a  day  or  two  after  the  fever  has  ceased,  the  rash 
disappears. 

Dexqiiamatinn. — This  begins  almost  as  soon  as  the  rash  has  subsided, 
and  is  first  noticed  on  the  face  and  neck,  where  the  eruption  first  ap- 
peared. The  nature  of  the  desquamation  is  invariably  fine,  branny  scales, 
never  in  large  patches,  as  in  scarlet  fever.  It  is  often  quite  indistinct  and 
may  be  overlooked.  Its  usual  duration  is  from  five  to  ten  days.  It  may, 
however,  be  prolonged  for  two  weeks.    The  amount  of  desquamation  varies 


916 


THE  SPECIFIC  INFECTIOUS  DISEASES. 


considerably  m  the  different  cases.  It  is  most  marked  in  those  in  which 
there  has  been  an  intense  eruption.  There  is  frequently  noticed  at  this 
time  an  odour  about  the  patient  wliich  is  quite  characteristic  of  measles. 
During  this  stage  the  cough  often  persists  and  the  eyes  remain  weak  and 
very  sensitive  to  light,  but  in  other  respects  the  patient  usually  feels  per- 
fectly well. 

1.  The  mild  cases. — The  mildest  cases  are  distinguished  by  low  tem- 
perature, which  at  the  height  of  the  eruption  usually  reaches  102°  F.,  but 
rarely  lasts  more  than  four  days.  The  eruption  is  often  scanty,  and  is 
never  confluent.  The  swelling,  itching,  and  other  cutaneous  symptoms 
are  wanting,  as  is  also  the  intense  red  colour  of  the  skin.  The  rash  is 
frequently  obscure,  and,  without  the  other  symptoms,  hardly  sufficient  for 
diagnosis.  The  catarrhal  symj^toms  are  more  uniform  than  the  rash,  but 
these  are  very  mild  as  compared  with  the  usual  form.  The  duration  of 
the  rash  is  shorter,  desquamation  is  scarcely  perceptible,  and  there  are  no 
complications. 

2.  The  cases  of  moderate  severity. — The  course  of  measles  is  much 
more  regular  in  children  over  three  years  old  than  in  infancy.  In  the 
former,  the  symptoms  of  invasion  come  on  gradually,  and  the  temperature 
rises  steadily  until  the  appearance  of  the  eruption,  which  is  in  most  cases 


DAY 

1 

2 

3 

i 

5 

G 

7 

s 

t 

I 
Z 

I 
< 

104° 

los" 
102' 

101^ 
100° 

9S' 

M      E 

M     E 

M     E 

M     E 

M     E 

M     E 

M     E 

X 

h 

r 

A 

N 

r 

J 

/ 

V 

s 

/ 

l^ 

N 

y 

r 

1 

1 

2 

3 

< 

5 

6 

7 

8 

9 

I 

z 

I 
< 

100° 

105' 
101' 

103° 
102' 
101° 
100" 
99' 

M      E 

M     E 

M     E 

M     E 

M     E 

M     E 

M     E 

M     E 

M     E 

X 

X 

, 

A 

h 

kI\ 

A 

V 

v\ 

A 

1/ 

\J^ 

J 

WA 

vA 

^ 

« 

1 

i/ 

V 

u 

Fio.  158. 


Fig.  159. 


Fig.  158. — Temperature  curve  in  uncomplicated  measles,  showingr  the  {rradual  rise  and  critical 
fall ;  patient  ten  years  old ;  x  =  tirst  eruption ;  ^  —  full  eruption  on  the  face. 

Fig.  159. — Typical  curve  in  uncomplicated  measles,  with  gradual  rise  and  gradual  fall ;  patient 
three  years  old. 


on  the  third  or  fourth  day  of  the  disease.  Figs.  158  and  159  represent 
the  typical  temperature  curve  in  average  uncomplicated  cases.  Such  a 
curve  was  seen  in  44  per  cent  of  173  cases  in  which  careful  observations 
were  made.  Sometimes  the  decline  in  the  fever  is  very  rapid,  almost  a 
crisis,  as  in  Fig.  158,  but  more  often  it  falls  gradually,  as  in  Fig.  159.  In 
such  cases  the  duration  of  the  fever  is  from  five  to  nine  days,  the  average 
being  about  a  week.  The  other  symptoms  follow  very  closely  the  course 
of  the  fever.    The  maximum  temperature  is  nearly  alwajs  coincident  with 


MEASLES. 


917 


the  full  rash  upon  the  face,  at  this  time  usually  being  in  uncomplicated 
cases  from  103°  to  104°  F.  in  older  children,  aud  101°  to  105°  in  infants 
and  young  children. 

A  not  very  uncommon  temperature  curve  is  that  of  Fig.  IGO,  where 
the  onset  of  the  disease  is 
marked  by  a  sudden  rise  to 
102°  or  even  104°  F.,  with  a 
fall  nearly  or  quite  to  nor- 
mal on  the  second  day,  after 
which  the  fever  rises  grad- 
ually, as  in  the  first  group. 
This  curve  was  seen  in  5  per 
cent  of  my  cases. 

3.  The  severe  cases. — h\ 
Fig.  161  is  shown  a  type  of 
the  disease  which  is  more 
frequent  in  infants  than  in 
older  children,  the  impor- 
tant features  being  the  late 

eruption  and  the  continuance  of  the  high  fever  for  several  days  after  the 
rash  has  begun  to  fade.  Such  a  prolonged  course  and  so  high  a  temper- 
ature are  almost  invariably  due  to  some  complication,  usually  broncho- 
pneumonia.    Where  the  pneumonia  goes  on  to  the  production  of  areas 


DAY 

1 

2 

3 

1 

« 

7 

8 

9 

10 

11 

12 

I 
z 

X 

< 

106' 
105' 
lOl' 
103 
102' 
101 

100° 

99' 

98' 

M     E 

M      E 

M      E 

M      E 

M      E 

M      E 

M     E 

M     E 

M     E 

M     E 

M     E 

M      E 

X 

X 

" 

X 

/ 

\, 

A 

\ 

A 

/ 

Y 

\ 

^ 

/ 

/ 

\ 

\ 

/ 

V 

\ 

V 

\ 

/ 

v^ 

V 

A 

V 

V 

V 

Flo.  160. — A  not  infrequent  teiiiperiitiire  curve  in  mea- 
sles, showina:  abrupt  invasion,  but  subsequent  course 
typical ;  uncomplieated  case :  patient  nine  months 
old. 


DAY 

1 

2 

3 

i 

5 

c 

7 

8 

9 

10 

11 

12 

13 

H 

15 

16 

17 

t 

X 
Z 

a 

X 

, 

M      E 

M      E 

M      E 

U      E 

M     E 

M     E 
X 

M     E 

M      E 

M      E 

M     E 

M      E 

U     E 

M     E 

M     E 

M     E 

M      E 

M     E 

105° 

lot" 

X 

" 

J 

11 

A 

/ 

1 

X 

I 

J 

\r 

f 

f 

,^ 

[A 

A 

103' 
101° 

100' 

99° 

98 

X 

f 

/ 

V 

V 

V 

, 

V 

/ 

^\ 

\ 

A 

\J 

V 

/ 

\ 

,/ 

J 

y 

I 

\ 

A 

/ 

\ 

V 

1/ 

V 

\/ 

\ 

^ 

1      ,» 

Fio.  161.— Measles  with  prolonged  invasion;  continuance  of  high  temperature  after  Cull  eruption 
due  to  severe  bronchitis  and  diarrha-a ;  child  two  years  old. 

of  consolidation,  the  fever  usually  continues  for  three  and  sometimes  for 
four  weeks,  even  though  terminating  in  recovery. 

Figs.  1G2  and  1G3  illustrate  two  types  of  the  disease  which  are  often 
seen  when  measles  is  complicated  by  pneumonia.  In  cases  like  that  shown 
in  Fig.  102  the  oni<ot  is  abrupt  with  high  temperature,  prostration,  and 
pulmonary  symptoms  not  unlike  those  of  primary  pneumonia.  A  tem- 
perature curve  resembling  this  was  seen  in  28  of  173  cases.  The  rash  is 
often  late  in  appearance;    it  is  faint  and  altogether  irregular;    it  may 


918 


THE  SPECIFIC  INFECTIOUS  DISEASES. 


recede  after  the  first  day  and  reappear  after  an  interval  of  one  or  two 
days.  The  catarrhal  symptoms  are  not  marked,  but  the  whole  force 
of  the  disease  seems  to  be  expended  iipon  the  lungs.  The  diagnosis  of 
these  cases  presents  great  difficulties,  and  very  often  it  would  not  be 
made  but  for  the  fact  that  there  are  other  cases  of  measles  in  the  family 
or  the  institution.  This  form  is  usually  seen  in  infants,  and  it  is  very 
fatal. 

In  other  cases  marked  by  a  sudden  severe  onset,  the  system  seems  to  be 
overpowered  by  the  poison  of  the  disease  itself.     There  are  profound  de- 


OAir 

1 

2 

3 

1 

c 

7 

s 

9 

10 

t 

I 

z 

a 

I 
< 

10G° 
105' 
104° 
103° 
102" 
lOl' 
lOO' 
99' 
98' 

M     E 

M      E 

M      E 

M      E 

M     E 

M     E 

M     E 

M      E 

M      E 

M      E 

X 

/ 

A 

f 

A 

/ 

J 

V 

Af 

V 

\\ 

/ 

/ 

V 

V 

V 

V 

/ 

V 

0.              1 

1 

2 

■i 

I 

5 

c 

M     E 

M     E 

M     E 

M     E 

I 

X 

107 

u 

10G° 



I 

t 

1 

I 

104 

1 

I 

I 
< 

103 
102' 

/ 

/ 

L 

101' 
100° 

99° 

9S' 

/ 

i- 

/ 

Fig.  162. 


Fig.  163. 


Fig.  162. — Fatal  attack  of  measles,  complicated  by  broncho-pneumonia;  very  severe  symptoms 

from  the  onset ;  patient  eitjhteen  mouths  old ;  death  on  tenth  day. 
Fig.  163. — Fatal  attack  of  measles,  complicated  by  broncho-pneumonia  ;  early  invasion  mild,  but 

rapid  development  of  severe  symptoms  on  fourth  day ;  rash  on  last  day ;   patient  eight 

months  old. 

pression,  and  hyperpyrexia,  and  the  patient  may  die  from  toxaemia  with 
cerebral  symptoms  before  the  appearance  of  the  rash  or  just  as  it  is  begin- 
ning to  show  itself.  Sometimes  the  pulmonary  symptoms  are  entirely 
wanting ;  at  others  the  rash,  if  it  appears,  is  hsemorrhagic. 

In  still  another  group  of  cases  the  onset  is  not  violent,  and  for  the  first 
two  days  the  attack  may  appear  to  be  of  only  average  severity ;  but  there 
may  then  develop,  often  quite  suddenly,  pulmonary  symptoms  of  such 
intensity  as  to  cause  death  within  twenty-four  hours.  The  eruption,  if 
seen  at  all,  is  faint  and  not  characteristic  (Fig.  163). 

A  secondary  rise  in  the  temperature  after  it  has  once  fallen  to  normal 
was  seen  in  8  of  173  cases,  being  due  to  the  development  of  otitis,  ileo- 
colitis, or  late  pneumonia. 

Complications  and  Sequelae. — The  most  frequent  and  most  important 
complication  of  measles  is  broncho-pneumonia,  and  next  to  this  are  ileo- 
colitis, otitis,  and  membranous  laryngitis.  Most  of  the  others  are  in- 
frequent; all  complications  are  relatively  rare  in  children  over  four 
vears  old. 


MEASLES.  919 

Lungs. — The  greatest  danger  in  measles  arises  from  pulmonary  com- 
plications, and  the  frequency  is  greatest  in  children  under  two  years  of 
age.  In  two  epidemics  in  the  Nursery  and  Child's  Hospital,  embracing 
about  300  cases,  nearly  all  in  children  under  three  years  old,  broncho- 
pneumonia occurred  in  about  40  per  cent  of  the  cases.  Of  those  who 
had  pneumonia,  70  per  cent  died.  Fortunately,  such  a  record  as  this  is 
never  seen  outside  of  asylums  or  hospitals  for  young  children.  Of  2,477 
cases,  embracing  several  epidemics  of  measles  among  children  of  all  ages, 
pneumonia  occurred  in  10  per  cent.  My  own  experience  in  the  post- 
mortem room  fully  bears  out  the  statement  of  Henoch,  that  a  certain 
amount  of  pneumonia  is  found  in  almost  every  fatal  case.  Pneumonia  is 
more  frequent  and  its  mortality  is  higher  in  spring  and  winter  epidemics 
than  in  those  occurring  at  other  seasons.  It  may  develop  at  any  time  from 
the  beginning  of  invasion  until  convalescence,  but  it  most  frequently 
begins  about  the  time  of  full  eruption. 

Lobar  pneumonia,  although  rare,  occasionally  occurs  as  a  complication 
in  children  over  three  years  old.  In  some  epidemics  many  of  the  cases 
of  pneumonia  are  complicated  by  severe  pleurisy,  which  adds  much  to 
the  danger  of  the  disease.  This  form  is  frequently  followed  by  empyema. 
Pneumonia  is  always  to  be  suspected  when  the  temperature  continues  high 
after  the  full  appearance  of  the  rash. 

Bronchitis  of  the  large  tubes,  always  accompanied  by  tracheitis,  is 
seen  in  every  case  of  measles,  possibly  excepting  a  few  of  the  very  mild- 
est. This  is  so  constant  a  feature  as  hardly  to  be  ranked  as  a  complica- 
tion. In  nearly  all  of  the  severe  cases  the  bronchitis  extends  to  the  me- 
dium-sized and  smaller  tubes. 

Larynx. — A  mild  catarrhal  laryngitis  accompanies  almost  every  case 
of  measles.  Severe  catarrhal  laryngitis  is  present  in  about  ten  per  cent  of 
the  cases ;  it  may  give  symptoms  which  closely  resemble  those  of  mem- 
branous laryngitis,  and  the  two  are  no  doubt  often  confused.  (For  the 
points  of  differential  diagnosis  see  page  443.) 

Membranous  laryngitis  is  more  often  seen  as  a  complication  of  measles 
than  of  scarlet  fever.  It  was  present  in  35  of  2,837  cases  taken  from 
miscellaneous  sources  ;  but  in  epidemics  in  institutions  it  is  much  more 
common  than  this.  As  a  cause  of  death  in  older  children  it  ranks  next 
to  pneumonia.  When  it  develops  at  the  height  of  the  disease,  as  it  usu- 
ally does,  it  is  due  in  nearly  all  cases  to  the  streptococcus ;  but  when  it 
develops  at  a  later  period,  it  is  usually  due  to  the  diphtheria  bacillus.  The 
streptococcus  inflammation  is  in  most  cases  associated  with  similar  changes 
in  the  pharynx  or  tonsils,  but  not  always.  True  diphtheria,  occurring 
as  a  complication  of  measles,  not  infrequently  begins  in  the  larynx.  The 
streptococcus  inflammation  may  be  as  serious  in  this  connection  as  is  true 
diphtheria,  from  the  probability,  which  amounts  almost  to  a  certainty,  of 
the  development  of  broncho-pneumonia.     No  complication  is  more  to  be 


920  THE  SPECIFIC  INFECTIOUS  DISEASES. 

dreaded  than  this.  The  diagnosis  between  the  true  and  pseudo-diphtheria 
may  sometimes  be  made  by  the  time  of  development,  but  only  with  cer- 
tainty by  cultures.  I  once  saw  in  measles,  where  no  false  membrane  was 
present  in  the  rest  of  the  larynx,  a  necrotic  inflammation  with  almost 
entire  destruction  of  the  vocal  cords — a  condition  which  may  be  compared 
to  that  seen  in  the  tonsils  or  epiglottis  in  scarlatina. 

Throat. — A  catarrhal  angina  is  part  of  the  disease,  and  is  as  charac- 
teristic of  measles  as  is  the  eruption  upon  the  skin.  There  is  acute  con- 
gestion and  swelling  of  the  tonsils,  uvula,  palate,  and  pharynx.  In  a 
certain  proportion  of  cases,  very  much  less  frequently  than  in  scarlatina, 
the  development  of  membranous  patches  is  seen  upon  the  tonsils  and  ad- 
jacent mucous  membranes.  These  occur  in  two  or  three  per  cent  of  the 
cases.  They  are  to  be  regarded  in  the  same  light  as  similar  conditions 
complicating  scarlet  fever  (page  899),  with  these  differences,  that  in 
measles  there  is  much  greater  likelihood  of  the  extension  of  the  disease 
to  the  larynx,  while  extension  to  the  nose  and  ears  is  much  less  probable. 
True  diphtheria,  however,  may  complicate  measles,  and  cases  of  mem- 
branous inflammation  of  the  tonsils  or  pharynx  developing  late  in  measles 
are  usually  due  to  the  Loeffler  bacillus. 

Although  in  most  cases  the  inflammations  of  the  pharynx  and  tonsils 
which  accompany  measles  are  not  serious  when  they  are  due  to  the  strep- 
tococcus, they  are  sometimes  quite  as  severe  as  any  that  accompany  scarlet 
fever.  They  may  cause  death  from  general  sepsis  apart  from  any  affec- 
tion of  the  larynx. 

Digestive  system. — Gastric  disorders  are  not  more  common  than  in 
other  febrile  diseases ;  but  diarrhoea  is  very  frequent,  and  in  summer  it 
may  be  even  more  serious  than  the  pulmonary  complications.  All  forms 
of  diarrhoea  are  seen,  from  that  which  results  from  simple  indigestion  to 
the  severe  types  of  ileo-colitis.  This  complication  is  most  often  seen  in 
children  under  two  years  old.  The  most  severe  intestinal  symptoms  are 
not  usually  seen  at  the  height  of  the  primary  fever ;  but,  beginning  at  this 
time,  they  often  increase  in  severity,  and  are  most  marked  in  the  second 
and  third  weeks  of  the  disease. 

Catarrhal  stomatitis  is  present  in  almost  every  case  of  m'easles ;  less 
frequently  the  herpetic  form  is  seen.  Ulcerative  stomatitis  is  not  uncom- 
mon, particularly  in  institutions.  One  of  the  worst  complications  of 
measles,  but  fortunately  a  rare  one,  is  gangrenous  stomatitis,  or  noma. 
This  usually  occurs  in  inmates  of  institutions,  or  in  children  with  bad 
surroundings  who  were  previously  in  wretched  condition.  It  is  nearly 
always  fatal. 

Gangrenous  inflammations  of  other  parts  of  the  body  are  sometimes 
seen  after  measles,  especially  of  the  vulva  or  the  prepuce. 

Nervous  system. — I  have  seen  convulsions  at  the  onset  of  measles  in 
but  a  single  case.     During  the  progress  of  the  disease  they  are  not  so  rare, 


MEASLES.  921 

and  may  occur  in  connection  with  otitis,  meningitis,  or  severe  broncho- 
pneumonia— chiefly  in  infants. 

Meningitis  is  rare,  but  either  the  simple  or  the  tuberculous  form  may 
occur,  more  often,  however,  as  a  sequel  than  as  a  complication.  Insanity, 
usually  of  a  temporary  character,  occasionally  follows  measles.  In  the 
epidemic  of  108  cases  reported  by  Smith  and  Dabney,  insanity  was  noted 
three  times,  all  the  cases  terminating  in  recovery.  Epilepsy  and  chorea 
are  rare  sequelae. 

Ears. — Otitis  is  not  so  frequent  as  in  scarlet  fever,  and  in  many  epi- 
demics it  rarely  occurs ;  in  others  it  is  often  seen.  In  one  hospital  epi- 
demic it  was  noted  in  14  per  cent  of  the  cases.  This  epidemic  occurred 
in  early  spring  and  affected  very  small  children,  both  of  which  circum- 
stances are  favourable  for  the  development  of  otitis.  Usually  both  ears 
are  affected,  and  the  inflammation  terminates  in  suppuration ;  but  the 
otitis  of  measles  is,  as  a  rule,  much  less  serious  than  that  of  scarlet  fever, 
and  much  less  frequently  leads  to  permanent  impairment  of  hearing. 

Eyes. — Simple  catarrhal  conjunctivitis  accompanies  nearly  every  case 
of  measles.  In  the  severe  form  there  is  a  muco-purulent  catarrh,  which 
may  attain  any  degree  of  severity.  In  neglected  cases,  and  among  chil- 
dren who  are  poorly  nourished,  especially  in  asylums,  the  disease  is  apt  to 
extend  to  the  cornea.  In  a  very  large  number  of  cases  chronic  conjunc- 
tivitis persists  after  measles,  particularly  in  the  class  of  children  just 
mentioned. 

Lymph  nodes. — Swelling  of  the  lymphatic  glands  of  the  neck  is  fre- 
quent, but  not  generally  severe,  and  rarely  terminates  in  suppuration.  In 
a  considerable  proportion  of  cases  chronic  enlargement  persists  for  months, 
and  sometimes  the  glands  may  become  tuberculous.  Similar  changes  and 
similar  consequences  may  occur  in  the  glands  of  the  tracheo-bronchial 
group. 

Kidneys. — The  infrequency  of  renal  complications  in  measles  is  in 
striking  contrast  to  scarlet  fever.  Transient  febrile  albuminuria  is  not 
uncommon,  but  a  serious  degree  of  nephritis,  either  clinically  or  at  au- 
topsy, I  have  never  seen,  and  literature  furnishes  but  few  cases.  Demme 
and  Browning  have  each  reported  cases  of  nephritis  following  measles,  in 
which  death  occurred  from  ursemia. 

Heart. — Both  endocarditis  and  pericarditis  have  occurred  in  the  course 
of  measles,  but  they  belong  to  the  rare  complications.  The  same  may  be 
said  of  changes  in  the  muscular  walls  of  the  heart. 

Shin. — As  complications,  erysipelas,  furunculosis,  impetigo,  and  pem- 
phigus have  been  noted ;  but  all  are  rare. 

Hcemorrhages. — Associated  with  the  hfemorrhagic  type  of  the  eruption, 
severe  and  even  fatal  haemorrhages  may  occur  from  the  mucous  mem- 
branes, and  the  latter  are  sometimes  seen  without  the  hemorrhagic 
eruption. 


922  THE  SPECIFIC  INFECTIOUS  DISEASES. 

Other  infections  diseases. — Measles  may  be  complicated  by  almost 
any  of  the  other  infectious  diseases— scarlet  fever,  varicella,  diphtheria, 
etc.  It  is  rare  that  the  two  diseases  are  exactly  simultaneous,  but  one 
usually  develops  as  the  other  is  subsiding.  Epidemics  of  measles  and 
whooping-cough  more  frequently  occur  together,  or  follow  each  other, 
than  do  any  of  the  others.  The  relation  of  measles  to  tuberculosis  seems 
to  be  particularly  close.  In  some  of  the  cases,  tuberculosis  follows  directly 
in  the  wake  of  measles,  an  irregular  temperature  continuing  from  three 
to  eight  weeks,  when  death  occurs  from  general  tuberculosis  with  the 
principal  lesions  in  the  lungs.  Acute  miliary  tuberculosis  may  follow 
even  more  closely.  As  a  late  manifestation,  the  most  common  one  is 
tuberculosis  of  the  bones,  occurring  as  hip-joint  disease,  caries  of  the 
spine,  etc.  The  relation  of  measles  to  tuberculosis  seems  to  be  that  it 
furnishes  conditions,  especially  in  the  lungs,  which  are  favourable  for  the 
development  of  tuberculosis  in  patients  who  have  been  previously  infected, 
but  in  whom  the  disease  has  been  latent  in  some  part  of  the  body,  espe- 
cially in  the  lymph  nodes.  In  other  cases  measles  seems  greatly  to  increase 
the  susceptibility  of  the  patient,  so  that  tuberculosis  is  subsequently  con- 
tracted after  the  slightest  exposure.  The  frequent  association  of  these 
diseases  should  never  be  forgotten,  and  on  this  account  an  attack  of  mea- 
sles in  a  child  with  tuberculous  antecedents  should  always  be  looked 
upon  with  apprehension. 

Diagnosis. — The  most  important  symptoms  for  diagnosis  are  the 
coryza,  at  first  slight,  but  steadily  increasing  in  severity,  the  gradual  rise 
in  temperature,  and  the  maculo-papular  eruption,  appearing  first  upon  the 
neck  and  face,  and  slowly  extending  over  the  body.  Before  the  rash  a 
diagnosis  is  impossible.  When  it  is  faint  and  of  doubtful  character, 
a  hot  mustard  bath  will  often  bring  it  out  so  distinctly  as  to  make  a  diag- 
nosis easy.  In  cases  where  the  rash  is  irregular  in  its  character  or  time  of 
appearance,  great  importance  is  to  be  attached  to  the  catarrhal  symptoms, 
especially  the  condition  of  the  eyes.  The  appearance  of  the  throat  and 
the  fine  red  spots  upon  the  hard  palate  are  also  important.  The  cases 
which  present  the  greatest  difficulties  are  the  very  severe  ones  and  those 
in  infants.  Mild  attacks  are  more  characteristic  than  are  the  mild  forms 
of  scarlet  fever. 

From  skin  diseases,  measles  is  distinguished  by  its  temperature,  which 
is  rarely  less  than  102-5°  F.  at  the  height  of  the  eruption  ;  from  other 
general  diseases  by  the  rash  itself. 

Prognosis. — This  depends  upon  the  age  and  previous  condition  of  the 
patient,  the  character  of  the  epidemic,  and  the  season  of  the  year  at  which 
it  occurs.  Except  in  children  under  three  years  of  age,  the  deaths  from 
measles  are  few  ;  but  in  institutions  containing  little  children,  no  epidemic 
disease  is  so  fatal.  The  following  statistics  illustrate  the  general  mortality 
of  the  disease  as  it  has  been  observed : 


MEASLES.  923 

Krauss  and  Hirschberg,  Dresden  Hospital,  49  years  1,461  cases ;  mortality,  4-2  per  cent. 

Sagoiski,  St.  Petersburg  Hospital,  11  years 7,050  "  "  9-2  " 

Embden,  one  epidemic 461  "  "  6*7  " 

Demme,  Berne  Hospital,  in  one  epidemic 224  "  "  5-8  " 

Alteberg,  one  epidemic 725  "  "  1  •  2  " 

Fleischmann 736  "  "  22*0  " 

Bendz,  Copenhagen 30,581  "  "  3-0  " 

The  average  mortality  of  the  disease  is  thus  from  four  to  six  per  cent; 
but  in  epidemics  observed  in  institutions  containing  only  young  children 
it  is  much  higher.  Henoch  records  an  epidemic  of  294  cases  among  chil- 
dren, nearly  one  half  of  whom  were  under  two  years  of  age,  with  a  mor- 
tality of  30  per  cent.  In  the  epidemic  of  1892,  in  the  Nursery  and  Child's 
Hospital,  New  York,  there  were  143  cases,  with  a  mortality  of  35  per  cent. 
The  figures  of  the  epidemic  of  1895  were  almost  identical.  All  these 
children  were  inmates  of  the  institution  at  the  time  they  were  taken  ill, 
and,  although  many  were  delicate,  few  were  suffering  from  other  dis- 
eases when  they  were  attacked  with  measles.  The  following  table 
gives  the  exact  figures  of  the  epidemic  of  1892  : 

From  six  to  twelve  months 42  cases ;  mortality,  33  per  cent. 

"      one  to  two  years 51     "  "  50       " 

"      two  to  three  years 27      "  "  30       " 

"      three  to  four  years 20      "  "  14       " 

"      four  to  five  years 8      "  "  0       " 

The  average  mortality  among  children  under  two  years  is  probably  not 
far  from  20  per  cent,  but  it  is  much  higher  in  institutions.  The  death- 
rate  diminishes  rapidly  after  the  second  year. 

In  any  single  case  the  important  symptoms  for  prognosis  are  the  tem- 
perature and  the  character  of  the  eruption.  An  initial  temperature  above 
103°  F.,  or  one  which  remains  high  until  the  eruption  appears,  is  a  bad 
symptom.  So  also  is  one  which  rises  after  a  full  eruption,  or  which  does 
not  fall  as  the  rash  fades.  The  following  table  shows  the  highest  tem- 
perature and  mortality  in  161  hospital  cases : 

Highest  temperature  not  over  102" 6  cases ;  mortality,  0  per  cent. 

102°  to  108-5" 14      "  "  7 

104''  "  104-5° 49      "  "        16       " 

105°  "  105-5° 65      "  "        40 

106°  or  over 27     "  "        80 

A  favourable  eruption  is  one  of  a  bright  colour,  covering  the  body,  re- 
maining discrete,  and  spreading  gradually.  It  is  unfavourable  for  the 
eruption  to  appear  late,  to  be  very  faint,  scanty,  or  hremorrhagic,  or  to 
recede  suddenly,  as  this  is  usually  due  to  a  weak  heart. 

Of  51  fatal  cases,  the  cause  of  death  was  broncho-pneumonia  in  45, 
ileo-colitis  in  4,  and  membranous  laryngitis  in  2.  More  than  half  the 
deaths  occurred  during  the  second  week,  the  earliest  being  upon  the  fifth 
day  of  the  disease. 


924  THE  SPECIFIC  INFECTIOUS  DISEASES. 

The  ultimate  result  of  an  attack  of  measles  may  not  be  evident  for 
some  time.  Cases  in  which  the  temperature  persists  for  two  or  three 
weeks  without  assignable  cause  after  the  disease  is  apparently  over,  should 
be  watched  with  the  greatest  solicitude.  The  explanation  of  this  is  most 
frequently  to  be  found  in  the  lungs,  although  the  physical  signs  are  often 
obscure.  The  condition  may  be  either  subacute  pneumonia  or  pulmonary 
tuberculosis.  Even  though  the  attack  of  measles  may  not  have  been  in 
itself  severe,  seeds  are  often  sown  the  full  fruits  of  which  are  not  seen 
until  long  afterward.  Chronic  glandular  enlargements  which  may  or 
may  not  be  tuberculous,  chronic  bronchitis,  chronic  laryngitis,  subacute 
or  chronic  nasal  catarrh,  hypertrophy  of  tlie  tonsils,  and  adenoid  growths 
of  the  pharynx, — all  are  frequent  sequelae. 

Prophylaxis. — Measles  is  often  regarded  by  the  laity  as  so  mild  a 
disease  that  its  prevention  is  thought  of  little  importance,  and  no  effort 
is  made  to  limit  its  extension.  The  great  probability  that  every  person 
at  some  time  in  his  life  will  have  the  disease,  is  no  justification  of  unneces- 
sary exposure.  Although  in  older  children  measles  is  usually  mild,  this 
is  not  so  in  infants,  who  should  be  carefully  protected  from  exposure. 
Special  care  should  also  be  taken  to  avoid  the  exposure  of  delicate  children 
or  those  with  a  strong  tendency  to  pulmonary  disease  or  to  tuberculosis. 
In  institutions  it  is  of  the  utmost  importance  to  secure  prompt  and  com- 
plete isolation  of  the  first  case  which  appears. 

The  disease  being  usually  spread  by  the  patient  and  rarely  from  apart- 
ments, it  follows  that  while  early  isolation  is  more  important,  there  is  not 
required  the  same  thorough  cleansing  and  disinfection  which  should  follow 
every  case  of  scarlet  fever.  In  an  institution,  the  ward  or  cottage  from 
which  a  case  has  been  removed  should  be  quarantined  for  at  least  sixteen 
days  after  the  appearance  of  the  last  case,  and  absolute  security  can  not 
be  said  to  exist  until  the  end  of  three  weeks.  The  same  rule  should  be 
applied  in  private  families  where  children  who  have  been  exposed 
should  be  quarantined  apart  from  the  patient,  but  not  sent  away.  Under 
ordinary  circumstances  the  quarantine  of  a  case  of  measles  should  last 
four  weeks  from  the  beginning  of  invasion.  It  should  be  continued  longer 
if  there  is  pneumonia,  otitis,  or  a  nasal  discharge. 

Thorough  cleansing  and  disinfection  of  the  sick-room  should  be  done 
before  it  is  again  occupied  by  children,  and  it  should  remain  vacant  at 
least  two  weeks.  Children  should  be  kept  from  all  schools  while  the 
disease  is  in  their  homes,  chiefly  because  they  are  otherwise  liable  to  spread 
the  disease  while  suffering  from  the  early  symptoms  of  invasion. 

Treatment. — Measles  is  a  self-limited  disease,  and  there  are  no  known 
measures  by  which  it  can  be  aborted,  its  course  shortened,  or  its  severity 
lessened.  The  indications  are  therefore  to  treat  serious  symptoms  as  they 
arise,  and,  as  far  as  possible,  to  prevent  complications,  which  are  the  prin- 
cipal cause  of  death. 


MEASLES.  925 

The  sick-room  should  be  darkened,  as  the  eyes  are  very  sensitive  to 
light.  Every  child  with  measles  should  be  put  to  bed  and  kept  there  with 
light  covering  during  the  entire  febrile  period.  There  can  be  no  possible 
advantage  in  causing  a  child  to  swelter  by  thick  blankets,  under  the  delu- 
sion that  the  disease  may  be  modified  thereby.  The  food  should  be  light, 
fluid,  and  given  at  regular  intervals.  If  the  conjunctivitis  is  severe,  iced 
cloths  should  be  applied  to  the  eyes^  which  should  be  kept  clean  by  the  fre- 
quent use  of  a  saturated  solution  of  boric  acid,  the  lids  being  jDrevented 
from  adhering  by  the  application  of  vaseline  or  simple  ointment.  The 
intense  itching  and  burning  of  the  skin  may  be  relieved  by  inunctions  of 
plain  or  carbolized  vaseline.  The  cough,  when  distressing,  may  be  allayed 
by  small  doses  of  opium,  either  in  the  form  of  the  brown  mixture  or  by 
equal  parts  of  paregoric  and  glycerin,  of  which  from  five  to  thirty  drops 
may  be  given,  according  to  the  age  of  the  child,  every  two  hours.  The 
restlessness,  headache,  and  the  general  discomfort  which  accompany  the 
height  of  the  fever  may  be  relieved  by  an  occasional  dose  of  phenacetine  or 
antipyrine.  As  soon  as  the  rash  has  subsided,  a  daily  warm  bath  should  be 
given,  followed  by  inunctions  to  facilitate  desquamation  and  prevent  the 
dissemination  of  the  fine  scales. 

The  important  indications  to  be  met  in  the  severe  cases  are  very  high 
temperature,  cardiac  depression,  and  nervous  symptoms — dulness,  stupor, 
sometimes  coma,  or  convulsions.  In  some  of  the  cases  there  are  in  addi- 
tion dyspnoea  and  cyanosis,  showing  severe  acute  pulmonary  congestion. 
For  the  nervous  symptoms  and  high  temperature,  nothing  is  so  reliable 
as  the  cold  baths  or  packs  (pages  47  and  48)  and  the  nearly  continuous 
use  of  ice  to  the  head.  I  do  not  think  there  is  any  evidence  that  the  use  of 
cold  increases  the  liability  to  pneumonia ;  but  cold  extremities,  feeble  pulse, 
and  cyanosis,  when  associated  with  high  temperature,  call  for  the  hot  mus- 
tard bath,  although  ice  should  still  be  applied  to  the  head.  The  indications 
for  stimulants  and  the  methods  of  using  them  are  the  same  as  in  broncho- 
pneumonia (page  510),  which  is  usually  present  in  cases  requiring  them. 

To  diminish  the  chances  of  pneumonia,  it  is  necessary  that  every  pa-, 
tient  should  be  kept  in  bed  during  the  attack,  and  care  exercised  to  avoid 
exposure ;  that  the  chest  should  be  protected  with  flannel  and  rubbed 
daily  with  oil.  But  still  more  important  is  it  in  hospitals  and  institutions 
where  most  of  the  cases  of  pneumonia  occur,  to  allow  the  patients  plenty 
of  air  space,  never  crowding  them  together  in  small  wards.  If  possible, 
cases  complicated  by  pneumonia  should  be  separated  from  simple  cases. 
From  the  fact  that  the  pneumococcus  and  the  streptococcus  are  found  in 
the  mouth  so  constantly  and  in  such  numbers  in  cases  complicated  by 
pneumonia,  Mery  and  Boulloque  have  suggested  systematic  disinfection 
of  the  mouth  several  times  a  day,  with  the  purpose  of  preventing  this 
complication.  There  is  reason  in  this  suggestion,  although  its  efficacy 
has  not  yet  been  put  to  a  practical  test. 


926  THE  SPECIFIC   INFECTIOUS  DISEASES, 

The  bronchitis  and  broncho-pneumonia  of  measles  should  be  managed 
as  in  cases  where  they  occur  as  primary  diseases,  as  the  coexistence  of 
measles  furnishes  no  new  indications.  The  same  is  true  of  the  diarrha?a, 
conjunctivitis,  and  otitis.  Membranous  laryngitis,  pharyngitis,  or  ton- 
sillitis should  be  treated  like  other  cases  of  pseudo-diphtheria.  Should 
cultures  show  the  presence  of  the  diphtheria  bacillus,  the  case  should  be 
treated  like  one  of  ordinary  diphtheria  in  the  same  situation. 

During  convalescence  the  eyes  should  be  used  very  carefully  for  at 
least  several  weeks.  Should  the  cough  and  slight  fever  persist,  with  or 
without  physical  signs  in  the  chest,  the  patient  should,  if  possible,  be  sent 
away  to  a  warm,  dry,  elevated  district,  as  the  development  of  tuberculosis 
is  always  to  be  feared.  Cod-liver  oil  should  be  given  continuously 
throughout  the  succeeding  cool  season,  and  iron,  wine,  and  other  tonics 
according  to  indications.  The  cough  itself  should  be  treated  as  when  it 
follows  an  ordinary  bronchitis  (page  470),  creosote  being  more  generally 
useful  than  any  other  drug. 


CHAPTER  III. 

RUBELLA. 

Synonyms  :  German  measles  ;  rotheln. 

EuBELLA  is  a  contagious  eruptive  fever  which  is  rarely  seen  except 
when  prevailing  epidemically.  It  is  characterized  by  a  short  invasion, 
with  mild,  indefinite  symptoms,  usually  lasting  but  a  few  hours,  and  by  an 
eruption  which  is  generally  well  marked  but  of  variable  appearance.  The 
constitutional  symptoms  are  very  mild,  and  the  disease  rarely  proves  fatal, 
not  often  being  even  serious.  For  a  long  time  rubella  was  confounded 
with  measles  and  scarlet  fever,  as  the  eruption  sometimes  resembles  one 
and  sometimes  the  other  disease.  Its  identity  is  now  fully  established, 
and,  as  Striimpell  well  says,  its  existence  is  doubted  only  by  those  who 
have  never  seen  it.  The  following  peculiarities  have  been  stated  by 
Griffith  (Philadelphia),  who  has  written  more  fully  on  rubella  than  any 
other  American  writer,  and  to  whom  I  am  indebted  for  many  facts  in  this 
article : 

(1)  Rubella  is  a  contagious,  eruptive  fever,  and  not  a  simple  affection 
of  the  skin ;  (2)  it  prevails  independently  either  of  measles  or  of  scarlet 
fever ;  (3)  its  incubation,  eruption,  invasion,  and  symptoms,  differ  materi- 
ally from  those  of  both  these  diseases  ;  (4)  it  attacks  indiscriminately  and 
with  equal  severity  those  who  have  had  measles  and  scarlet  fever  and 
those  who  have  not,  nor  does  it  protect  in  any  degree  against  either  of 
them ;  (5)  it  never  produces  anything  but  rubella  in  those  exposed  to  its 
contagion ;  (6)  it  occurs  but  once  in  the  individual. 


RUBELLA.  927 

Etiology. — Rubella  is  beyond  question  contagious,  but  is  decidedly 
less  so  than  either  measles  or  scarlet  fever ;  so  that  some  observers  have 
doubted  its  contagion  altogether.  It  can  be  communicated  at  any  time 
during  its  course,  but  is  especially  contagious  during  the  early  stage. 
Epidemics  usually  prevail  in  the  winter  or  spring.  As  in  the  other 
eruptive  fevers,  a  striking  immunity  is  seen  in  infants  under  six  months 
old ;  but,  with  this  exception,  all  ages  are  liable  to  the  disease. 

The  incubation  of  rubella  varies  considerably  ;  the  usual  period  is 
from  eight  to  sixteen  days,  although  the  limits  are  from  five  to  twenty-two 
days. 

Symptoms. — Inva.sion. — This  is  rarely  more  than  half  a  day,  and  in 
many  cases  no  prodromata  whatever  are  noticed,  the  rash  being  the  first 
thing  to  attract  attention.  In  a  few  cases  there  are  mild  catarrhal  symp- 
toms, with  general  malaise  and  slight  fever.  At  other  times  there  may  be 
vomiting,  convulsions,  delirium,  epistaxis,  rigors,  headache,  or  dizziness ; 
but  all  are  to  be  regarded  as  very  exceptional. 

Enqjfion. — Frequently  a  child  wakes  in  the  morning  covered  with  the 
rash,  no  symptoms  having  been  previously  noticed.  It  generally  appears 
first  upon  the  face,  and  spreads  rapidly  to  the  whole  body,  the  lower  ex- 
tremities being  last  covered.  Less  than  a  day  is  usually  required  for  its 
full  development.  Exceptionally  the  eruption  comes  first  upon  the  chest 
and  back,  and  sometimes  nearly  the  whole  body  is  covered  almost  at  once. 
The  rash  has  occasionally  been  observed  in  the  roof  of  the  mouth  before 
it  was  visible  on  the  face.  In  a  considerable  number  of  cases  the  entire 
body  is  not  covered ;  but  the  rash  is  more  constantly  seen  upon  the  face 
than  upon  any  other  part. 

Its  character  is  subject  to  considerable  variation.  The  eruption  is 
most  frequently  composed  of  very  small  maculo-papules;  they  are  of  a 
pale-red  colour,  and  vary  in  size  from  a  pin's  head  to  a  pea.  The  spots 
are  usually  discrete,  but  may  cover  the  greater  part  of  the  body  where  it 
is  seen.  On  the  face  it  is  frequently  confluent,  and  often  appears  here 
as  large,  irregular  blotches  of  a  red  colour.  From  this  description  the 
rash  will  be  seen  to  resemble  that  of  measles  more  than  that  of  any  other 
disease.  Very  often,  however,  there  is  a  tolerably  uniform  red  blush  which 
bears  a  close  resemblance  to  the  rash  of  scarlet  fever ;  but  even  in  such 
cases  there  will  nearly  always  be  found  upon  some  part  of  the  body,  usu- 
ally the  wrists,  fingers,  or  forehead,  some  typical  maculo-papules.  Between 
these  two  extremes  all  variations  are  seen.  The  colour  of  the  eruption  is 
sometimes  dark  red,  and  rarely  it  has  been  noted  to  be  hemorrhagic.  The 
degree  of  elevation  above  the  surface  is  also  variable  ;  sometimes  this  is  so 
marked  as  to  give  to  the  skin  a  "  shotty  "  feel,  while  in  others  the  elevation 
is  scarcely  perceptible.  The  duration  of  the  eruption  is  usually  three  days. 
Occasionally  it  lasts  only  two  days,  and  it  may  last  but  one ;  it  is  rare  for 
it  to  remain  as  long  as  four  days.  It  fades  in  the  order  of  its  appearance, 
60 


928  THE   SPECIFIC   INFECTIOUS   DISEASES. 

and  more  rapidly  than  the  eruption  of  measles.  A  slight  brown  pigmen- 
tation of  the  skin  sometimes  remains  for  a  few  days  after  the  rash. 

The  highest  temperature  is  coincident  with  the  full  eruption  ;  this  does 
not  usually  exceed  102°,  and  often  it  is  only  100°  F.  As  a  rule,  the  tem- 
jierature  continues  but  two  days,  falling  as  the  eruption  fades.  Very 
often  the  fall  to  normal  is  abrupt.  Rarely  severe  cases  are  seen  in  which 
the  fever  lasts  for  four  or  five  days,  being  101°  or  102°  F.  during  the  inva- 
sion, and  rising  to  104°  or  105°  F.  during  the  full  eruption.  The  other 
symptoms  are  in  most  cases  even  less  marked  than  the  fever.  Occasionally 
catarrhal  symptoms  resembling  a  mild  attack  of  measles  are  present,  or  a 
sore  throat  suggesting  mild  scarlet  fever ;  but  more  frequently  all  these 
are  absent.  The  eruption  is  usually  out  of  all  proportion  to  the  other 
signs  of  disease. 

Swelling  of  the  post-cervical  glands  is  one  of  the  most  constant  fea- 
tures of  rubella.  In  most  epidemics  it  is  seen  in  nearly  all  cases  ;  but  as  a 
symptom  for  differential  diagnosis  it  is  not  of  great  importance,  as  it  is 
not  uncommon  in  measles.  The  glandular  swelling  is  most  marked  at  the 
height  of  the  disease ;  it  is  never  very  great,  and  subsides  slowly  without 
suppuration.  Both  vomiting  and  diarrhoea  are  rare  in  rubella.  Swelling 
and  itching  of  the  skin  are  occasionally  jDresent,  but  to  a  much  less  extent 
than  in  scarlet  fever  or  measles. 

Desquamation. — This  is  always  slight,  and  occurs  in  very  fine  scales 
lasting  from  one  to  five  days.  In  many  cases  it  can  be  discovered  only  by 
the  most  careful  examination,  and  occasionally  it  is  entirely  wanting. 
Writers  who  have  observed  some  fairly  typical  epidemics  have  stated  that 
desquamation  did  not  occur. 

Complications  and  Sequelae. — A  characteristic  feature  of  rubella  is  the 
absence  both  of  complications  and  sequelae.  In  the  great  majority  of 
cases  none  are  seen.  Isolated  instances  have  been  reported  in  which  have 
occurred,  severe  bronchitis  or  pneumonia,  severe  catarrhal  pharyngitis,  al- 
buminuria, diarrhoea,  phlyctenular  conjunctivitis,  multiple  abscesses,  otitis, 
erysipelas,  and  urticaria ;  but  all  are  to  be  regarded  as  very  exceptional. 

Prognosis. — There  are  few  diseases  so  free  from  danger  as  rubella. 
A  fatal  termination  is  extremely  rare,  and  is  usually  due  to  pulmonary 
complications.  Squire  makes  the  significant  statement  that  if  the  mor- 
tality reaches  three  per  cent  the  disease  is  not  rubella,  but  measles. 

Diagnosis. — The  principal  interest  attaching  to  rubella  is  in  its  diag- 
nosis. This  is  a  matter  of  extreme  difficulty,  and  often  it  is  an  impossi- 
bility. The  most  characteristic  thing  about  the  disease  is  a  well-marked 
eruption  with  very  few  other  symptoms.  Cases  so  closely  resemble  mild 
scarlet  fever  or  mild  measles  that  the  differentiation  by  symptoms  is  im- 
possible ;  it  must  be  made  from  the  surroundings  and  the  fact  that  the  dis- 
ease is  prevailing  epidemically.  Scarlet  fever  with  a  low  temperature  and 
abundant  rash  should  always  be  regarded  with  suspicion,  as  should  mea- 


VARICELLA. 


929 


sles  with  a  doubtful  or  absent  catarrh.  These  difficulties  in  diagnosis  can 
be  appreciated  only  by  one  who  has  seen  epidemics  of  measles  and  scarlet, 
fever  in  institutions,  and  has  watched  the  mild  course  of  undoubted  cases 
of  these  diseases  which  have  there  occurred. 

It  is  never  safe  to  make  the  diagnosis  of  rubella  unless  the  disease  is 
prevailing  epidemically.  Sporadic  cases  in  which  the  diagnosis  is  made 
are,  I  believe,  almost  invariably  instances  of  mild  measles  or  scarlet  fever. 
The  first  cases  of  rubella  in  an  epidemic  thus  become  difficult  of  recog- 
nition and  are  often  overlooked.  The  continued  absence  in  succeeding 
cases  of  the  characteristic  symptoms  and  complications  of  measles  or  scar- 
let fever  should  suggest  to  the  physician  that  he  is  probably  dealing  with 
rubella. 

Treatment. — Xone  whatever  is  required  for  the  disease  excepting  iso- 
lation, and  even  this  is  not  imperative.  The  individual  symptoms  and 
complications  are  to  be  met  with  as  they  arise. 


CHAPTER   IV. 

VARICELLA. 

Synonym  :  Chicken-pox. 

Varicella  is  an  acute,  contagious  disease,  characterized  by  a  cuta- 
neous eruption  of  papules  and  vesicles  and  by  mild  constitutional  symp- 
toms, serious  complications  and  sequela?  being  very  rare.  Although  long 
confounded  Avith  varioloid,  its  existence  as  a  distinct  disease  has  been  gen- 
erally admitted  for  many  years. 

Etiology. — It  is  well  established  that  the  contagium  of  the  disease  is 
contained  in  the  vesicles,  as  it  may  be  communicated  by  inoculation  with 
their  contents.  The  specific  poison,  however,  has  not  yet  been  isolated. 
Varicella  is  contracted  by  exposure  to  another  case  or  through  the  medium 
of  a  third  person.  It  affects  children  of  all  ages,  one  attack  being  as  a 
rule  protective.  It  is  very  contagious,  resembling  measles  in  this  respect. 
The  duration  of  incubation  is  quite  uniformly  from  fourteen  to  sixteen 
days. 

Sjrmptoms. — Slight  fever  and  general  indisposition  may  be  noticed  for 
twenty-four  hours  before  the  appearance  of  the  eruption,  but  in  most 
cases  the  eruption  is  the  first  symptom.  It  usually  appears  first  upon 
the  face,  scalp,  or  shoulders,  as  small,  red,  widely-scattered  papules,  and 
spreads  slowly  over  the  trunk  and  extremities.  The  papules  in  most  cases 
come  in  crops,  new  ones  continuing  to  appear  for  three  or  four  days,  even 
upon  the  same  part  of  the  body.  The  earlier  ones  have  generally  begun  to 
dry  up  by  the  time  the  later  ones  appear,  so  that  all  stages  of  the  eruption 
may  be  present  at  one  time  in  the  same  region,  this  being  one  "of  its  most 


930  THE  SPECIFIC   INFECTIOUS   DISEASES. 

diagnostic  features.  The  papules  are  at  first  very  small,  but  gradually  in- 
crease in  size,  and  are  surrounded  by  an  areola  from  one  fourth  to  half  an 
inch  in  width.  Many  of  them  go  no  further  than  this  stage,  but  the  ma- 
jority become  vesicular.  The  vesicles  are  usually  flat,  and  vary  a  good  deal 
in  size — the  largest,  being  about  one  fourth  of  an  inch  in  diameter.  The 
process  of  drying  up  generally  begins  at  the  centre,  which  causes  a  slight 
depression,  giving  the  vesicle  a  somewhat  umbilicated  appearance.  The 
areola  is  most  distinct  at  the  time  of  the  fully-formed  vesicle,  and  fades 
as  the  latter  dries.  Crusts  now  form,  which  fall  off  in  from  five  to  twenty 
days,  depending  upon  the  depth  to  which  the  skin  has  been  involved.  In 
the  majority  of  cases  no  mark  is  left,  but  after  the  most  severe  attacks, 
where  the  true  skin  has  been  involved,  scars  remain,  and  occasionally 
there  is  quite  deep  pitting.  Such  marks  are  few  in  number,  and  are  most 
likely  to  occur  upon  the  face. 

Sometimes,  especially  upon  hands  and  feet,  the  vesicle  appears  without 
having  been  preceded  by  a  papule ;  often  there  is  no  areola,  and  the  vesi- 
cle resembles  a  drop  of  water  upon  healthy  skin.  In  most  cases  pustules 
are  not  seen,  but  they  may  develop  in  consequence  of  irritation  or  infec- 
tion, the  result  of  scratching,  or  in  children  who  are  poorly  nourished. 
Under  these  circumstances  deeper  ulceration  may  occur,  lasting  for  weeks. 
In  rare  cases  there  may  be  a  necrotic  inflammation  about  the  site  of  the 
pock,  a  condition  to  which  is  sometimes  given  the  name  varicella  gangre- 
nosa. It  is  not  peculiar  to  varicella,  and  is  described  elsewhere  under  the 
head  of  Gangrenous  Dermatitis  (page  872). 

The  jDocks  are  usually  most  abundant  over  the  back  and  shoulders,  and 
their  number  is  in  proportion  to  the  severity  of  the  disease.  In  mild 
cases  only  twenty  or  thirty  may  be  found  upon  the  entire  body,  but  in 
severe  cases  the  skin  may  in  certain  regions  be  nearly  covered.  The  erup- 
tion is  never  confluent.  The  pocks  are  almost  invariably  seen  on  the 
hairy  scalp,  and  frequently  three  or  four  may  be  found  on  the  mucous 
membrane  of  the  mouth  or  pharynx, — a  point  of  some  diagnostic  value. 
In  the  latter  situation  the  appearance  is  first  a  tiny  vesicle,  and  later  a 
superficial  ulcer  resembling  that  of  herpetic  stomatitis. 

The  temperature  is  highest  when  the  eruption  is  most  rapidly  appear- 
ing, this  usually  being  the  second  or  third  day.  In  an  average  case  it 
reaches  only  101°  or  102°  F.,  and  lasts  but  two  days ;  in  severe  cases  it 
may  rise  to  104°  or  105°  F.,  and  last  for  four  or  five  days.  It  falls  gradu- 
ally to  normal  as  the  rash  fades.  The  other  symptoms  are  mild  and 
not  characteristic.  There  is  no  coryza,  cough,  vomiting,  or  diarrhoea, 
but  instead  only  the  general  indisposition  which  accompanies  any  febrile 
disorder. 

Complications. — The  most  serious  complication  is  erysipelas,  which 
develops  about  the  pocks,  particularly  when  they  are  deep  and  attended 
with  some  ulceration.     I  have  known  of  three  fatal  cases  from  this  cause. 


VACCINIA.— VACCINATION.  931 

Adenitis,  either  simple  or  suppurative,  and  abscesses  in  the  cellular  tissue, 
are  occasionally  seen.  Nephritis  is  very  infrequent,  but  a  number  of  cases 
are  recorded.  It  may  occur  at  the  height  of  the  disease,  but  more  often 
at  a  later  jieriod,  like  the  nephritis  of  scarlet  fever.  Varicella  is  quite 
frequently  complicated  by  other  infectious  diseases.  In  the  New  York 
Infant  Asylum  epidemics  of  varicella  and  scarlet  fever  at  one  time  oc- 
curred together,  and  in  at  least  a  dozen  children  both  diseases  were  seen 
at  the  same  time. 

Diagnosis. — The  diagnosis  of  varicella  is  usually  easy,  provided  the 
following  points  are  kept  in  mind :  First,  that  the  eruption  comes  out 
slowly  and  in  crops,  so  that  papules,  vesicles,  and  crusts  may  be  seen  upon 
the  skin  in  close  proximity;  secondly,  that  the  umbilication  is  due  only 
to  the  mode  of  drying  up  of  the  vesicle,  which  begins  at  the  center; 
thirdly,  the  appearance  of  the  pocks  upon  the  mucous  membranes,  and 
the  history  of  exposure.  It  is  distinguished  from  urticaria  and  other 
forms  of  skin  disease  by  the  presence  of  fever. 

Treatment. — Although  it  is  usually  a  trivial  disease,  isolation  of  cases 
of  varicella  should  be  enforced  in  schools  and  in  institutions  containing 
many  infants.  In  the  home,  unless  the  other  children  are  delicate  or  in 
poor  condition,  quarantine  is  unnecessary.  The  disease  may  probably  be 
conveyed  as  long  as  the  crusts  are  present,  hence  isolation  should  be 
maintained  until  they  have  fallen  off.  In  most  cases  constitutional  symp- 
toms of  the  disease  are  so  mild  as  to  require  no  treatment. 

Locally,  the  itching,  when  annoying,  may  be  allayed  by  sponging  with 
a  weak  solution  of  carbolic  acid  or  the  use  of  carbolized  vaseline.  When 
the  crusts  have  formed,  this  ointment  or  vaseline  containing  two  pev  cent 
ichthyol  should  be  applied.  Care  is  necessary  to  keep  the  skin  clean,  and, 
in  the  case  of  infants,  to  prevent  scratching.  In  severe  cases  the  urine 
should  invariably  be  examined. 


CHAPTER   V. 
VA  CCINIA—  VA  COIN  A  TION. 

Vaccinia  (cowpox)  is  a  febrile  disease  induced  in  man  by  inocula- 
tion with  the  virus  obtained  either  directly  from  the  cow  (bovine  virus) 
or  from  a  person  who  has  been  inoculated  (humanized  virus).  The  dis- 
ease is  not  contagious  in  the  ordinary  sense  of  the  term,  but  is  communi- 
cated by  inoculation  either  accidental  or  intentional. 

The  nature  of  the  protection  against  smallpox  which  vaccination 
affords  is  even  now  but  imperfectly  understood.  The  fact,  however,  re- 
mains one  of  the  best  attested  in  medical  history.  It  is  the  imperative 
duty  of  the  physician  to  see  to  it  that  every  young  infant  is  vaccinated. 


932  THE  SPECIFIC   INFECTIOUS  DISEASES. 

and  no  foolish  sentiment  or  prejudice  on  the  part  of  the  parents  should 
be  allowed  to  stand  in  the  way. 

Re-vaccination. — Regarding  the  duration  of  the  protective  power  of  a 
single  vaccination,  positive  statements  are  impossible.  Nearly  all  writers 
are  agreed  that  vaccination  should  be  done  in  infancy,  again  at  puberty, 
and  a  third  time  at  about  the  age  of  twenty  or  twenty- live.  Many  also 
insist  upon  re-vaccination  at  about  the  seventh  year.  It  is  a  safe  rule 
when  smallpox  is  prevalent  to  vaccinate  every  person  who  has  not  been 
successfully  vaccinated  within  five  years. 

Choice  of  Virus. — Modern  experience  is  quite  unanimous  in  tlie  substi- 
tution of  bovine  for  humanized  virus,  the  advantages  being  that  the  lymph 
is  much  more  likely  to  be  obtained  pure,  uncontaminated  by  the  germs  of 
erysipelas  or  suppuration,  and  that  the  risk  of  transmitting  syphilis  is 
thereby  avoided.  There  is  now  no  difficulty  in  obtaining  the  ivory  or 
quill  points  used  for  the  preservation  of  bovine  virus.  There  are  many 
vaccine  farms  which  can  be  depended  upon  for  the  purity  and  freshness 
of  the  virus  which  they  supply.* 

Time  for  Vaccinating. — In  selecting  a  time  for  vaccination,  the  child's 
age  and  general  health  must  be  taken  into  consideration.  It  is  pretty  well 
established  that  the  constitutional  disturbance  is  much  less  in  infancy 
than  in  later  childhood,  and  less  in  very  young  infants  (under  one  month) 
than  in  those  of  five  or  six  months.  Wolff  states  that  of  forty-two  infants 
successfully  vaccinated  during  the  first  week  of  life,  not  one  showed  any 
constitutional  disturbance ;  after  the  fifth  month,  however,  febrile  symp- 
toms were  invariably  present,  and  occasionally  severe.  A  good  rule  for 
general  practice  is  to  vaccinate  every  healthy  infant  as  soon  as  it  begins 
to  gain  regularly  in  weight,  this  being  in  most  cases  during  the  first  two 
months  of  life.  In  delicate  infants  or  in  those  whose  nutrition  is  a 
matter  of  great  difficulty,  those  who  are  syphilitic,  those  suffering  from 
eczema  or  any  other  form  of  active  skin  disease,  vaccination  should  be 
deferred  until  the  child  is  in  good  condition,  unless  it  is  likely  to  be  ex- 
posed to  smallpox.  As  a  rule,  vaccination  should  be  avoided  during  den- 
tition. 

Methods  of  Vaccinating. — In  my  experience  it  is  better  to  vaccinate  in 
one  place  rather  than  to  make  two  or  three  inoculations.  Either  the  leg  or 
the  arm  may  be  chosen ;  in  young  infants  it  is  usually  easier  to  protect  the 
vaccine  sore  upon  the  leg  than  upon  the  arm.  The  point  selected  for  inocu- 
lation should  be  either  the  outer  aspect  of  the  left  calf,  about  the  junction 
of  the  middle  with  the  upper  third  of  the  leg,  or  the  insertion  of  the  left 
deltoid.  The  skin  should  be  washed  -with  soap  and  water,  dried,  and  then 
washed  with  alcohol.     With  an  ordinary  large-sized  cambric  needle,  which 

*  My  own  experience  with  that  of  the  New  England  Vaccine  Company  of  Massa- 
chusetts has  been  extremely  satisfactory. 


VACCINIA.— VACCINATION.  933 

should  be  a  new  one,  three  or  four  scratches  should  be  made  a  quarter  of 
an  inch  long,  and  these  crossed  by  as  many  more,  just  deeply  enough  to 
draw  blood.  The  moistened  vaccine  point  is  now  thoroughly  rubbed  for 
a  full  minute  over  the  wound.  After  this  has  dried  thoroughly  the  part 
may  be  covered  with  isinglass  plaster  moistened  in  boiled  water,  although 
if  thorough  drying  has  taken  place  the  plaster  is  not  necessary.  The 
needle  should  not  be  used  for  a  second  child.  The  vaccinated  limb  should 
not  be  washed  for  twenty-four  hours. 

The  Normal  Course  of  Vaccinia. — The  course  of  a  proper  vaccination- 
pock  is  quite  uniform,  and  one  which  does  not  follow  this  course  should 
not  be  considered  protective.  The  original  wound  heals  like  any  other 
scratch,  nothing  of  importance  being  seen  until  the  fourth  or  fifth  day, 
when  a  slight  areola  is  visible  about  the  site  of  inoculation,  which  enlarges 
until  it  is  an  inch  or  two  in  diameter.  Then  there  rises  a  vesicle,  some- 
times two,  which  afterward  coalesce.  The  vesicle  is  from  one  fourth  to 
one  half  an  inch  in  diameter,  and  has  a  depressed  centre  {Fig.  164).  By 
the  ninth  or  tenth  day  the  fully-formed  vesicle  is  seen.  The  areola  is 
now  two  or  three  inches  wide,  and  there  is  more  or  less  swelling.  The 
lymph  nodes  in  the  axilla,  or  in  the  groin  if  the  leg  has  been  inoculated, 
are  slightly  swollen,  tender,  and  sometimes  painful.  The  vaccine  pock 
changes  but  slightly  for.  a  day  or  two,  after  which,  usually  upon  the 
■eleventh  day,  the  areola  fades,  the  vesicle  ruptures  and  discharges,  or  dries 
to  a  crust,  this  process  occupying  about  two  days.  The  crust  remains  for 
from  one  to  three  weeks,  when  it  falls  off  leaving  a  smooth  bluish  scar 
which  afterward  fades  to  a  white,  and  becomes  somewhat  honeycombed. 

In  some  cases  the  symptoms  are  more  severe.  There  may  be  swelling 
of  the  whole  limb  and  marked  pain.  The  original  vesicle  may  be  two  or 
three  times  as  large  as  usual,  and  secondary  vesicles  may  form  in  the 
neighbourhood  (Fig.  165).  The  inflammation  may  extend  deeply  into 
the  subcutaneous  tissue,  and  it  may  be  followed  by  suppuration  or  even 
sloughing.  There  is  then  left  an  ugly  ulcer,  sometimes  an  inch  wide  and 
one  fourth  of  an  inch  deep,  to  be  filled  slowly  by  granulation.  In  such 
cases  the  whole  course  of  the  disease  may  be  from  five  to  eight  weeks. 

If  in  a  young  infant  the  first  inoculation  is  unsuccessful,  at  least  three 
trials  should  be  made  with  good  virus,  and  in  the  event  of  further  failure, 
after  a  year  vaccination  should  be  repeated.  A  failure  to  inoculate  does 
not  mean  insusceptibility  to  smallpox,  as  is  often  popularly  believed,  but 
most  frequently  arises  from  the  fact  that  the  virus  is  inert.  I  have  known 
one  case  in  which  the  seventh,  and  another  in  which  the  thirteenth,  inocu- 
lation was  successful  after  previous  failures ;  occasionally  there  are  seen 
children  who  can  not  be  inoculated  at  all. 

Constitutional  symptoms,  as  previously  stated,  are  often  absent  in  the 
case  of  very  young  infants;  but  in  others  there  is  quite  constantly  present 
a  fever  which  runs  a  fairlv  resjular  course.     It  usuallv  begins  on  the  fourth 


« 


?"3  ^ 

C    <U    r/, 


CO  {-• 

Cb  -0 

o  f^  o 

«^  C 


b  i 

^-, 

"  j: 

2 

:h  oj 

5-^ 

53 

s 

01 

j-c 

<P 

3.£ 

^ 

■r^ 

<U    ^ 

C3 

— -d 

o 

■^  5 

CG 

CC   o 

05 

OJ    3 

,J= 

p^ 

w 

a>  —  a 

O   -C    4J 

CO 

> 

5=0  T:  • 

n  2-« 

W 

■>-ss 

?5 

,  o   en 

CJ 

O    ;!-,    <u 

o 

S  g  >- 

< 

f-^§ 

> 

t£  ■"  — 

^  §  a 


>  o  a 


o 


.2  2-^Q 

M    M    t,    ,- 

fe^  ^ « s 

^   ^  .-  O 

c  o  ^  a 


934 


VACCINIA.— VACCINATION.  935 

or  fifth  day,  is  remittent  in  type,  and  rises  gradually,  reaching  its  high- 
est point  with  the  full  development  of  the  vesicle.  At  this  time  it  varies 
from  101°  to  lOi"  F.,  falling  gradually  to  normal.  The  duration  of  the 
fever  in  cases  running  the  usual  course  is  four  or  five  days.  Accompany- 
ing it  there  may  be  anorexia,  restlessness,  loss  of  sleep,  slight  indigestion, 
and  other  symptoms  of  a  general  indisposition. 

Variations  in  the  Course  of  Vaccinia. — Occasionally  the  period  of  in- 
cubation is  prolonged,  and  no  evidence  that  the  inoculation  has  been 
successful  is  seen  for  from  ten  to  fourteen  days,  or  even  longer,  and  yet 
the  subsequent  course  may  be  normal.  In  some  cases  multiple  pocks  are 
present,  which  may  be  produced  by  auto-inoculation,  usually  by  scratch- 
ing.. They  may  be  only  in  the  neighbourhood  of  the  original  one,  or 
upon  any  other  part  of  the  body.  In  cases  of  eczema  of  the  face,  inocu- 
lation has  not  infrequently  been  carried  thither.  A  generalized  eruption 
of  pocks  is  sometimes  seen,  although  this  is  very  rare.  In  secondary 
vaccination  both  the  local  and  general  symptoms  may  be  quite  as  intense 
as  in  the  primary  cases,  and  in  many  instances  they  are  even  more  severe. 

Complications  and  Sequelae. — Post-vaccine  eruptions  occur  in  great 
variety,  and  from  three  quite  distinct  causes.  Even  with  pure  virus  there 
may  be  urticaria,  erythema,  or  a  general  roseola  which  often  resembles 
the  eruption  of  measles,  and  occasionally  purpura  has  been  seen.  As  the 
result  of  mixed  infection  at  the  time  of  the  original  inoculation,  there 
may  be  produced  impetigo  contagiosa,  syphilis,  or  even  tuberculosis. 
From  subsequent  infection  of  the  vaccination  wound,  there  may  be  f urun- 
culosis,  cellulitis,  or  erysipelas.  The  complications  are  in  the  main  the 
result  of  the  causes  just  enumerated.  In  addition  to  the  diseases  men- 
tioned, there  may  be  pyaemia,  gangrenous  dermatitis,  suppurative  adenitis, 
and  in  rare  cases  pneumonia  or  nephritis.  Sequelae  are  very  rare ;  but 
where  latent  constitutional  tendencies  have  existed  they  may  be  aroused 
to  activity,  as  in  the  case  of  tuberculosis.  A  child  who  has  once  had  ecze- 
ma is  liable  to  a  recurrence  at  such  a  time ;  and  in  very  delicate  children 
a  condition  of  malnutrition  is  frequently  intensified  if  the  vaccinia  has 
been  particularly  severe. 

The  mortality  of  vaccination  is  stated  by  Voigt,  from  careful  statis- 
tics drawn  from  German  sources,  to  have  been  35  in  2,275,000  cases,  in- 
cluding both  primary  and  secondary  vaccinations.  Of  the  deaths,  19 
were  due  to  erysipelas,  8  to  gangrene,  2  to  cellulitis,  3  to  "  blood  poison- 
ing," and  3  to  other  causes.  It  will  be  observed  that  these  were  all,  or 
nearly  all,  from  preventable  causes. 

Treatment. — The  purpose  of  this  is  simply  cleanliness  and  protection, 
to  prevent  the  irritation  of  clothing,  and  also  to  prevent  the  child  from 
scratching,  for  by  these  means  the  vesicle  usually  becomes  infected.  No 
treatment  is  required  until  the  vesicle  has  formed.  The  limb  should  then 
be  protected  by  clean  linen,  or,  better,  by  a  vaccine  shield,  of  which  one 


936  THE  SPECIFIC   INFECTIOUS  DISEASES. 

made  of  a  wire  network  and  fastened  to  the  limb  by  a  tape,  is  probably  the 
best  form.  As  soon  as  the  vesicle  ruptures  and  begins  to  discharge  serum, 
it  should  be  frequently  dusted  with  boric  acid.  If  there  is  suppuration, 
the  pock  should  be  treated  antiseptically,  like  any  other  granulating 
wound.  If  a  vaccinated  limb  is  kept  perfectly  clean,  and  the  pock  dry 
by  the  free  use  of  the  powder  mentioned,  very  little  trouble  need  be  ap- 
prehended. If  the  local  symptoms  are  at  all  severe,  the  limb  should  be 
kept  at  rest.  For  this  reason,  a  child  old  enough  to  w'alk  should  not  be 
vaccinated  upon  the  leg. 

The  complications  are  to  be  treated  as  when  these  conditions  arise  un- 
der other  circumstances. 


CHAPTER   VI. 

PERTUSSIS. 
Synonym :  Whooping-cough. 

Pertussis  is  a  contagious  disease  which  prevails  epidemically  and  in 
'most  large  cities  endemically.  Although  it  may  affect  persons  of  any 
age,  it  is  generally  seen  in  young  children,  and  as  a  rule  it  occurs  but  once 
in  the  same  individual.  While  in  later  childhood  pertussis  may  be  ranked 
as  one  of  the  milder  infectious  diseases,  in  infancy  it  is  one  of  the  most 
fatal.  Its  principal  complications  are  broncho-pneumonia  and  convul- 
sions. Pertussis  is  characterized  by  catarrhal  and  nervous  symptoms. 
The  catarrh  affects  the  mucous  membranes  of  the  respiratory  tract,  and  is 
probably  due  to  a  S23ecific  form  of  infection.  It  is  accompanied  by  a  hyper- 
aesthetic  condition  of  these  mucous  membranes.  The  most  prominent 
nervous  manifestation  is  a  peculiar  spasmodic  cough  which  occurs  in  par- 
oxysms, and  from  which  the  disease  takes  its  name.  The  cough  is  no 
doubt  of  reflex  origin,  from  an  irritation  which  by  different  writers  has 
been  located  in  various  parts  of  the  respiratory  tract.  In  addition  to  these 
conditions,  there  is  present  in  pertussis  a  very  marked  irritability  of  the 
nervous  system  generally,  which  ii\  infancy  frequently  shows  itself  by 
convulsions.  • 

Etiology. — Pertussis  is  probably  due  to  a  micro-organism,  but  its  nature 
is  as  yet  unknown.  Proximity  to  a  patient  is  all  that  is  required  to  com- 
municate the  disease,  and  as  in  the  case  of  measles  even  close  proximity  is 
not  necessary.  There  seems  to  be  no  doubt,  from  clinical  experience,  that 
the  disease  may  be  contracted  in  the  open  air. 

Predisjyosition. — Fully  one  half  the  cases  of  pertussis  occur  during  the 
first  two  years  of  life.  This  statement,  which  is  in  accord  with  general 
experience,  is  borne  out  by  the  following  statistics  of  Szabo  (Buda-Pesth), 


PERTUSSIS. 


937 


showing  the  ages  at  which  the  disease  was  met  with  in  4,591  cases,  com- 
prising the  records  of  one  clinic  for  thirty-four  years : 


Under  one  year 1,028  eases. 

One  to  two  years 1,008     " 

Two  to  three  years 659     '• 


Three  to  four  years 904  cases. 

Four  to  seven  years    803     " 

Over  seven  vears 189     " 


Pertussis  thus  shows  a  stronger  tendency  to  affect  very  young  infants 
than  does  any  other  contagious  disease.  It  not  infrequently  occurs  during 
the  first  six  months  of  life,  a  number  of  cases  are  on  record  in  which  it 
has  occurred  during  the  first  month,  and  one  has  recently  come  to  my 
notice  where  a  child  twelve  days  old  was  attacked,  whose  mother  was 
suffering  from  the  disease  at  the  time  the  child  was  born.  Statistics  taken 
from  a  large  number  of  epidemics  show  that  the  disease  is  nearly  twice  as 
frequent  in  the  winter  and  spring  as  in  the  summer  and  autumn.  Epidem- 
ics of  pertussis  often  occur  at  the  same  time  with  or  follow  those  of  measles. 

The  susceptibility  to  pertussis  is  very  great,  and  is  equalled  only  by 
that  to  measles.  Biedert  reports  that  of  401  children  exposed  during  an 
epidemic  in  a  certain  village,  366,  or  ninety-one  per  cent,  took  the  disease. 

Infective  period. — Pertussis  may  be  communicated  from  the  very  be- 
ginning of  the  catarrhal  stage ;  exactly  how  long  a  given  case  may  be 
contagious  it  is  impossible  to  say  positively.  It  is  pretty  certain  that  it  is 
so  during  the  entire  spasmodic  stage,  and  probably  longer.  In  most  cases 
quarantine  is  required  for  two  months  from  the  beginning  of  the  attack, 
and  in  many  cases  for  a  much  longer  time.  The  usual  source  of  the  con- 
tagion is  the  patient,  rarely  the  room  or  the  clothing.  While  it  is  possible 
that  pertussis  may  be  carried  by  a  third  party,  this  is  very  unlikely  unless 
a  person  has  been  in  very  close  contact  with  a  patient,  and  goes  at  once 
without  change  of  clothing  to  another  child. 

Incuhation. — The  very  gradual  onset  of  pertussis  renders  it  impossible 
in  the  majority  of  cases  to  fix  the  exact  date,  and  hence  to  establish  the 
definite  duration  of  the  period  of  incubation.  In  cases  where  it  could  best 
be  determined  it  has  usually  been  found  to  be  from  seven  to  fourteen 
days,  or  about  the  same  as  measles.  If,  after  an  exposure,  sixteen  days  pass 
without  the  development  of  a  cough,  the  probabilities  are  very  strong  that 
the  disease  has  not  been  contracted. 

Lesions. — The  only  constant  lesions  of  pertussis  consist  in  a  catarrhal 
inflammation  of  varying  intensity,  which  affects  the  mucous  membrane  of 
the  larynx,  trachea,  and  bronchi,  and  sometimes  that  of  the  nose  and 
pharynx.  If  the  child  dies  during  a  paroxysm,  either  with  or  without  con- 
vulsions, the  brain  is  found  intensely  congested  and  may  be  the  seat  of 
punctate  htemorrhages,  or  even  larger  extravasations.  The  lungs  always 
show  emphysema  if  the  attack  has  been  severe  or  protracted.  The  other 
pulmonary  lesions  are  due  to  complications,  the  most  frequent  of  which  is 
broncho-pneumonia.     Catarrhal  enteritis  and  colitis  are  not  infrequent. 


938  THE  SPECIFIC  INFECTIOUS  DISEASES. 

Symptoms. — The  symptoms  of  pertussis  are  usually  divided  into  three 
stages — the  catarrhal,  the  spasmodic,  and  the  stage  of  decline. 

The  catarrhal  stage  continues  on  the  average  for  about  ten  days,  al- 
though cases  show  considerable  variation  on  this  point.  Some  children 
whoop  almost  from  the  very  beginning  of  the  disease,  while  others  may 
cough  for  several  weeks  before  a  typical  whoop  is  noticed.  The  symp- 
toms in  the  beginning  are  indistinguishable  from  those  of  an  ordinary 
attack  of  subacute  tracheo-bronchitis,  and  unless  there  has  been  an  expos- 
ure to  pertussis  no  suspicion  is  excited.  After  five  or  six  days,  however, 
the  cough,  instead  of  abating  as  in  an  ordinary  cold,  gradually  increases 
in  severity  and  occurs  in  paroxysms.  At  first  these  are  mild,  and  there 
are  only  two  or  three  a  day,  but  they  gradually  increase  in  frequency  and 
severity  until  the  typical  whoop  is  heard  which  marks  the  beginning  of 
the  spasmodic  stage.  During  the  first  stage  there  may  be  symptoms  of  a 
mild  grade  of  catarrhal  inflammation  of  the  nose,  pharynx,  and  larynx, 
and  often  there  is  a  slight  elevation  of  temperature. 

The  spasmodic  stage. — In  a  typical  paroxysm  of  average  severity  the 
child,  who  can  usually  foretell  it,  vill  often  run  for  support  to  the  lap  of 
the  mother  or  the  nurse,  or  seize  a  chair  with  both  hands.  There  now 
occurs  a  series  of  explosive  coughs,  from  ten  to  twenty  in  number,  coming 
in  such  rapid  succession  that  the  child  can  not  get  its  breath  between 
them ;  the  face  becomes  of  a  deep  red  or  purple  colour,  sometimes  almost 
black ;  the  veins  of  the  face  and  scalp  stand  out  prominently ;  the  eyes 
are  suifused,  and  seem  almost  to  start  from  their  sockets;  there  follows  a 
long-drawn  inspiration  through  the  narrowed  glottis,  producing  the  crow- 
ing sound  known  as  the  whoop ;  and  then  another  succession  of  rapid 
coughs  follows  and  another  whoop.  In  a  single  severe  paroxysm,  which 
lasts  two  or  three  minutes,  the  child  may  whoop  half  a  dozen  times ;  with 
the  final  paroxysm  a  mass  of  tenacious  mucus  is  usually  brought  up. 
The  most  common  attendant  symptoms  of  the  paroxysm  are  vomiting 
and  epistaxis.  In  a  young  child  vomiting  is  almost  certain  to  follow,  if 
food  has  been  recently  taken.  Epistaxis  sometimes  occurs  with  nearly 
every  severe  paroxysm,  but  in  most  cases  the  bleeding  is  slight.  After 
such  an  attack  as  that  described,  a  child  is  at  times  so  exhausted  as  to  be 
hardly  able  to  stand ;  there  is  profuse  perspiration  ;  his  mind  is  confused, 
and  he  may  be  completely  dazed.  In  infants  the  attack  may  result  in  a 
degree  of  asphyxia  so  deep  as  to  necessitate  artificial  respiration. 

The  number  of  severe  paroxysms  or  "  kinks "  in  twenty-four  hours 
varies,  according  to  the  severity  of  the  case,  between  half  a  dozen  and 
forty  or  fifty.  There  are  always  many  more  of  a  milder  form.  Paroxysms 
are  often  excited  by  eating  or  drinking  anything  which  is  cold,  by  a 
draught  of  air,  or  by  imitation ;  they  are  usually  more  frequent  during 
the  night  than  the  day,  and  in  a  close  room  than  in  the  open  air. 

In  less  severe  cases  no  paroxysms  of  the  grade  above  described  may 


PERTUSSIS.  939 

occur,  and  no  typical  whoop  may  be  heard  throughout  the  attack ;  but 
the  paroxysmal  nature  of  the  cough  which  continues  until  the  plug  of 
mucus  is  raised,  the  watery  eyes,  and  the  vomiting  which  follows  a  par- 
oxysm, stamp  the  disease  as  pertussis.  In  young  infants  the  whoop  is 
frequently  not  marked.  The  child  sometimes  coughs  until  it  is  asphyxi- 
ated, and  yet  no  whoop  occurs.  The  paroxysms  are  also  modified  by  inter- 
current disease,  especially  by  attacks  of  pneumonia  or  severe  bronchitis. 
At  such  times  they  usually  become  less  frequent  and  less  typical,  and  may 
be  absent  for  several  days,  returning  as  the  complication  subsides. 

The  seat  of  irritation  which  produces  the  cough  has  been  located  by 
different  observers  in  different  mucous  membranes  :  some  have  thought  it 
to  be  in  the  nose,  others  in  the  trachea,  the  bronchi,  or  the  larynx.  It  is 
very  probable  that  it  may  not  always  be  in  the  same  mucous  membrane ; 
and  that  the  infectious  catarrh,  which  is  really  the  most  important  ele- 
ment in  the  disease,  may  vary  in  its  intensity  and  location  in  different 
cases.  The  weight  of  evidence  seems  to  be  that  in  the  great  majority  of 
cases  the  source  of  irritation  is  in  the  larynx  or  trachea.  From  laryn- 
goscopic  examinations  made  during  the  disease,  Von  Herff  found  the 
mucous  membrane  of  the  larynx  to  be  swollen  and  congested,  and  occa- 
sionally the  seat  of  small  hajmorrhages  or  superficial  ulcers.  He  states 
that  the  frequency  and  severity  of  the  paroxysms  corresponded  with  the 
degree  of  laryngitis,  and  he  fonnd  that  a  paroxysm  could  always  be  ex- 
cited by  irritating  the  mucous  membrane  between  the  arytenoid  cartilages. 
During  a  paroxysm  he  observed  that  there  was  a  collection  of  mucus  on 
the  posterior  laryngeal  wall,  the  removal  of  which  had  the  effect  of  short- 
ening the  paroxysm. 

Rossbach  made  laryngoscopic  examinations,  with  negative  results  so 
far  as  the  larynx  was  concerned,  but  he  states  that  a  plug  of  mucus  could 
always  be  seen  in  the  lower  trachea  for  one  or  two  minutes  before  the 
paroxysm  occurred.  There  is  little  doubt  that  this  collection  of  mucus  is 
the  exciting  cause  of  the  paroxysm,  as  it  is  a  familiar  clinical  fact  that 
the  paroxysm  always  continues  until  this  is  dislodged. 

The  average  duration  of  the  spasmodic  stage  is  about  one  month.  It 
increases  in  intensity  for  the  first  two  weeks,  remains  stationary  for  about 
a  week,  and  then  gradually  diminishes  in  severity.  The  course  and  dura- 
tion are,  however,  subject  to  wide  variations.  In  mild  cases  this  stage 
may  last  only  a  week ;  in  severe  cases,  especially  in  the  winter  season,  it 
may  continue  for  three  months,  at  times  greatly  subsiding,  but  lighting 
up  again  with  all  its  previous  severity  with  every  fresh  attack  of  cold. 
After  it  has  entirely  ceased  the  whoop  may  return  with  an  attack  of  bron- 
chitis, and  continue  for  a  month  or  more.  This  is  not  to  be  regarded 
as  a  true  relapse  of  pertussis.  The  habit  of  the  paroxysmal  cough  once 
established,  it  tends  to  recur  with  every  slight  bronchitis,  often  for  months 
afterward. 


940  THE   SPECIFIC   INFECTIOUS   DISEASES. 

The  stage  of  decline. — Gradually  the  severity  of  the  paroxysm  abates, 
the  whoop  ceases,  and  the  cough  resembles  more  and  more  that  of  ordi- 
nary bronchitis.  This  stage  usually  continues  about  three  weeks,  but 
may  be  prolonged  indefinitely  in  the  winter  months. 

Complications. — Hiemorrhages. — The  haemorrhages  of  pertussis  are 
mechanical,  and  depend  upon  the  intense  venous  congestion  which  ac- 
companies the  paroxysm.  Epistaxis  is  the  most  fi'equent  variety,  and 
occurs  in  a  considerable  proportion  of  the  severe  cases,  in  a  few  with  al- 
most every  severe  paroxysm,  but  it  is  rarely  severe  enough  to  require  local 
treatment.  Haemorrhages  from  the  mouth  may  have  their  origin  either 
in  the  pharynx  or  the  bronchi,  the  blood  being  brought  up  by  the  cough ; 
such  haemorrhages  are  usually  small.  Conjunctival  haemorrhages  are  less 
frequent,  and  are  usually  slight,  although  I  have  seen  the  entire  conjunc- 
tiva of  one  eye  covered.  In  a  case  under  my  observation  there  was  bleed- 
ing from  both  ears  with  every  severe  paroxysm,  for  more  than  a  week. 
This  child  had  previously  suffered  from  scarlatinal  otitis,  with  perfora- 
tion of  the  drum  membrane.  Small  extravasations  into  the  cellular 
tissue  beneath  the  eyes  are  occasionally  seen,  giving  an  appearance  some- 
what like  an  ordinary  "  black  eye."  Intracranial  hfemorrhages  are  not 
frequent,  but  many  examples  have  been  recorded,  and  they  may  be  severe 
enough  to  produce  death.  They  are  usually  meningeal,  very  rarely  cere- 
bral ;  according  to  their  extent  and  location  they  may  produce  hemiplegia, 
monoplegia,  aphasia,  facial  paralysis,  or  disturbances  of  the  special  senses 
of  sight,  hearing,  sensation ;  in  addition,  there  may  be  convulsions  or 
rigidity,  but  rarely  complete  coma.  The  extravasations  are  usually  small, 
and  the  symptoms  which  they  produce  disappear  at  the  end  of  a  few 
weeks.  Fatal  cases  with  autopsies  have  been  reported  by  Cazin,  Marshall, 
and  others.  In  almost  every  instance  these  haemorrhages  have  occurred 
as  a  direct  result  of  severe  paroxysms  of  the  cough.  Purpura  haemor- 
rhagica  as  a  sequel  of  pertussis  was  twice  seen  at  the  New  York  Infant 
Asylum. 

Respiratory  system. — The  most  serious  complications  of  pertussis  are 
connected  with  the  lungs.  By  far  the  largest  proportion  of  deaths  is  due 
to  pulmonary  complications,  usually  broncho-pneumonia.  This  is  more 
frequent  in  winter  and  spring  than  in  the  summer  months,  and  is  espe- 
cially to  be  dreaded  during  infancy.  In  later  childhood  lobar  pneumonia 
is  occasionally  seen.  Pneumonia  rarely  begins  before  the  second  week 
of  the  disease,  and  most  frequently  develops  at  the  height  or  toward  the 
close  of  the  spasmodic  stage.  The  physical  signs  present  no  peculiarities ; 
the  cough  changes  somewhat  in  character  during  the  pneumonia,  and 
the  whoop  may  not  be  heard.  The  prognosis  of  the  pneumonia  is  bad, 
because  of  the  debilitated  condition  of  the  children  at  the  time  of  its 
occurrence.  A  great  danger  is  from  the  supervention  of  convulsions,  this 
being  a  frequent  mode  of  termination.     As  there  is  always  considerable 


PERTUSSIS  941 

emphysema  the  rapidity  of  breathing  is  frequently  out  of  proportion  to  the 
temperature,  which  often  is  only  moderately  elevated.  If  the  child  escapes 
the  dangers  of  the  acute  stage,  death  may  still  occur  from  exhaustion, 
owing  to  the  protracted  course  which  the  disease  frequently  runs.* 

Bronchitis  of  the  large  tubes  is  present  in  almost  all  the  severe  cases, 
and  is  not  of  itself  serious.  Bronchitis  of  the  small  tubes  has  the  same 
dangers  and  the  same  complications  as  broncho-pneumonia. 

Vesicular  emphysema  has  been  present,  I  think,  in  every  case  which  I 
have  seen  upon  the  post-mortem  table ;  a  certain  amount  of  it,  no  doubt, 
occurs  in  every  severe  case.  It  is  produced  by  the  forcible  cough  of  the 
paroxysm.  In  very  severe  cases  interstitial  emphysema  is  also  found. 
ISTorthrup  has  reported  a  remarkable  instance  of  this  complication.  Rup- 
ture of  the  air-blebs  which  form  on  the  surface  of  the  lung,  may  lead  to 
emphysema  of  the  cellular  tissue  of  the  mediastinum,  and  the  air  may 
find  its  way  along  the  great  vessels  into  the  neck,  and  finally  into  the  sub- 
cutaneous cellular  tissue  of  the  entire  body.  Cases  of  general  subcutane- 
ous emphysema  have  been  reported  by  Croker  and  Hodge,  both  of  which 
ended  fatally,  one  in  three  and  one  in  eight  days  from  the  beginning  of 
the  emphysema.  In  the  great  majority  of  the  cases  vesicular  emphysema 
is  not  permanent. 

Digestive  system. — During  the  summer,  infants  with  pertussis  are 
almost  certain  to  suffer  from  diarrhoea ;  it  may  be  only  an  occasional 
symptom,  or  the  attack  may  be  severe  and  prolonged,  resulting  in  the  de- 
velopment of  ileo-colitis.  The  intestinal  comj^lications  may  be  almost  as 
serious  in  summer  as  are  those  of  the  respiratory  tract  in  winter.  Vomit- 
ing is  even  more  frequent  than  diarrhoea,  and,  while  it  may  be  distressing 
at  any  age,  it  is  especially  so  in  infancy.  So  frequently  does  the  taking 
of  food  excite  vomiting,  that  the  nutrition  of  these  patients  often  becomes 
a  matter  of  the  greatest  difficulty,  and  in  fact  the  most  serious  problem 
in  the  management  of  a  case.  Malnutrition  and  even  marasmus  may 
follow,  or  the  general  resistance  of  the  child  may  become  so  reduced  by 
lack  of  food  that  it  falls  a  ready  prey  to  pneumonia. 

Nervous  system. — There  may  be  convulsions,  coma,  paralysis,  aphasia, 
disturbances  of  sight  or  hearing,  and  in  rare  cases  even  of  the  mental  con- 
dition. The  most  serious  of  these  complications  are  convulsions.  They 
are  much  more  frequent  in  infancy  than  later,  and  are  particularly  so  in 
those  who  are  rachitic,  where  they  are  often  fatal.  Convulsions  are  of 
course  more  common  in  severe  attacks,  but  they  may  occur  suddenly  where 
there  has  previously  been  no  cause  for  anxiety.  They  are  especially  to  be 
dreaded  if  pneumonia  is  present.  The  attack  of  convulsions  may  be  the 
culmination  of  the  extreme  degree  of  nervous  irritability  which  accom- 
panies the  paroxysm,  it  may  be  due  to  asphyxia,  or  to  an  intracranial 

*  For  further  particulars  regarding  the  pneumonia  of  whooping-cough,  see  page  503. 


942  THE  SPECIFIC  INFECTIOUS  DISEASES. 

lesion ;  if  the  latter,  there  is  usually  meningeal  haemorrhage.  This  is  to 
be  suspected  if  there  are  continued  convulsions  for  several  hours,  with 
general  rigidity  or  hemiplegia. 

Disturbances  of  the  sight  are  not  infrequent  in  severe  cases ;  usually 
these  are  transient,  but  there  may  be  blindness  lasting  two  or  three 
days  or  even  weeks.  The  transient  symptoms  most  likely  depend  upon 
circulatory  changes  in  the  brain  during  the  paroxysm,  while  those  which 
last  for  two  or  three  weeks  are  probably  due  to  meningeal  hgemorrhage. 
Disturbances  of  hearing  are  rare.  The  different  forms  of  paralysis  occur- 
ring with  pertussis  may  likewise  be  transient  or  permanent.  They  are  to 
be  explained  in  the  same  way  as  the  disturbances  of  the  special  senses. 
The  most  common  form  is  hemiplegia. 

Albuminuria  is  not  infrequent,  being  found  in  66  of  86  examinations 
by  Knight.  The  quantity  of  albumin  is  rarely  large,  and  it  may  be  ac- 
companied by  a  few  hyaline  casts.  Both  are  probably  the  result  of  circu- 
latory disturbances  in  the  kidney.  Other  complications  of  pertussis  are 
hernia,  prolapsus  ani,  and  ulcer  of  the  frenum  linguse. 

Diagnosis. — In  the  early  part  of  the  catarrhal  stage  it  is  impossible  to 
make  a  diagnosis ;  there  is  no  way  by  which  the  disease  can  be  distin- 
guished at  that  period  from  an  ordinary  cough ;  but  after  a  week  the 
gradual  increase  in  severity  in  spite  of  treatment,  and  the  fact  that  the 
cough  becomes  more  and  more  paroxysmal,  and  that  it  is  accompanied  by 
vomiting  and  suffusion  of  the  eyes,  should  make  one  strongly  suspect  per- 
tussis. If  the  disease  is  prevalent,  the  diagnosis  may  be  regarded  as  certain 
when  these  symptoms  are  reached,  even  without  the  typical  whoop.  Cases 
which  present  the  greatest  difficulty  in  diagnosis  are  those  of  a  mild  type, 
where,  perhaps,  without  ever  having  a  typical  paroxysm,  a  child  who  has 
been  exposed  to  pertussis  coughs  for  a  number  of  weeks.  Under  these 
circumstances  it  may  be  impossible  to  say,  even  at  the  close  of  the  attack, 
whether  it  was  or  was  not  pertussis ;  but  if  a  child  has  no  fever  and 
no  physical  signs  of  bronchitis,  and  has  been  exposed  to  the  disease,  the 
probabilities  are  strong  that  a  severe  cough  which  continues  six  or  eight 
weeks,  and  upon  which  ordinary  treatment  has  little  or  no  effect,  is  per- 
tussis. 

The  diagnosis  is  difficult  also  in  early  infancy,  for  at  this  period  every 
cough  is  likely  to  show  more  or  less  of  a  spasmodic  character,  and  there 
may  be  occasionally  heard  a  fairly  typical  whoop  in  the  course  of  an  ordi- 
nary attack  of  bronchitis.  This  is  to  be  compared  to  the  laryngeal  spasm 
which  occurs  with  a  mild  attack  of  catarrhal  laryngitis.  Abortive  cases 
also  present  difficulty  in  diagnosis.  I  have  seen  in  a  single  family  three 
children  with  pertussis  of  typical  duration  and  severity,  and  a  fourth  child 
suffering  from  a  cough,  which  lasted  but  two  weeks,  and  in  whom  the 
whoop  was  heard  only  for  one  day.  If  such  cases  occurred  by  themselves, 
it  would  be  impossible  to  make  a  positive  diagnosis. 


PERTUSSIS.  943 

Irritation  of  the  pneumogastric  or  recurrent  laryngeal  nerve  from  en- 
larged tracheal  or  bronchial  lymph  nodes,  whether  of  a  simple  or  tubercu- 
lous character,  may  give  rise  to  a  spasmodic  cough,  which  in  certain  cases 
may  be  indistinguishable  from  whooping-cough.  The  prolonged  duration 
of  these  cases  is  sometimes  the  only  diagnostic  point ;  but  the  paroxysms 
are  usually  not  so  severe  as  in  true  pertussis,  and  the  course  is  generally 
less  typical. 

Prognosis. — The  most  important  factor  in  the  prognosis  of  the  disease 
is  the  age  of  the  patient.  After  the  fourth  year  it  is  indeed  rare  that 
either  a  fatal  result  or  serious  complications  are  seen  ;  but  during  infancy, 
and  particularly  during  the  first  year,  there  are  few  diseases  more  to  be 
dreaded.  This  is  especially  true  on  account  of  the  connection  of  whoop- 
ing-cough with  the  three  most  fatal  conditions  of  infantile  life — broncho- 
pneumonia, diarrhoeal  diseases,  and  convulsions.  Fully  two  thirds  of  the 
deaths  from  whooping-cough  occur  during  the  first  year  of  life.  The 
prognosis  is  very  much  worse  in  infants  of  the  first  three  months  than  in 
those  who  are  older  and  consequently  have  more  resistance.  It  is  better 
in  the  summer  than  in  the  winter,  because  broncho-pneumonia  is  then  less 
frequent.  It  is  particularly  bad  in  delicate  infants,  in  those  who  are  rachitic, 
in  those  who  are  prone  to  attacks  of  bronchitis,  in  those  who  have  suffered 
previously  from  pneumonia,  and  in  those  with  a  strong  tendency  to  tuber- 
culosis. 

The  exact  mortality  of  whooping-cough  it  is  difficult  to  state  in  fig- 
ures. During  the  first  year  of  life  it  is  probably  not  far  from  twenty-five 
per  cent,  although  it  diminishes  rapidly  after  this  time.  In  foundling 
asylums  and  hospitals  for  infants  it  is  to  be  ranked  among  the  most  fatal 
diseases,  and  in  some  epidemics  the  mortality  in  such  institutions  is  as  high 
as  fifty  per  cent. 

Fully  two  thirds  of  the  deaths  during  whooping-cough  are  from 
broncho-pneumonia;  the  next  most  frequent  cause  is  diarrhoeal  diseases. 
Convulsions  may  be  the  mode  of  death  in  either  of  the  above  conditions, 
or  may  occur  apart  from  them.  During  the  first  year,  death  often  results 
from  marasmus,  the  child  having  been  reduced  by  the  prolonged  disease. 
Occasionally  death  is  due  to  asphyxia  following  a  severe  paroxysm,  to 
intracranial  haemorrhage,  or  to  general  emphysema. 

As  a  predisposing  cause  of  tuberculosis,  pertussis  is  second  only  to 
measles.  In  both  diseases  tuberculosis  develops  in  much  the  same  way 
and  from  much  the  same  causes  (p  922). 

Prophylaxis. — Pertussis  is  a  contagious  disease,  and  a  child  suffering 
from  it  should  be  isolated  from  other  children  wherever  this  is  possible. 
Children  with  pertussis  should  never  be  allowed  to  attend  school,  and 
needless  exposure  should  always  be  avoided. 

Young  infants,  delicate  children,  and  those  with  a  predisposition  to 

tuberculosis,  should  be  most  carefully  protected  against  exposure,  since  it 
61 


94:4  THE  SPECIFIC  INFECTIOUS   DISEASES. 

is  in  them  chiefly  that  the  disease  is  likely  to  be  serious.  As  it  is  from 
the  patient  that  the  disease  is  nearly  always  contracted,  there  does  not  exist 
the  same  necessity  for  the  fumigation  and  disinfection  of  apartments  as 
after  other  contagious  diseases.  In  institutions,  however,  this  should 
always  be  practised,  and  in  private  houses  if  the  room  is  subsequently  to 
be  occupied  by  an  infant. 

It  is  as  undesirable  as  it  is  impossible  to  confine  a  child  with  pertussis 
to  a  single  room  during  the  attack ;  all  those  persons  for  whom  exposure 
would  be  dangerous  should  therefore  be  sent  away  from  the  house.  Quar- 
antine should  continue  on  the  average  for  six  weeks,  or  until  the  spas- 
modic stage  is  over. 

Treatment. — General  measures. — It  is  extremely  important  that  chil- 
dren should  have  plenty  of  fresh  air  throughout  the  attack.  It  is  a 
matter  of  common  observation  that  they  have  fewer  paroxysms  while  out 
of  doors  than  in  the  house,  and  that  the  paroxysms  are  very  much  more 
frequent  w^hen  children  are  confined  in  close  r.ooms.  They  should  be  kept 
in  the  open  air  as  much  as  possible  during  the  day,  in  pleasant  weather, 
and  even  on  unpleasant  days  the  windows  should  be  freely  opened.  If  a 
child's  temperature  is  above  100°  F.,  he  should  not  be  sent  out,  but  may 
have  fresh  air  in  the  room.  In  all  cases  it  is  important  to  have  the  win- 
dows freely  opened  at  night,  unless  bronchitis  or  broncho-pneumonia  is 
present. 

A  change  of  air  is  desirable  for  cases  in  which  the  cough  is  unduly 
prolonged.  A  warm  place  at  the  seashore  is  one  which  is  most  likely  to 
be  beneficial.  The  improvement  during  a  sea  voyage  is  sometimes  very 
marked,  and  it  surpasses  even  a  residence  at  the  seashore. 

The  rooms  occupied  by  children  suffering  from  pertussis  should  be 
frequently  changed,  thoroughly  aired,  and,  when  possible,  occasionally 
fumigated.  This  change  of  rooms,  clothing,  bedding,  etc.,  sometimes 
exerts  a  marked  influence  on  the  course  of  very  prolonged  attacks,  the 
inference  being  that  continued  re-infection  takes  place.  Such  a  change 
should  be  made  twice  a  week,  and  it  is  of  special  importance  in  hospitals, 
where  many  children  quarantined  in  a  ward  seem  to  cough  interminably. 

Vomiting  and  indigestion  are  both  so  frequent  that  feeding  becomes 
at  times  very  difficult.  In  most  cases  it  is  necessary  to  repeat  the  meal  in 
a  short  time,  if  the  first  one  has  been  vomited  in  consequence  of  a  severe 
paroxysm.  Children  over  two  years  old  should  in  all  such  cases  be  kept 
upon  a  fluid  diet,  chiefly  of  milk.  For  infants,  milk  should  be  diluted, 
and  in  many  instances  it  must  also  be  partially  peptonized.  Any  medi- 
cation which  causes  disturbance  of  the  stomach  must  be  omitted.  In 
severe  cases,  on  account  of  the  inability  to  retain  a  proper  amount  of 
food,  the  child's  strength  should  be  kept  up  by  the  use  of  alcoholic 
stimulants. 

Local  treatment. — This  may  be  in  the  form  of  insufflations  of  powder 


PERTUSSIS.  945 

into  the  nose,  local  applications  to  the  larynx  by  a  spray  or  swab,  and 
inhalations. 

The  first  two  methods  have  been  advocated,  in  the  belief  that  the 
cough  is  due  to  an  infectious  catarrh  having  its  seat  in  the  nose  or 
larynx.  For  insufflation,  quinine  or  benzoic  acid  is  preferred,  mixed 
with  some  finely  divided,  inert  powder,  such  as  bicarbonate  of  sodium, 
talcum,  or  coffee  ;  these  are  used  with  the  powder  insufflator  once  or 
twice  daily.  Local  applications  to  the  larynx  may  be  made  by  means 
of  the  spray  or  swab.  Resorcin  and  carbolic  acid,  each  in  a  one-per-cent 
solution,  are  most  used.  These  applications  are  made  once  or  twice 
daily.  I  have  not  seen  from  any  of  the  above  methods  the  beneficial 
results  claimed,  and  I  believe  them  to  have  been  exaggerated.  The  appli- 
cation of  cocaine  to  the  larynx,  although  highly  recommended,  should 
never  be  employed  in  young  children  on  account  of  the  danger  of  poi- 
soning. 

Inhalations  are  of  much  more  value.  They  are  useful  to  modify  the 
catarrh  by  allaying  irritation,  facilitating  the  expulsion  of  the  mucus,  and 
possibly  as  antiseptics.  Those  most  employed  are  carbolic  acid,  creosote, 
and  cresoline.  In  my  experience  creosote  is  by  far  the  best.  These  sub- 
stances may  be  used  dropped  upon  cotton  in  a  respirator,  or  vapourized 
over  an  alcohol  lamp  (page  58),  or  cloths  may  be  dipped  in  solutions  and 
hung  in  the  patient's  room.  In  using  carbolic  acid  the  possibility  of 
absorption  should  not  be  forgotten,  and  the  urine  should  be  watched. 
In  paroxysms  of  great  severity,  inhalation  of  chloroform  may  be  required 
as  the  only  means  of  warding  off  convulsions  or  preventing  dangerous 
asj)hyxia. 

Internal  medication. — Of  the  innumerable  drugs  which  have  been 
recommended  for  this  disease,  three  possess  undoubted  advantages  over 
all  others — viz.,  quinine,  belladonna,  and  antipyrine.  Quinine  is  best 
given  to  young  children  as  an  aqueous  solution  of  the  bisulphate  ;  it 
should  be  given  in  full  doses,  from  eight  to  ten  grains  daily  to  an  infant 
under  two  years,  and  from  fifteen  to  twenty  grains  to  children  from 
two  to  four  years  old.  The  only  objection  to  quinine  is  its  tendency 
to  upset  the  stomach ;  if  it  causes  vomiting  the  dose  must  be  reduced 
or  the  drug  discontinued.  It  will  usually  be  found  more  successful  in 
children  over,  than  in  those  under,  four  years.  I  rarely  attempt  to  use 
it  in  infants. 

Belladonna  may  be  used  in  the  form  of  the  fluid  extract  or  atropine. 
It  is  important  to  begin  with  a  small  dose  and  gradually  increase  both  its 
frequency  and  size  until  the  physiological  effects  of  the  drug  are  produced. 
To  an  infant  two  years  old,  half  a  minim  of  the  fluid  extract  may  be 
given  every  four  hours  as  an  initial  dose,  gradually  increasing  to  every 
two  hours;  if  atropine  is  used,  gr.  ^^  may  be  given  in  the  same  way. 
Although  belladonna  usually  has  a  decided  influence  in  reducing  both  the 


946  THE  SPECIFIC  INFECTIOUS  DISEASES. 

frequency  and  the  severity  of  the  paroxysms,  it  causes  so  many  unpleasant 
symptoms  that  it  is  difficult  to  continue  its  use  for  a  long  period. 

Antipyrine  has  been  in  my  hands  more  satisfactory  than  either  quinine 
or  belladonna.  It  may  be  used  with  safety  even  in  young  infants  in  con- 
siderably larger  doses  than  are  ordinarily  employed.  For  a  child  six 
months  old  the  initial  dose  should  be  one  grain  every  three  hours ;  later, 
this  may  be  given  every  two  hours,  and  sometimes  even  more  frequently. 
For  a  child  two  years  old  the  initial  dose  should  be  two  grains  every  four 
to  six  hours,  gradually  increased  if  necessary  up  to  two  grains  every  two 
hours.  The  frequency  of  the  dose  will  depend  upon  the  severity  of  the 
case.  In  the  event  of  the  development  of  pneumonia  the  antipyrine 
should  be  discontinued. 

With  bromoform  and  other  newer  remedies  I  have  had  much  less  suc- 
cess than  with  those  referred  to.  Nearly  all  drugs  which  allay  nervous 
irritability  have  a  certain  amount  of  effect  in  controlling  the  paroxysms 
of  pertussis ;  chloral  and  trional  are  often  useful  where  the  night  attacks 
are  so  severe  as  to  prevent  sleep.  Better  results  are  sometimes  obtained 
from  a  combination  of  the  bromide  of  sodium  with  antipyrine  than  from 
the  latter  given  alone.  I  do  not  believe  that  any  form  of  internal  medica- 
tion or  local  treatment  shortens  pertussis ;  but,  inasmuch  as  the  disease  is 
self -limited,  great  benefit  to  the  patient  results  from  the  reduction  of  the 
number  and  the  diminution  of  the  severity  of  the  paroxysms. 

In  establishing  the  value  of  any  method  of  treatment,  it  should  be 
remembered  that  the  number  of  cases  in  which  the  disease  is  considerably 
shorter  than  the  average  is  large,  and  also  that  almost  any  method  of  treat- 
ment if  employed  after  the  attack  has  reached  its  height  will  be  thought 
beneficial,  as  the  natural  tendency  is  then  to  improve.  The  value  of  any 
particular  line  of  treatment  is  to  be  judged  in  a  given  case  only  by  its 
effect  in  reducing  the  number  and  severity  of  the  paroxysms.  This  ought 
to  be  evident  in  the  case  of  drugs  within  two  or  three  days,  and  can  only 
be  determined  by  keeping  a  careful  record  of  the  number  of  severe  par- 
oxysms day  and  night.     No  drug  succeeds  equally  well  in  all  cases. 

In  a  mild  case,  where  the  number  of  severe  paroxysms  does  not  ex- 
ceed eight  or  ten  during  the  day,  where  there  is  no  vomiting  and  the  gen- 
eral health  is  not  affected,  it  is  not  usually  advisable  to  continue  the 
administration  of  any  drugs  throughout  the  disease.  A  single  dose  of 
antipyrine  or  phenacetine  at  night  may  be  all  that  is  necessary.  All  cases 
in  infants  must  be  watched  with  great  care  and  the  parents  warned  of  the 
possible  dangers  which  may  supervene  suddenly,  even  in  the  course  of 
mild  attacks.  For  severe  cases  antipyrine  should  be  given  to  diminish  the 
frequency  and  the  severity  of  the  paroxysms  and  inhalations  of  creosote 
used  if  much  catarrh  is  present.  All  the  fresh  air  possible  should  be 
allowed.  For  older  children  the  same  plan  of  treatment  may  be  followed, 
or  quinine  or  belladonna  may  be  substituted  for  the  antipyrine. 


MUMPS.  947 

As  these  drugs  are  given  solely  for  the  purpose  of  diminishing  the 
frequency  and  severity  of  the  paroxysms,  their  continuous  i;se  should  be 
deferred  until  the  symptoms  are  sufficiently  severe  to  greatly  disturb  the 
child,  the  benefit  at  this  period  being  more  striking  than  if  they  are  begun 
early  and  used  continuously. 


CHAPTER   VII. 

MUMPS. 

Synonym  :  Epidemic  parotitis. 

Mumps  is  a  contagious  disease  characterized  by  swelling  of  the  parotid, 
and  sometimes  of  the  other  salivary  glands,  with  constitutional  symptoms 
which  are  usually  mild.  Both  severe  complications  and  a  fatal  termina- 
tion are  extremely  infrequent.  The  disease  is  not  a  very  common  one, 
and  general  epidemics  are  rare. 

Pathology  and  Lesions. — The  contagious  character,  definite  incuba- 
tion, and  typical  course,  stamp  the  disease  as  a  general  one  due  to  a  spe- 
cific poison,  probably  a  micro-organism,  whose  nature  is  as  yet  unknown. 
It  is  probable  that  infection  takes  place  through  the  salivary  ducts. 

The  precise  nature  of  the  changes  in  the  gland  is  still  a  matter  of 
dispute,  as  opportunities  for  pathological  examination  are  very  rare.  From 
existing  evidence  it  would  appear  that  the  gland  substance  is  first  involved, 
and  afterward  the  surrounding  connective  tissue.  The  gland  is  the  seat 
of  an  intense  hypertemia  and  oedema ;  the  walls  of  the  salivary  ducts  are 
swollen,  and  the  ducts  are  obstructed.  While  the  primary  disease  does 
not  tend  to  excite  suppuration,  pyogenic  germs  may  occasionally  gain 
entrance  and  an  abscess  form ;  but  this  is  to  be  regarded  as  a  rare,  acci- 
dental infection. 

In  the  great  proportion  of  cases  the  parotids  alone  are  affected,  al- 
though the  same  changes  are  occasionally  found  in  the  other  salivary 
glands.  There  are  no  other  essential  lesions  of  the  disease,  those  which 
are  found  depending  upon  complications. 

Etiology. — Mumps  is  spread  by  contagion,  close  contact  being  usually 
required  to  communicate  the  disease,  although  it  is  known  to  have  been 
carried  by  a  third  party  and  even  by  clothing.  The  susceptibility  of  chil- 
dren to  the  poison  of  mumps  is  much  less  than  is  the  case  with  the  other 
contagious  diseases,  so  that  only  a  small  number  of  those  who  are  exposed 
take  the  disease.  The  greatest  predisposition  is  between  the  fourth  and 
fourteenth  years.  Infants  are  rarely  affected,  although  a  case  in  a  child 
three  weeks  old  is  vouched  for  by  so  good  an  observer  as  Demme. 

Mumps  is  contagious  from  the  beginning  of  the  symptoms.  Two  cases 
have  come  under  my  notice   in  which  the  disease  was   communicated 


948  THE  SPECIFIC  INFECTIOUS  DISEASES. 

before  any  swelling  was  seen.  It  is  impossible  to  fix  with  certainty  the 
duration  of  the  infective  period.  The  disease  is  undoubtedly  communi- 
cable for  several  days  after  the  swelling  has  subsided  ;  and  for  safety  a  case 
should  be  isolated  for  three  weeks  from  the  beginning  of  symptoms,  or  at 
least  ten  days  after  the  swelling  has  disappeared. 

Incnhation. — In  forty-eight  collected  cases  in  which  the  incubation 
was  definitely  determined,  it  varied  between  three  and  twenty-five  days. 
It  was  less  than  fourteen  days  in  only  four  cases,  and  in  twenty-six  of  the 
forty-eight  cases  it  was  between  seventeen  and  twenty  days.  In  three 
cases  of  my  own  in  which  it  could  be  definitely  fixed,  the  incubation  was 
nineteen  days  in  one  and  twenty  days  in  two  cases.  The  average  period  of 
incubation,  then,  may  be  stated  to  be  from  seventeen  to  twenty  days. 

Symptoms. — In  the  milder  cases  the  local  symptoms  are  the  first  to  at- 
tract attention ;  in  those  which  are  more  severe  there  are  frequently  pro- 
dromal symptoms  of  from  twelve  to  forty-eight  hours'  duration, — anorexia, 
headache,  vomiting,  pains  in  the  back  and  limbs,  and  fever.  Soltmann 
has  reported  a  case  ushered  in  by  convulsions.  The  initial  tem.perature 
in  a  mild  attack  is  100°  to  101°  F. ;  in  a  severe  one,  from  102°  to  104°  F. 

Of  the  local  symptoms,  the  pain  usually  precedes  the  swelling ;  it  is 
increased  by  movement  of  the  Jaws,  by  pressure,  and  sometimes  by  the 
presence  of  acid  substances  in  the  mouth.  It  is  usually  referred  to  the 
posterior  part  of  the  jaw  just  below  the  ear.  The  swelling  may  begin 
simultaneously  in  both  parotids,  but  more  frequently  one  side  is  involved 
a  day  or  two  in  advance  of  the  other.  It  usually  reaches  its  maximum  on 
the  third  day,  often  on  the  second,  remains  stationary  for  two  or  three 
days,  and  then  subsides  gradually.  The  degree  of  swelling  varies  with  the 
severity  of  the  attack.  When  it  is  marked,  the  patient  presents  a  ridicu- 
lous appearance  and  is  scarcely  recognisable  ;  it  fills  the  lateral  I'egion  of 
the  neck  between  the  jaw  and  the  sterno-mastoid  muscle  and  extends 
forward  upon  the  face  to  the  zygomatic  arch,  so  that  the  centre  of  the 
tumour  is  usually  the  lobe  of  the  ear.  The  other  salivary  glands  may 
swell  simultaneously  with  the  parotids,  or  several  days  later,  even  after  the 
parotid  tumour  has  disappeared.  Occasionally  swelling  of  the  submaxil- 
lary or  the  sublingual  glands  occurs  before  that  of  the  parotid,  and  in  rare 
instances  these  may  be  the  only  glands  affected. 

As  a  rule,  the  parotid  of  both  sides  is  involved.  Of  282  cases  both 
sides  were  affected  in  215.  When  one  side  alone  is  involved,  it  is  the  left 
a  little  more  frequently  than  the  right.  The  interval  between  the  swell- 
ing of  the  two  sides  may  be  a  week,  or  even  five  or  six  weeks,  but  usually 
it  is  only  two  or  three  days. 

The  salivary  secretion  is  usually  very  much  diminished,  and  the  dry 
mouth  causes  great  discomfort.  An  exceptional  instance  has  been  re- 
ported by  Simon,  in  which  a  distressing  salivation  occurred,  the  secretion 
amounting  to  six  or  eight  ounces  daily. 


MUMPS.  949 

Although  as  a  rule  the  patient  is  not  seriously  ill,  mumps  may  in  rare 
cases  produce  most  alarming  and  even  dangerous  symptoms.  The  tem- 
perature may  for  several  days  reach  104°  F.  or  more,  deglutition  may  be 
extremely  difficult,  pressure  on  the  jugular  veins  may  lead  to  venous  hyper- 
emia of  the  brain,  causing  headache  and  sometimes  delirium ;  there  is 
sometimes  great  prostration  and  the  symptoms  of  the  typhoid  condition. 
These  severe  attacks  are  nearly  always  in  children  over  twelve  years  old. 

The  constitutional  symptoms  of  mumps  usually  last  from  three  to  five 
days ;  the  swelling  continues  on  an  average  a  little  less  than  a  week.  If 
the  case  has  been  a  severe  one,  slight  swelling  may  continue  for  two  weeks 
or  even  longer.  Relapses,  in  which  the  opposite  side  from  the  one  first 
affected  is  involved,  are  quite  frequent,  occurring  in  about  ten  per  cent  of 
the  eases. 

Complications  and  Seq^uelse. — In  childhood  the  compHcations  are  few 
and  usually  unimportant ;  but  in  adolescence  they  are  occasionally  serious. 
Orchitis  is  exceedingly  rare  in  childhood  ;  of  230  cases  observed  by  Eilliet 
and  Barthez,  this  was  seen  in  but  10,  and  only  3  of  these  cases  were  under 
fifteen  years,  and  no  case  under  twelve  years  old.  When  orchitis  occurs  it 
is  generally  toward  the  end  of  the  second  or  the  beginning  of  the  third 
week ;  it  is  usually  marked  by  an  accession  of  fever,  sometimes  by  a  chill ; 
if  severe,  nervous  symptoms  may  be  present.  The  local  symptoms  do  not 
differ  from  those  of  an  ordinary  attack  of  orchitis.  The  body  of  the  tes- 
ticle and  not  the  epididymis  is  generally  affected.  The  acute  symptoms 
continue  for  three  or  four  days,  and  the  entire  duration  is  about  a  week ; 
although  the  testicle  is  often  enlarged  for  some  time  afterward,  and 
atrophy  of  the  organ  may  follow. 

In  females,  congestion  and  swelling  of  the  breasts,  ovaries,  or  labia 
majora  may  occur ;  and,  although  they  are  all  very  rare,  most  of  them 
have  been  observed  even  in  young  children. 

Nephritis  has  in  a  few  instances  followed  mumps,  sometimes  coming 
on  as  late  as  four  or  five  weeks  after  the  attack.  Single  cases  have  been 
reported  by  Croner,  Isham,  Henoch,  and  others.  Nervous  sequela  are 
more  frequent,  but  even  these  are  rare.  Jaffrey  has  reported  a  case  of 
multiple  neuritis  with  typical  symptoms,  occurring  three  weeks  after  an 
attack.  Facial  paralysis  three  weeks  after  mumps  has  been  reported  by 
Hellier,  apparently  due  to  an  extension  of  inflammation  from  the  gland 
to  the  seventh  nerve. 

Pearce  *  has  collected  an  interesting  series  of  forty  cases  of  deafness 
following  mumps,  in  which  there  was  no  sign  of  otitis,  the  symptoms 
coming  on  suddenly  with  vertigo,  a  staggering  gait,  and  often  with  vomit- 
ing. In  most  of  the  cases  the  deafness  was  unilateral  and  the  loss  of 
hearing  was  permanent.     The  cause  assigned  was  disease  of  the  auditory 


*  Manchester  Chronicle,  1885. 


950  THE  SPECIFIC   INFECTIOUS  DISEASES. 

nerve,  the  seat  of  the  trouble  being  in  the  labyrinth.  Toynbee  has  re- 
ported an  instance  of  haemorrhage  into  the  labyrinth.  Otitis  media  is 
rarely  seen. 

Suppuration  of  the  parotid  glands  occurs  iu  about  one  per  cent  of  the 
cases,  and  is  probably  due  to  accidental  infection.  Gangrene  and  slough- 
ing of  the  parotid  were  observed  twice  by  Demme  in  117  cases,  both  of 
which  proved  fatal.  Pneumonia,  meningitis,  endocarditis,  and  pericar- 
ditis have  all  been  observed  as  complications  of  mumps,  although  all  are 
extremely  rare. 

Prognosis. — In  the  great  proportion  of  cases  mumps  is  a  mild  disease, 
and  terminates  in  complete  recovery  in  a  few  days.  In  young  children 
complications  are  infrequent,  and  those  which  occur  are  rarely  severe. 

Diagnosis. — Mumps  is  most  likely  to  be  confounded  with  acute  swell- 
ing of  the  cervical  lymph  nodes.  In  a  parotid  swelling,  the  lobe  of  the 
ear  is  near  the  centre  of  the  tumour,  which  extends  backward  to  the 
sterno-mastoid  muscle  and  forward  upon  the  face  as  far  as  the  zygomatic 
arch,  embracing  the  angle  and  ramus  of  the  jaw. 

A  swollen  lymph  node  is  usually  entirely  below  the  ear  and  behind  the 
jaw,  never  extending  upon  the  face.  The  tumour  is  generally  smaller 
and  more  circumscribed  if  only  a  single  node  is  involved,  and  it  comes  on 
much  more  slowly  than  does  mumps.  When  only  the  submaxillary  or 
sublingual  glands  are  affected,  the  diagnosis  from  swollen  lymph  nodes  is 
sometimes  impossible  except  by  the  course  of  the  disease.  Mumps  is 
characterized  by  the  rapidity  with  which  the  swelling  occurs,  and  by  its 
relatively  short  duration. 

Treatment. — The  disease  is  self-limited  and  the  individual  symptoms 
rarely  distressing,  so  that  in  most  cases  very  little  treatment  is  required. 
If  constitutional  symptoms  are  present  the  patient  should  be  kept  in  bed, 
and  if  there  are  none  he  should  be  confined  to  the  house.  The  gland 
should  be  protected  by  cotton  or  spongio-piline,  and  if  the  pain  is  severe 
heat  should  be  applied  or  the  gland  painted  with  belladonna.  The  diet 
should  be  liquid,  on  account  of  the  pain  produced  by  mastication.  The 
mouth  should  be  kept  clean  by  the  use  of  some  antiseptic  mouth-wash. 
The  general  symptoms  and  complications  are  to  be  treated  according  to 
the  indications  in  the  individual  cases.  Cases  of  mumps  occurring  in 
schools  or  institutions  should  be  quarantined  for  three  weeks,  and  in 
private  practice  where  there  are  susceptible  persons.  Fumigation  and 
disinfection  after  an  attack  are  unnecessary. 


DIPHTHERIA.  951 


CHAPTEE    VIII. 
DIPHTHERIA. 

Until  within  the  last  few  years  it  has  been  customary  to  class  as 
diphtheria  all  diseases  characterized  by  the  production  of  a  false  mem- 
brane upon  the  mucous  membranes  of  the  throat  or  air  passages.  Bacte- 
riological study  of  these  cases  has  yielded  results  so  uniform  that  we  are 
now  able  to  separate  them  into  two  groups :  In  one,  there  has  been  demon- 
strated the  constant  presence  of  the  Klebs-Loefller  bacillus — the  Bacillus 
diplitlierice, ;  this  group  includes  cases  formerly  classed  as  primary  diph- 
theria, and  also  certain  others  such  as  primary  membranous  laryngitis  and 
rhinitis,  the  pathology  of  which  has  been  the  subject  of  much  dispute. 
In  the  other  group  the  Klebs-Loeffler  bacillus  is  absent ;  this  group  in- 
cludes most  of  the  membranous  inflammations  of  the  throat  which  occur 
as  complications  of  measles  and  scarlet  fever,  and  many  primary  cases  of 
such  inflammations  affecting  only  the  tonsils  or  the  tonsils  and  pharynx, 
and  formerly  regarded  by  some  as  croupous  tonsillitis,  by  others  as  mild 
or  doubtful  diphtheria.  The  form  of  bacteria  which  has  usually  been 
found  in  these  inflammations  which  simulate  diphtheria,  is  the  streptococ- 
cus pyogenes,  occasionally  the  staphylococcus.  In  the  following  pages  the 
term  dipMlieria  will  be  limited  to  those  cases  in  which  the  Klebs-Loeffler 
bacillus  is  present,  the  others  being  grouped  under  the  head  of  false  or 
'pseudo-diplitlieria. 

Diphtheria  may  then  be  defined  as  an  acute,  specific,  communicable 
disease  due  to  the  bacillus  of  Klebs  and  Loeffler.  It  is  usually  charac- 
terized by  the  formation  of  a  false  membrane  upon  certain  mucous  mem- 
branes, especially  those  of  the  tonsils,  pharynx,  nose,  or  larynx.  Like 
other  pathogenic  organisms,  however,  this  germ  acts  with  varying  in- 
tensity, and  may  cause  inflammation  of  all  degrees  of  severity,  from  a  mild 
catarrhal  angina  to  the  most  serious  membranous  inflammation ;  but  to 
all  alike  the  term  diphtheria  should  be  applied.  In  its  mild  form  it  may 
be  almost  without  constitutional  symptoms ;  but  in  its  severe  form  it  is 
attended  by  great  general  prostration,  cardiac  depression,' and  angemia,  it 
is  frequently  complicated  by  pneumonia  and  nephritis,  and  it  may  be  fol- 
lowed by  localized  or  general  paralysis ;  it  then  constitutes  one  of  the 
diseases  most  to  be  dreaded  in  childhood.  While,  therefore,  there  are  now 
included  under  the  term  diphtheria  many  cases  formerly  not  recognised 
as  such,  there  are  excluded  many  others  which  somewhat  resemble  it 
clinically,  but  in  which  the  bacillus  of  diphtheria  is  absent. 

Etiology. —  The  Bacillus  Dij)litliericB. — This  was  first  described  by 
Klebs  in  1883,  and  during  the  following  year  it  was  isolated  by  Loeffler 


952  THE  SPECIFIC  INFECTIOUS  DISEASES. 

and  shown  to  be  pathogenic.  Little  was  added  to  this  discovery  until 
1888,  but  from  that  time  until  1891  very  extensive  observations  were  made 
in  France,  Germany,  and  America,*  all  confirming  the  early  conclusions 
of  Loeffler.  By  1891  all  the  conditions,  says  Welch,  had  been  fulfilled  to 
demonstrate  that  this  bacillus  was  the  cause  of  diphtheria, — viz.,  (1)  its 
constant  presence  ;  (2)  its  isolation  in  pure  culture;  (3)  the  reproduction 
of  the  disease  in  animals  by  inoculation  with  pure  cultures ;  (4)  the  find- 
ing of  a  similar  distribution  of  the  bacilli  in  the  original  and  in  the  ex- 
perimental disease. 

The  bacillus  of  diphtheria  varies  considerably  in  size  and  shape  even 
in  the  same  culture.  Its  length  is  from  1-5  to  6-5  micro-millimetres ;  its 
diameter,  from  0-3  to  0-8  micro-millimetres.  In  a  specimen  it  occurs 
singly  or  in  pairs,  sometimes  in  chains  of  three  or  four ;  the  bacilli  may 
lie  parallel,  but  frequently  two  form  an  acute  or  an  obtuse  angle  (Plate 
XVIII,  3,  4,  and  5).  They  are  straight  or  slightly  curved,  and  are  some- 
what swollen  or  club-shaped  at  their  ends.  The  bacilli  have  no  spores, 
but  contain  highly  refractile  bodies,  which  cause  them  to  stain  peculiarly. 
With  alkaline  methyl  blue  (Loeffler's  stain)  they  stain  in  a  very  charac- 
teristic way ;  not  uniformly,  but  the  oval  bodies  in  the  central  parts  or  in 
the  extremities  of  the  bacillus,  stain  more  deeply  than  the  rest  of  the 
protoplasm.  This  difference  is  not  seen  in  the  old  cultures  which  stain 
with  difficulty  (Park). 

The  best  culture  medium  is  Loeffler's  blood-serum. f  After  ten  or 
twelve  hours,  at  a  temperature  of  about  100°  ¥.,  the  colonies  (Plate  XVIII, 
1  and  2)  appear  slightly  elevated,  of  a  white  or  grayish  colour,  with 
rounded  but  generally  irregular  borders.  They  may  increase  to  one 
fourth  of  an  inch  in  size ;  and  although  the  early  colonies  are  about  the 
same  size  as  those  of  the  streptococcus,  the  later  ones  are  larger.  They 
do  not  liquefy  tlie  blood-serum. 

Distribution  and  mode  of  communication. — Diphtheria  prevails  epi- 
demically, endemically,  and  sporadically.  In  most  large  cities  it  is  en- 
demic, occasional  cases  occurring  throughout  the  year,  with  periods  in 
which  outbreaks  of  considerable  severity  are  observed.  In  the  country  it 
prevails  chiefly  as  an  epidemic.  The  disease  is  often  introduced  into  re- 
mote districts  in  some  inexplicable  manner,  and  before  its  nature  is 
recognised  a  large  number  of  persons  have  been  exposed,  and  an  epidemic 
results.  J 

*  For  a  summary  of  the  literature  upon  this  subject  see  Welch  and  Abbott,  Johns 
Hopkins  Hospital  Bulletin,  February  and  March,  1891 ;  Prudden,  New  York  Medical 
Record,  April.  1891 ;  Park,  New  York  Medical  Record,  July  and  August,  1892. 

\  Blood-serum  two  thirds,  nutrient  bouillon  one  third,  glucose  one  per  cent. 

X  The  following  is  an  example  of  the  way  in  which  diphtheria  may  be  introduced : 
In  the  country  branch  of  the  New  York  Infant  Asylum,  consisting  of  a  somewhat  iso- 
lated community  of  about  five  hundred  persons,  chiefly  children,  there  had  been  no 


DIPHTHERIA.  953 

Diphtheria  does  not  arise  de  novo.  Every  case  has  its  origin  in  a  pre- 
vious case  either  directly  or  remotely.  The  bacilli  may  enter  the  body 
through  the  inspired  air ;  they  may  be  taken  into  their  mouth  with  toys 
or  other  articles  upon  which  they  have  lodged,  or  by  kissing,  and  some- 
times accidental  inoculation  occurs.  As  a  rule,  the  bacilli  first  gain  a 
foothold  upon  the  mucous  membrane  of  the  tonsils,  nose,  or  larynx. 

Direct  infection  is  the  cause  in  the  great  majority  of  the  cases.  There 
is  no  proof  that  the  bacilli  are  contained  in  the  breath  of  a  person  suffer- 
ing from  the  disease.  They  are  discharged  in  great  numbers  in  the  saliva 
and  mucus  from  the  mouth  and  nose,  and  in  pieces  of  membrane  which 
are  coughed  up ;  they  are  not  present  in  the  urine  or  fgeces.  The  most 
contagious  cases  are  those  of  pharyngeal  diphtheria  of  severe  type  and 
long  duration,  chiefly  on  account  of  the  amount  of  discharge  which 
accompanies  them.  The  cases  that  are  least  contagious,  and  for  precisely 
opposite  reasons,  are  those  in  which  the  membrane  is  limited  to  the  larynx 
and  lower  air  passages. 

Direct  infection  may  occur  from  persons  convalescent  from  diphtheria, 
whose  throats  still  contain  virulent  bacilli,  or  from  persons  suffering 
from  a  mild  form  of  the  disease,  which  is  not  recognised  as  diphtheria. 
In  the  latter  way  it  is  often  spread  in  schools.  It  has  been  shown  that  a 
person  may  harbour  virulent  bacilli  in  his  nose  or  throat,  and  may  even 
communicate  the  disease  to  others,  without  himself  suffering  from  diph- 
theria at  any  time. 

The  length  of  time  during  which  a  patient  with  diphtheria  may  con- 
vey the  disease  to  others  is  somewhat  uncertain.  Transmission  is  possible 
so  long  as  virulent  bacilli  remain  in  the  throat ;  these  are  frequently  found 
two  weeks  after  the  membrane  has  disappeared  and  the  patient  is  regarded 
as  entirely  well,  and  in  a  few  cases  they  are  found  five  or  six  weeks  or 
longer  after  recovery. 

Indirect  infection  is  not  uncommon,  and  may  occur  from  the  bed  or 
clothing  of  the  patient,  from  the  carpet,  furniture,  wall-paper  or  hangings 
of  the  room,  from  toys  or  picture-books,  from  dishes,  feeding-bottles,  or 
drinking-cups,  from  swabs  and  brushes  used  for  local  applications  to  the 
throat,  from  spoons  and  tongue-depressors,  and  from  surgical  instruments 
with  which  tracheotomy  or  intubation  has  been  done.  Diphtheria  may  be 
carried  by  a  third  person,  but  rarely  except  by  one  who  has  been  in  close 


case  of  diphtheria  for  several  years  until  1887.  The  first  case  was  one  of  membranous 
laryngitis,. proving  rapidly  fatal  in  two  days.  At  autopsy,  membrane  was  found  only 
in  the  larynx.  The  case  was  regarded  at  that  time  as  evidence  of  the  existence  of  a 
primary  non-diphtheritic  membranous  croup.  In  the  course  of  the  next  few  weeks 
there  developed  a  number  of  cases  of  typical  diphtheria.  On  investigation,  it  was  dis- 
covered that  the  nurse  who  had  charge  of  the  child  first  affected,  had  been  a  few  weeks 
before  in  attendance  upon  a  case  of  diphtheria.  During  the  five  years  following,  cases 
of  diphtheria  occurred  in  the  institution  every  year. 


954  THE  SPECIFIC  INFECTIOUS  DISEASES. 

contact  with  the  patient — either  the  piiysician  or  nurse.  The  frequency 
of  diphtheria  in  physicians'  families  bears  witness  to  the  great  danger  of 
infection  in  this  manner. 

Bacilli  may  retain  their  virulence  for  an  indefinite  period.  Both  Park 
and  Loeffler  found  cultures  in  blood-serum  to  be  virulent  after  seven 
months ;  Roux  and  Yersin,  bacilli  in  dried  membrane  to  be  virulent  after 
twenty  weeks ;  and  Abel,  upon  a  child's  toy  after  five  months. 

Domestic  animals  may  in  rare  instances  be  carriers  of  infection,  and 
in  the  case  of  pigeons,  at  least,  they  may  themselves  suffer  from  the  dis- 
ease. Diphtheria  has  been  repeatedly  spread  by  milk,  but  very  rarely 
through  the  contamination  of  a  water  supply.  Bad  drainage,  defective 
sewerage,  and  decomposing  organic  matter  are  occasionally  associated  with 
outbreaks  of  diphtheria,  these  furnishing  conditions  favourable  to  the 
development  of  the  bacilli ;  but  apart  from  the  presence  of  the  bacilli 
they  are  incapable  of  producing  the  disease. 

Predisjjosmg  causes. — Local  conditions  in  the  throat  influence  very 
largely  the  occurrence  of  diphtheria.  •  An  important  predisposing  cause 
is  the  existence  of  a  chronic  catarrhal  inflammation  of  the  mucous  mem- 
branes of  the  nose  and  throat,  so  frequently  found  in  children  suffering 
from  adenoid  growths  of  the  pharynx  or  enlarged  tonsils.  These  adenoid 
growths,  the  tonsillar  crypts,  and  the  cavities  of  carious  teeth,  may  harbour 
the  bacilli  for  a  considerable  time  both  before  and  after  an  attack.  The 
condition  of  these  membranes  in  other  acute  infectious  diseases  furnishes 
a  marked  predisposition  to  diphtheria.  This  is  most  striking  in  the  case 
of  measles  and  scarlet  fever ;  it  is  seen  less  frequently  in  typhoid  fever 
and  influenza.  Children  with  very  sensitive  mucous  membranes,  such  as 
those  reared  in  institutions  or  in  tenement  houses,  are  peculiarly  sus- 
ceptible. Infection  through  a  healthy  mucous  membrane,  if  not  impos- 
sible, is  certainly  very  unlikely. 

The  two  sexes  are  about  equally  liable  to  the  disease.  Children  under 
ten  are  much  more  often  affected  than  those  who  are  older,  the  greatest 
susceptibility  as  regards  age  being  between  the  second  and  fifth  years. 
Of  14,688  deaths  occurring  in  New  York  from  diphtheria  during  ten 
years,  the  ages  were  as  follows  (Billington) : 

Under  one  year 1,214 

One  to  five  years 9,622 

Five  to  ten  years 3,312 

Ten  to  fifteen  years 311 

Over  fifteen  years 329 

14,688 

While  diphtheria  is  seen  throughout  the  year,  it  is  rather  more  fre- 
quent during  the  cold  than  the  warm  months.  Of  18,088  deaths  occur- 
ring in  New  York  from  diphtheria  during  thirteen  years,  there  were 


DIPHTHERIA.  955 

10,769  from  October  to  March,  inclusive,  and  7,919  from  April  to  Sep- 
tember, inclusive  (Bosworth). 

The  incubation  of  diphtheria  is  short.  In  most  of  the  cases  in  which 
it  conld  be  definitely  traced  it  has  been  between  two  and  five  days.  It  is 
shorter  when  the  disease  is  epidemic,  when  the  patient  is  very  susceptible, 
when  the  local  conditions  in  the  mucous  membranes  are  favourable,  and 
when  the  type  is  virulent.  The  virulence  varies  much  in  different  cases 
and  in  different  seasons,  and  while  it  is  frequently  true  that  persons  in- 
fected from  a  mild  case  have  a  mild  type  of  the  disease,  and  those  infected 
from  a  malignant  one  a  severe  type,  there  is  no  certainty  that  such  will  be 
the  sequence.  Dr.  W.  H.  Park  informs  me  that,  out  of  many  hundreds 
tested  in  the  laboratory  of  the  New  York  Health  Department,  by  far  the 
most  virulent  type  of  the  bacillus  was  obtained  from  the  throat  of  a  boy 
who  had  what  was  clinically  regarded  as  a  very  mild  form  of  tonsillar 
diphtheria. 

Second  attacks  of  diphtheria,  while  more  frequent  than  those  of 
measles  or  scarlet  fever,  are  relatively  rare.  It  seems  to  be  established  by 
recent  observations  that  the  immunity  conferred  by  one  attack  of  diph- 
theria is  of  comparatively  short  duration,  amounting  probably  to  a  few- 
months  only.  In  my  own  experience,  however,  I  can  recall  but  very  few 
instances  of  second  attacks.  R.  W.  Parker  (London)  believes  the  protec- 
tion afforded  by  one  attack  to  be  quite  as  complete  as  that  of  measles  or 
scarlet  fever. 

Lesions. — The  essential  lesions  of  diphtheria  consist  not  in  the  produc- 
tion of  a  membrane,  but,  as  long  ago  pointed  out  by  Oertel,  and  more 
recently  by  Babes,  Sidney  Martin,  and  others,  in  certain  acute  degenerative 
changes  in  the  cells  of  the  body  caused  by  the  diphtheria  toxines.  These 
changes  are  seen  particularly  in  the  epithelial  cells  of  the  affected  mucous 
membranes,  the  heart  muscle,  the  kidney,  the  liver,  the  peripheral  nervous 
system,  the  spleen,  and  the  lymph  glands ;  the  most  characteristic  being 
those  of  the  nerves  and  the  liver.  There  are  other  lesions  which  are  the 
result  of  the  action  of  other  organisms,  especially  the  streptococcus  pyo- 
genes and  the  pneumococcus,  either  alone,  together,  or  in  conjunction 
with  the  diphtheria  bacillus.  The  most  important  lesions  due  to  these 
organisms  are  broncho-pneumonia  and  nephritis ;  but  there  may  be  found 
in  the  blood,  and  in  many  of  the  organs  of  the  body,  the  evidences  of  the 
invasion  of  these  bacteria— i.  e.,  a  streptococcus  septicaemia,  less  frequently 
a  general  pneumococcus  infection. 

Distribution  of  the  diphtheria  bacillus  in  the  lodij. — Unlike  many 
other  pathogenic  organisms,  the  diphtheria  bacillus  is  not  widely  dis- 
tributed throughout  the  body.  It  is  found  in  great  numbers  on  the 
surface  of  the  affected  mucous  membranes  and  in  the  false  membrane 
itself,  particularly  in  its  superficial  portion,  but  it  does  not  invade  deeply 
the  subjacent  structures.     It  is  only  exceptionally  found  in  the  blood  and 


956  THE  SPECIFIC  INFECTIOUS  DISEASES. 

in  distant  organs,  and  then  in  such  small  numbers  that  its  presence  is 
rarely  discovered  except  by  cultures. 

Tlie  diphtheria  toxines. — The  wide-spread  effects  seen  in  diphtheria  are 
due  to  the  action  of  certain  substances  called  toxines  which  the  diphtheria 
bacillus  produces  during  its  growth  on  mucous  membranes.  The  toxines 
have  been  studied  especially  by  Eoux  and  Yersin,  Brieger  and  Fraenkel, 
and  have  been  called  tox-albumins.  They  are  very  diffusible,  readily 
entering  the  lymphatic  circulation  and  the  blood,  and  through  these 
channels  may  affect  the  entire  body.  It  has  been  shown  by  Welch  and 
Flexner  and  others  that  in  susceptible  animals  there  may  be  produced  by 
the  injection  of  the  toxines  all  the  characteristic  lesions  of  diphtheria 
except  the  membrane,  as  well  as  the  essential  symptoms  of  the  disease, 
even  including  paralysis.  For  the  production  of  the  membrane  living 
bacilli  are  required. 

"  Catarrhal "  diphtheria. — It  has  been  already  stated  that  a  membrane 
is  not  always  present  in  inflammations  excited  by  the  diphtheria  bacillus. 
The  routine  practice  of  making  cultures  from  diseased  throats  has  estab- 
lished the  fact  that  in  a  large  number  of  cases  catarrhal  inflammation  may 
be  the  only  result  of  diphtheritic  infection.  To  the  naked  eye  there  may 
be  only  the  ordinary  changes  of  a  catarrhal  inflammation  of  a  mucous 
membrane  ;  but  even  in  such  cases  Oertel  found  the  characteristic  degen- 
erative changes  in  the  epithelial  cells.  These,  of  course,  vary  in  degree 
with  the  severity  of  the  process. 

The  diphtheritic  meml)rane. — The  membrane  is  most  frequently  seen 
upon  the  mucous  membrane  of  the  tonsils,  soft  palate,  uvula,  pharynx, 
nose,  larynx,  trachea,  and  bronchi ;  less  frequently  upon  the  mouth,  lips, 
CBSophagus,  conjunctivas,  middle  ear,  stomach,  and  genital  organs.  It  may 
also  affect  fresh  wounds,  notably  a  tracheotomy  wound,  or  any  abraded 
cutaneous  surface.  The  gross  appearance  of  the  membrane  varies  greatly 
(Plate  XVII).  It  is  most  frequently  of  a  gray  or  mouse-colour,  but  it 
may  be  pearly  white,  yellow,  green,  and  sometimes  almost  black.  It  is 
composed  of  fibrin,  cells,  granular  matter,  and  bacteria.  Its  consistency 
varies  with  the  relative  j^roportions  of  the  different  elements.  When  made 
up  chiefly  of  fibrin  it  is  firm  and  retains  its  form,  often  being  discharged 
as  a  complete  cast  of  the  nose,  larynx,  or  trachea.  When  the  amo.unt 
of  fibrin  is  small  the  membrane  is  soft,  friable,  and  sometimes  granular. 
It  is  more  closely  adherent  upon  the  mucous  membranes  covered  with 
squamous  epithelium,  as  in  the  pharynx  and  upper  air  passages,  than  upon 
those  covered  with  columnar  and  ciliated  epithelium,  as  in  the  lower  air 
passages. 

The  microscopical  examination  shows  the  fibrin  to  be  sometimes  gran- 
ular, but  usually  in  the  form  of  a  network,  inclosing  in  its  meshes  small 
round  cells  and  epithelial  cells  in  various  stages  of  degeneration.  On  the 
surface  and  in  the  sujoerficial  layer  there  is  usually  found  quite  a  variety 


DIPHTHERIA.  957 

of  bacteria  including  diphtheria  bacilli.  Beneath  this  is  a  cellular  layer 
containing  little  or  no  fibrin,  in  which  also  the  diphtheria  bacilli  are  usu- 
ally found.  In  the  deepest  parts  of  the  false  membrane  and  in  the  mucous 
membrane  itself  they  are  few  in  number  or  absent. 

Characteristic  changes  which  are  similar  in  all  the  affected  mucous 
membranes  are  found  in  the  epithelial  cells.  The  cells  undergo  marked 
proliferation  and  infiltration  with  leucocytes  ;  they  show  also  degenerative 
changes  in  their  protoplasm  and  fragmentation  of  their  nuclei,  which 
result  in  the  formation  of  granular  masses  of  necrotic  substance.  The 
infiltration  with  small  round  cells  is  variable  in  degree  in  the  different 
mucous  membranes  ;  in  some  it  extends  deeply  into  the  submucous  and 
even  the  muscular  layers,  while  in  others  it  is  very  superficial.  Marked 
evidences  of  cell  death  are  seen  also  in  the  cells  infiltrating  the  deeper 
layers.  In  places  the  epithelium  is  detached,  in  others  the  line  between 
the  false  membrane  and  the  granular  mucous  membrane  is  scarcely  dis- 
tinguishable. 

The  seat  and  the  distribution  of  the  membrane. — This  varies  somewhat 
with  the  age  of  the  patient,  the  season,  and  the  peculiarity  of  the  epi- 
demic. In  the  following  table  are  given  some  figures  from  the  records  of 
the  New  York  Infant  Asylum.  These  cases  were  taken  consecutively,  and 
did  not  belong  to  a  single  epidemic  : 


.,         .,    ,  r  Tonsils  only , 

Above  the  larvnx    I      ,  •'   ,  -,  ,       ., 

,„„  ,  <   Pharynx  or  pharynx  and  tonsils 

I  Pharynx  and  nose  or  rhino-pharynx 

r  Larynx  only 

Not  above  the      I  larynx  and  trachea 

larynx  i^  Larynx,  trachea,  and  large  bronchi 

(lU  cases).         j^  Larynx,  trachea,  large  and  to  smallest  bronchi 

Pharynx  and  larynx 

Pharynx,  larynx,  and  trachea. 

Pharynx,  larynx,  trachea,  and  large  bronchi 

Pharynx,  larynx,  trachea,  large  and  to  smallest  bronchi . 

below  the  larynx  i  ^^^^'^  pharynx,  larynx,  and  trachea 


Both  above  and 


(36  cases), 


Nose,  larynx,  and  trachea 

Pharynx  and  trachea  (none  in  larynx) 

Pharynx,  trachea,  and  bronchi  (none  in  larynx). 


27 

cases 

18 

« 

18 

" 

6 

« 

1 

case. 

1 

(( 

2 

cases. 

12 

a 

6 

" 

4 

u 

10 

" 

1 

case. 

1 

" 

1 

" 

1 

" 

09 

cases. 

All  these  cases  were  in  young  children,  80  per  cent  of  them  being  under 
two  years  old.  In  the  first  group  the  mortality  was  30  j^er  cent ;  in  the 
second  group,  90  per  cent ;  in  the  third  group,  92  per  cent.  The  larynx 
was  involved  in  42*3  per  cent  of  the  cases.  The  location  of  the  membrane 
was  determined  by  autopsies  in  all  the  sixty-one  fatal  cases.  The  strong 
tendency  of  the  disease  in  young  children  to  invade  the  lower,  air  passages, 
and  to  extend  far  into  the  bronchi  when  once  the  larynx  is  involved,  is  also 
shown  in  a  report  upon  eighty-seven  autopsies  in  laryngeal  cases  made  by 


958  THE  SPECIFIC  INFECTIOUS  DISEASES. 

Northrnp.  In  ouly  three  was  the  larynx  alone  the  seat  of  membrane ;  in 
57  per  cent  the  membrane  descended  into  the  bronchi,  and  in  37  per  cent, 
to  the  finest  bronchi.     All  these  records  are  of  the  pre-antitoxine  days. 

An  interesting  comparison  with  the  figures  above  given  may  be  made 
with  those  of  Lennox  Brown  of  1,000  cases,  including  persons  of  all  ages, 
but  mainly,  doubtless,  children  : 

'  Fauces  (inckiding  tonsils)  alone 672  cases. 

Above  the  larynx      Nose  alone 2 

(841,  or  84-1       <  Fauces  and  nose 1C5     " 

per  cent).  Mouth  or  lips  alone 1  case. 

1^  Hard  palate  alone 1     " 

Involving  the      r  Larynx  alone '    4  cases. 

larynx  *  (159,  or   ^  Larynx  and  fauces 109     " 

15-9  per  cent).      I  Larynx,  fauces,  and  nose 46     " 

The  tonsils  are  the  most  frequent  and  usually  the  earliest  seat  of  the 
diphtheritic  membrane  ;  it  may  form  here  a  tough,  leathery  patch,  par- 
tially or  completely  covering  and  very  adherent  to  them  ;  or  the  disease 
may  affect  only  the  tonsillar  crypts,  so  that  the  gross  lesion  may  resemble 
that  of  ordinary  follicular  tonsillitis.  There  is  in  most  cases  only  moder- 
ate swelling,  but  it  may  be  so  great  that  the  tonsils  are  in  contact.  The 
surrounding  cellular  tissue  is  infiltrated  with  inflammatory  products. 

The  membrane  covering  the  pharynx  and  uvula  is  also  usually  very 
adherent  and  intimately  blended  with  the  mucous  membrane.  The  uvula 
is  swollen  and  oedematous.  Membrane  may  be  seen  only  upon  the  fauces 
and  uvula,  or  the  posterior  and  lateral  pharyngeal  walls  may  be  covered 
down  to  the  level  of  the  cricoid  cartilage,  but  generally  not  below  this 
point.  If  the  posterior  pharyngeal  wall  is  covered,  the  membrane  is  apt 
to  extend  into  the  rhino-pharynx,  and  may  fill  the  entire  pharyngeal 
vault,  covering  the  posterior  portion  of  the  velum  and  extending  into  the 
posterior  nares.  The  adenoid  tissue  of  the  vault  is  a  favourite  seat,  and 
is  frequently  the  part  most  affected.  The  amount  of  infiltration  of  the 
submucous  tissue  varies  much  in  the  different  cases. 

The  nose  may  be  involved  secondarily  to  the  rhino-pharynx,  or  infec- 
tion may  be  through  the  anterior  nares  ;  if  the  latter,  it  is  not  infre- 
quently the  only  part  involved.  Many  cases  classed  as  nasal  are  really 
rhino-pharyngeal.  The  membrane  in  the  pure  nasal  cases  is  usually  thick 
and  tough  and  often  separates  en  masse.  Both  sides  are  generally  in- 
volved, but  it  may  be  unilateral.  Catarrhal  diphtheria  of  the  nose  and 
rhino-pharynx  is  probably  more  frequent  than  in  any  other  location. 

The  epiglottis  is  swollen  to  three  or  four  times  its  normal  thickness, 
and  the  aryteno-epiglottic  folds  are  oedematous.     The  anterior  surface  of 

*  These  being  clinical  and  not  pathological  records,  the  number  in  which  the  dis- 
ease extended  below  the  larynx  is  not  given. 


DIPHTHERIA.  959 

the  epiglottis  is  rarely  covered  by  membrane ;  but  its  lateral  borders  and 
posterior  surface,  and  the  aryteno-epiglottic  folds  are  involved  in  most  of 
the  severe  pharyngeal  cases  (Plate  XV^II,  C).  This  lesion  is  associated 
with  pharyngeal  rather  than  with  laryngeal  diphtheria. 

The  lesions  which  extend  most  deeply  are  thus  seen  in  the  tonsils, 
uvula,  ijharynx,  and  epiglottis.  But  even  here  there  is  very  rarely  deep 
or  extensive  sloughinsr. 

The  lesions  of  the  larynx,  trachea,  and  bronchi  are  similar  to  the 
above,  although  much  more  superficial.  The  interior  of  the  larynx  may 
be  completely  covered,  the  membrane  coating  the  true  and  false  vocal 
cords  and  lining  the  ventricles  of  the  larynx ;  or  it  may  extend  from 
the  epiglottis  down  to  the  anterior  surface  of  the  larynx,  while  the  pos- 
terior surface  is  free.  The  membrane  in  the  larj-nx  is  not  usually  very 
adherent,  and  it  frequently  separates  and  is  coughed  up  in  large  pieces 
or  even  as  a  cast.  The  membrane  covering  the  epiglottis  and  the 
aryteno-epiglottic  folds  is  very  adherent,  like  that  of  the  pharynx. 
Catarrhal  laryngitis  is  not  an  uncommon  complication  of  pharyngeal 
diphtheria. 

In  a  considerable  number  of  cases  the  membrane  stops  abruptly  at  the 
lower  border  of  the  larynx.  In  the  trachea  it  is  generally  loosely  attached, 
and  often  it  is  found  at  autopsy  entirely  separated  from  the  mucous  mem- 
brane. It  is  almost  invariably  associated  with  membrane  in  the  larvnx. 
Usually  the  membrane  in  the  bronchi  is  continuous  with  that  in  tlie 
trachea.  Occasionally  I  have  seen  the  trachea  and  larger  bronchi  passed 
over  and  found  membrane  only  in  the  larynx  and  smaller  bronchi.  As  a 
rule,  the  bronchi  of  both  sides  are  affected,  and  to  the  same  degree.  I 
once  saw  a  case  of  laryngeal  diphtheria  in  which  membrane  was  found 
only  in  the  bronchi  of  one  lung.  The  above  exceptions  are  to  be  explained 
as  accidents  in  the  mechanical  transportation  of  bacilli. 

The  extent  of  the  membrane  varies  greatly  in  different  cases.  It  may 
stop  at  the  bifurcation  of  the  trachea  or  at  the  bifurcation  of  the  primary 
bronchi ;  but  if  it  goes  beyond  this  point  it  is  likely  to  extend  to  the 
minutest  subdivisions.  In  the  large  bronchi,  as  in  the  trachea,  the  mem- 
brane is  loosely  attached.  In  the  smallest  bronchi  it  is  more  adherent, 
and  sometimes  only  to  be  made  out  by  the  microscope.  Exceptionally  a 
very  tough  fibrinous  membrane  forms  in  the  trachea  and  bronchi,  of  suf- 
ficient thickness  and  consistency  to  be  expelled  as  a  cast,  rejiroducing 
almost  the  entire  bronchial  tree. 

The  inflammation  of  the  mucous  membrane  of  the  larynx,  trachea,  and 
bronchi  is  very  much  less  severe  and  more  superficial  in  character  than 
that  of  the  pharynx,  tonsils,  and  upper  air  passages. 

The  buccal  cavity  is  seldom  covered  by  the  membrane,  and  then  only 
in  the  worst  cases  of  pharyngeal  disease;  it  may  line  the  cheeks,  cover  the 
lip?,  gums,  and  more  or  less  of  the  hard  palate,  but  rarely  the  tongue.  It 
62 


960  THE  SPECIFIC   INFECTIOUS  DISEASES. 

usually  occurs  in  patches  rather  than  as  a  continuous  membrane.  In  a 
recent  case  I  saw  the  membrane  on  the  lower  lip,  extending  on  to  the  face, 
though  the  buccal  cavity  was  free.  Only  once  have  I  seen  the  membrane 
in  diphtheria  extend  from  the  pharynx  into  the  oesophagus ;  it  is  surpris- 
ingly infrequent.  The  membrane  is  very  rarely  found  in  the  stomach,  and 
in  no  case,  so  far  as  I  am  aware,  has  the  diagnosis  of  true  diphtheria  been 
confirmed  by  cultures.  I  have  in  several  instances  seen  membrane  in  the 
stomach;  cultures, however, showed  streptococci,  but  no  diphtheria  bacilli. 

The  middle  ear  is  not  very  often  involved.  Otitis  usually  results  from 
direct  extension  of  the  membrane  from  the  rhino-pharynx  through  the 
Eustachian  tube.  It  may  lead  to  very  extensive  destruction  of  the  mucous 
membrane  of  the  tympanum,  and  often  to  permanent  injury.  Infection 
of  the  conjunctivae  is  also  rare,  and  is  probably  due  to  accidental  inocula- 
tion rather  than  to  extension  from  the  nose  through  the  lachrymal  duct. 

Diphtheria  may  attack  an  abraded  cutaneous  surface  usually  by  direct 
inoculation,  or  it  may  involve  a  fresh  wound.  This  is  most  frequently 
seen  in  the  wound  in  the  neck  from  tracheotomy.  Most  of  the  recorded 
cases  in  which  diphtheria  is  stated  to  have  involved  the  folds  of  the  anus, 
the  female  genitals,  the  prepuce,  or  recent  wounds,  were  observed  before 
we  had  the  means  of  separating  by  cultures,  true  from  pseudo-diphtheria. 
A  very  considerable  proportion  of  these  cases  doubtless  belong  to  the  lat- 
ter grouj). 

Visceral  lesions. — The  visceral  lesions  of  diphtheria  are  due  partly  to 
the  action  of  the  diphtheria  toxines  and  partly  to  the  invasion  of  the 
body  with  other  organisms,  especially  the  streptococcus.  It  is  to  experi- 
mental diphtheria  that  we  owe  our  most  accurate  knowledge  of  the  former 
changes,  for  in  human  diphtheria  the  large  proportion  of  all  the  fatal 
cases  show  evidences  of  so-called  "  mixed  infection."  Thus,  of  forty-two 
autopsies  upon  cases  in  which  the  diphtheria  bacillus  was  demonstrated 
during  life,  Reiche  *  reports  that  both  the  streptococcus  and  the  staphy- 
lococcus were  found  by  culture  in  the  kidney  or  spleen  in  64*3  per  cent, 
and  in  45-2  per  cent  the  streptococcus  alone.  He  found  the  streptococcus 
in  the  kidney  in  some  cases  dying  very  earl}', — in  one  on  the  second  day 
of  the  disease. 

The  visceral  lesions  of  diphtheria  consist  in  wide-spread  areas  of  cell 
death  similar  to  those  which  have  already  been  described  as  occurring  in 
the  epithelial  cells  of  affected  mucous  membranes,  together  with  haemor- 
rhages due  to  changes  in  the  blood-vessels  and  possibly  in  the  blood  itself. 
The  lesions  are  found  in  the  lymph  nodes,  spleen,  heart  muscle,  epithe- 
lium of  the  kidney,  liver  cells,  peripheral  nerves,  and  in  the  lungs. 

The  lymph  nodes  of  the  cervical  region  are  the  most  constantly  and 

*  Centralblatt  fiir  innere  Medicin,  1895,  No.  3.  Quoted  by  Welch,  Transactions  of 
the  Association  of  American  Physicians,  1895. 


DIPHTHERIA.  961 

the  most  seriously  affected.  Similar  but  less  marked  changes  are  seen  in 
the  tracheo-bronchial  and  the  mesenteric  groups,  and  in  the  lymph  nodules 
of  the  mucous  membrane  of  the  stomach  and  intestine.  There  are  degen- 
erative changes  in  the  cells  of  the  nodes  most  affected,  with  marked  infil- 
tration with  leucocytes  and  frequently  small  haemorrhages.  The  cellular 
tissue  in  the  neighbourhood  of  the  cervical  nodes  is  often  extensively  infil- 
trated with  cells.  The  process  in  the  lymph  nodes  usually  terminates  in 
resolution,  rarely  in  suppuration. 

The  changes  in  the  spleen  are  quite  constant.  The  organ  is  swollen, 
sometimes  very  much  so,  and  deeply  congested.  Haemorrhages  are  often 
seen  beneath  the  capsule ;  the  spleen  pulp  is  soft,  the  follicles  are  large, 
and  cell  degeneration  is  quite  constantly  observed  similar  to  that  which 
takes  place  in  the  lymph  nodes. 

There  are  frequently  small  hfemorrhages  beneath  the  capsule  of  the 
liver,  and  sometimes  these  are  seen  throughout  the  organ.  There  are 
found  scattered  through  the  liver,  areas  of  necrotic  hepatic  cells  which  are 
peculiar  to  this  disease  ;  some  of  these  areas  are  infiltrated  with  leucocytes. 

The  kidneys  are  involved  in  almost  all  fatal  cases  except  where  death 
occurs  early  from  laryngeal  stenosis,  also  in  nearly  every  severe  case  which 
terminates  in  recovery.  There  is  in  the  milder  cases  only  acute  degenera- 
tion of  the  epithelium  of  the  tubes  and  the  tufts,  which  is  the  result  of 
the  action  of  the  diphtheria  toxines ;  or  in  the  more  severe  forms  there 
may  be  acute  exudative  or  even  acute  diffuse  nephritis,  the  latter  usually 
coming  on  at  a  later  period  of  the  disease.  In  the  production  of  these 
two  forms  of  inflammation,  infection  with  streptococci  probably  plays  the 
principal  part.  Welch  states  that  hj'aline  changes  iu  the  glomerular 
capillaries  and  small  arteries  are  characteristic  features  of  the  nephritis  of 
diphtheria. 

In  cases  dying  suddenly  in  the  early  stage  of  the  disease,  cardiac 
thrombi  are  occasionally  found.  These  may  be  formed  rapidly  only  a 
short  time  bofore  death,  or  slowly  during  several  days  when  the  circula- 
tion is  very  feeble.  Portions  of  these  thrombi  may  be  carried  into  the 
pulmonary  or  systemic  circulation,  causing  embolism  in  any  of  the  arteries 
of  the  extremities,  the  lungs,  or  other  viscera.  Even  in  the  early  fatal 
cases  the  heart  muscle  may  be  seriously  affected  ;  in  the  later  ones  this  is 
almost  constant.  The  changes  consist  in  a  toxic  myocarditis,  the  left 
ventricle  being  most  involved. 

Degeneration  of  the  arteries,  especially  of  the  endothelial  layer,  is 
occasionally  seen,  and  there  may  be  infiltration  of  the  adventitia.  The 
arteries  of  any  of  the  viscera  may  be  the  seat  of  hyaline  degeneration. 

The  lesions  of  the  brain  are  very  slight  and  inconstant.  In  the  spinal 
cord  there  have  been  found  multiple  ha3morrhages  into  the  membranes, 
and  certain  degenerative  changes  in  the  ganglion  dells  in  the  anterior 
horns,  to  which  great  significance  was  formerly  attached,  as  they  were 


952  THE  SPECIFIC  INFECTIOUS  DISEASES. 

thought  to  be  the  explanation  of  post-diphtheritic  paralysis.  These 
changes  are,  however,  slight  in  comparison  with  those  which  have  been 
found  in  the  spinal  nerves,  with  which  they  are  generally  associated. 
That  diphtheritic  paralysis  is  due  not  to  the  central  lesion  but  to  peripheral 
neuritis  was  first  shown  by  Westphal  in  1876,  and  more  fully  by  Dejenie 
during  the  following  year.  Degenerative  changes  have  been  demonstrated 
not  only  in  the  spinal  nerves  but  also  in  the  hypoglossal,  spinal  accessory, 
motor-oculi,  pneumogastric,  and  even  in  the  nerves  of  the  heart.  Accord- 
ing to  Sidney  Martin  *  these  nerve  degenerations  constitute  the  most 
characteristic  lesion  of  diphtheria.  (See  chapter  on  Multiple  Neuritis, 
page  785.) 

In  infants  and  young  children  broncho-pneumonia  is  found  at  autopsy, 
it  is  safe  to  say,  in  at  least  three  fourths  of  the  cases,  and  in  a  large  pro- 
portion of  these  it  is  the  cause  of  death.  It  is  well-nigh  constant  in  cases 
of  diphtheritic  bronchitis  of  the  finer  tubes,  and  is  usually  present  where 
the  membrane  has  extended  to  the  bifurcation  of  the  trachea.  The  most 
important  factor  in  the  production  of  pneumonia  is  the  aspiration  of  bac- 
teria, chiefly  streptococci,  from  the  upper  air  passages.  These  germs  are 
always  present  in  the  throat,  and  find  in  diphtheria  conditions  most  favour- 
able to  their  development.  The  pneumonia  of  diphtheria  seems  therefore 
to  be  due  to  auto-infection  rather  than  to  outside  causes.  Prudden  and 
Northrup  found  streptococci  almost  constantly  present  in  the  pneu- 
monia of  diphtheria,  often  in  pure  culture.  In  cases  studied  by  others 
the  streptococcus  has  been  found  alone  or  associated  with  the  pneumo- 
coccus  or  with  the  diphtheria  bacillus,  or  with  both  of  them. 

Where  there  has  been  laryngeal  stenosis,  some  emphysema  is  invariably 
present,  and  usually  it  is  of  the  vesicular  variety.  In  extreme  or  pro- 
tracted cases  of  stenosis  there  may  be  interstitial  emphysema.  Kupture 
of  some  of  these  blebs  may  lead  to  the  escape  of  air  into  the  cellular  tissue 
of  the  mediastinum  or  of  the  neck,  which  may  result  in  the  production  of 
a  general  emphysema  of  the  subcutaneous  cellular  tissue. 

Blood. — According  to  the  recent  studies  of  Ewing,  Morse,  Billings,  Jr., 
and  others,  there  is  found  in  all  severe  cases  of  diphtheria  a  reduction  in  the 
number  of  red  cells  to  the  extent  of  500,000  to  2,000,000  (5,000,000  being 
assumed  to  be  normal).  There  is  a  nearly  proportionate  reduction  in  the 
haemoglobin,  this  amounting  to  from  twelve  to  twenty-eight  per  cent. 
While  the  hsemoglobin  falls  coincidently  with  the  number  of  red  cells, 
it  is  regained  much  more  slowly.  Leucocytosis  was  found  in  twenty-six 
of  thirty  cases  studied  by  Morse,  and  in  forty-nine  of  fifty-three  by  Ewing. 
It  is  said  to  be  generally  proportionate  to  the  severity  of  the  attack,  but  is 
occasionally  wanting  in  the  most  severe  as  well  as  in  some  of  the  very 
mildest  cases.     The  increase  in  the  leucocytes  is  in  the  polynuclear  forms. 

*  British  Medical  Journal,  August  24,  189o. 


DIPHTHERIA.  963 

Symptoms. — The  clinical  picture  of  diphtheria  is  one  which  presents 
wide  variations,  depending  upon  the  principal  location  of  the  disease,  its 
severity,  and  its  complications.  For  practical  purposes  the  following 
seems  the  simplest  grouping  that  can  be  made  : 

1.  The  mild  cases,  in  which  there  is  either  no  membrane,  or  the 
amount  of  membrane  is  small  and  limited  to  the  tonsils  or  to  the  nose, 
with  few  or  none  of  the  constitutional  symptoms  which  follow  absorption 
of  the  diphtheria  poison.  These  cases  partake  essentially  of  the  character 
of  a  local  disease. 

2.  The  severe  cases,  which  are  of  two  kinds :  first,  those  in  which 
there  are  marked  evidences  of  constitutional  poisoning  from  diphtheria 
toxines ;  and,  secondly,  those  with  laryngeal  stenosis.  The  first  form 
is  usually  accompanied  by  an  extensive  formation  of  membrane  in  the 
pharynx  and  sometimes  in  the  nose.  The  larynx  may  be  involved 
secondarily  to  disease  in  the  pharynx  or  nose,  or  it  may  be  primarily 
atfected. 

3.  The  cases  of  mixed  infection  or  the  septic  cases.  In  very  many  of 
the  cases  of  the  two  preceding  groups  streptococci  are  found  in  the  throat, 
but  they  are  not  in  suflEicient  numbers  or  of  sufficient  virulence  to  modify 
the  course  of  the  disease.  In  the  cases  to  which  the  term  mixed  infection 
is  applied,  in  addition  to  the  constitutional  symptoms  of  diphtheritic 
toxaemia  and  the  local  conditions  which  usually  attend  it,  there  are  marked 
evidences  of  a  general  septicemia,  usually  due  to  the  streptococcus.  In 
these  cases  the  symptoms  of  inflammation  are  especially  prominent,  not 
only  in  the  pharynx  but  sometimes  in  the  lymph  glands  and  cellular  tissue 
of  the  neck,  which  may  be  followed  by  suppuration  or  sloughing.  This 
form  is  frequently  complicated  by  broncho-pneumonia  even  without  laryn- 
geal disease,  and  sometimes  by  severe  nephritis. 

Cases  ivithout  membrane. — During  an  epidemic  of  diphtheria  in  a 
family  or  an  institution,  cases  are  frequently  seen  which  present  the  clin- 
ical evidences  of  only  a  catarrhal  inflammation  of  the  nose  or  pharynx, 
and  yet  cultures  show  the  presence  of  the  diphtheria  bacillus.  These 
bacilli  have  been  found  by  Koplik,  Park,  and  others  to  be  virulent  in  very 
many  of  the  cases  tested,  but  not  in  all.  Such  cases  are  susceptible  of  two 
explanations  :  first,  that  they  are  examples  of  simple  catarrhal  inflamma- 
tion due  to  other  causes,  such  as  cocci,  the  diphtheria  bacillus  althougli 
present  not  being  the  active  cause  of  the  inflammation, — in  other  words, 
they  are  cases  of  simple  catarrhal  inflammation  with  the  accidental  pres- 
ence of  the  diphtheria  bacillus;  the  second  is,  that  they  are  cases  of 
"catarrhal  diphtheria,"  or  an  inflammation  caused  by  infection  with  the 
diphtheria  bacillus,  but  not  of  sufficient  intensity  to  lead  to  the  produc- 
tion of  a  membrane.  The  latter  is  the  view  of  pathologists,  and  the  one 
to  which  clinicians  must,  it  seems,  inevitably  come.  However,  a  mem- 
brane has  so  long  been  regarded  as  a  sme  qua  non  of  this  disease  that  the 


964  THE  SPECIFIC  INFECTIOUS  DISEASES. 

existence  of  diphtheria  without  it,  is  something  which  the  cliniciau  finds 
it  hard  to  grasp. 

Cases  of  the  kind  mentioned  may  be  either  pharyngeal  or  nasah  In 
the  pharyngeal  cases  there  are  present  the  usual  appearances  belonging  to 
a  catarrhal  inflammation  of  moderate  severity,  often  accompanied  by  swell- 
ing and  tenderness  of  the  cervical  lymph  glands.  In  the  cases  classed  as 
nasal  the  usual  seat  of  the  pathological  process  in  children  is  the  rhino- 
pharynx.  There  is  a  persistent  and  usually  abundant  nasal  discharge, 
which  is  thin,  irritating,  and  occasionally  streaked  with  blood,  and 
which  may  continue  for  weeks.  In  most  of  these  cases  constitutional 
symptoms  are  absent ;  in  a  few  there  may  be  a  very  slight  rise  of  tem- 
perature. The  clinical  evidence  that  these  are  cases  of  diphtheria  is,  first, 
that  they  may  infect  others ;  and,  secondly,  that  they  may  be  followed  by 
the  sudden  development  of  the  symptoms  of  laryngeal  diphtheria.  How- 
ever, nothing  but  a  bacteriological  examination  is  conclusive.  The  mild- 
ness of  these  cases  may  be  due  to  the  fact  that  the  bacilli  are  only  slightly 
virulent,  that  their  number  is  small,  or  that  the  resistance  of  the  patient 
is  great.  Catarrhal  diphtheria  is  not  in  itself  serious,  but  it  may  be  fol- 
lowed, particularly  in  young  children,  by  laryngeal  diphtheria  and  steno- 
sis, or,  after  it  has  existed  for  a  time,  pharyngeal  diphtheria  may  develop 
in  its  usual  form.  Cases  like  those  just  described  are  to  be  distinguished 
from  others  in  which  bacilli,  either  of  the  virulent  or  the  non-virulent 
variety,  are  found  without  any  evidence  of  inflammation. 

Cases  with  a  small  amount  of  inemhrane. — Tonsillar  diphtheria. — The 
exudation  is  usually  limited  to  the  tonsils  (Plate  XVII  A),  and  may  par- 
take of  the  character  of  either  follicular  or  croupous  tonsillitis ;  some- 
times there  is  a  slight  extension  to  the  faucial  pillars  or  to  the  pharynx. 
These  cases  are  quite  common,  and  in  some  epidemics  most  of  those  seen 
are  of  this  variety.  They  are  more  frequent  in  older  children  and  adults 
than  in  infants  and  young  children. 

The  onset  is  accompanied  by  a  little  soreness  of  the  throat ;  the  initial 
temperature  is  from  100°  to  103°  F. ;  but  the  symptoms  are  often  not 
severe  enough  to  keep  the  patient  in  bed.  If  seen  early,  the  throat  shows 
slight  redness,  followed  by  a  gray  film,  and  later  by  a  gray  or  white  de- 
posit upon  the  tonsils.  It  may  start  as  a  small  patch  which  enlarges,  or 
as  small,  isolated  spots  which  coalesce  or  remain  separate.  Until  it  disap- 
pears the  membrane  generally  remains  of  its  original  colour.  It  is  gener- 
ally quite  adherent,  and  can  not  easily  be  removed  with  a  swab  ;  usually  it 
is  sharply  defined,  but  with  a  somewhat  irregular  outline.  In  many  cases 
the  patch  is  not  larger  than  the  finger  nail.  The  inflammatory  changes 
in  the  pharynx  are  slight ;  a  faint  red  areola  is  frequently  present  at  the 
border  of  the  patch.  The  lymph  glands  behind  the  jaw  are  slightly 
swollen  or  may  be  normal.  There  is  no  nasal  discharge  and  very  little 
increase  in  the  saliva  or  mucus  from  the  pharynx.     The  constitutional 


DIPHTHERIA.  965 

symptoms  are  slight,  sometimes  almost  absent.  The  temperature  com- 
monly continues  above  the  normal  while  the  membrane  lasts,  its  usual 
range  being  from  100°  to  102°  F.  The  membrane  remains  from  three  to 
ten  days, — a  shorter  time  if  antitoxiue  is  used.  It  is  very  often  a  matter  of 
surprise  that  so  small  an  exudate  is  so  persistent.  The  urine  is  generally 
normal.  The  parents  are  loatli  to  believe  that  strict  quarantine  is  neces- 
sary in  so  mild  an  illness ;  and  where  the  membrane  is  only  upon  the 
tonsils,  even  after  the  disease  has  run  its  course,  the  physician  may  be  led 
to  doubt  the  diagnosis  of  diphtheria. 

The  points  which  characterize  this  form  of  the  disease  are :  the  preva- 
lence of  diphtheria  in  the  house  or  in  the  neighbourhood,  a  lower  tem- 
perature than  is  usual  in  simple  tonsillitis,  the  absence  of  marked  inflam- 
matory signs  in  the  throat,  the  adherence  of  the  membrane,  its  duration, 
and  its  white,  fibrinous  appearance.  In  most  cases  one  with  experience 
can  usually  make  an  accurate  diagnosis  from  the  clinical  symptoms ;  but 
there  are  others  in  which  the  diagnosis  from  ordinary  tonsillitis  is  impos- 
sible, even  by  the  most  practised  observers,  except  by  bacteriological 
examination.  When  diphtheria  bacilli  are  found  in  these  mild  cases  the 
question  often  arises  whether  they  may  not  be  the  non-virulent  form. 
Park  tested  forty  such  cases,  and  found  the  bacilli  to  be  virulent  in  thirty- 
five  and  non-virulent  in  five.  In  twenty  of  the  forty  cases  the  clinical 
diagnosis  was  follicular  tonsillitis.* 

These  experiments  of  Park,  corroborated  by  many  other  observers, 
show  how  great  is  the  error  of  regarding  lightly  the  possibility  of  infec- 
tion from  mild  cases. 

Unless  the  lai'ynx  is  involved — a  not  very  infrequent  occurrence  in 
young  children — cases  in  which  the  amount  of  membrane  is  small  almost 
invariably  recover.  Occasionally  even  such  mild  diphtheria  is  followed  by 
post-diphtheritic  paralysis,  but  usually  affecting  the  throat  only. 

Severe  cases. — The  onset  may  be  gradual,  even  insidious.  There  is 
then  a  slight  indisposition  for  a  day  or  two,  and  perhaps  some  soreness 
of  the  throat;  the  temperature,  however,  is  but  little  elevated,  often  less 
than  100°  F.  The  symptoms  may  steadily  increase  in  intensity  for  four 
or  five  days,  until  the  maximum  is  reached.  At  other  times  the  disease 
begins  abruptly  with  vomiting,  headache,  chilly  sensations,  and  a  tem- 
perature of  103°  or  104°  F.  Occasionally,  the  first  thing  to  attract  atten- 
tion is  the  swelling  of  the  cervical  lymph  glands,  which  may  be  so  great 
that  mumps  is  suspected.  The  abrupt  onset  is  more  often  seen  in  young 
children  than  in  those  who  are  older. 

*  From  one  of  these  mild  cases  was  obtained  a  baciUus  whose  virulence  so  greatly  ex- 
ceeded that  obtained  from  any  other  case  of  diphtheria,  that  its  cultures  were  used  for  the 
preparation  of  toxines  for  injecting  horses.  It  was  by  means  of  these  powerful  toxines 
that  the  strongest  antitoxiue  was  produced.  The  toxines  from  this  bacillus  are  now  used 
in  half  a  dozen  of  the  principal  laboratories  of  this  country  where  antitoxine  is  prepared. 


966  THE   SPECIFIC  INFECTIOUS  DISEASES. 

The  membrane  upon  the  tonsils  resembles  that  of  the  mild  form  pre- 
viously described,  but,  instead  of  remaining  limited  to  them,  it  gradually 
spreads  to  the  fauces,  the  lateral  wall  of  the  pharynx,  the  uvula,  the 
rhino-pharynx,  and  into  the  posterior  nares.  The  rapidity  with  which  the 
membrane  extends  is  in  direct  proportion  to  the  severity  of  the  attack. 
In  some  it  may  cover  all  the  parts  mentioned  in  twenty-four  hours  from 
its  first  appearance ;  in  others  this  may  require  four  or  five  days.  When 
the  nose  is  first  affected  there  is  an  abundant  discharge  of  serum  and 
mucus,  occasionally  tinged  with  blood,  which  may  continue  several  days 
before  any  membrane  is  visible.  Such  cases  sometimes  develop  much  more 
slowly,  and  no  membrane  may  be  seen  in  the  anterior  nares  for  a  week. 

When  a  severe  case  is  fully  developed  there  is  a  very  abundant  dis- 
charge of  mucus  from  the  mouth  and  nose.  The  tonsils,  the  entire  fau- 
cial  ring,  and  the  pharynx  are  covered  with  membrane  (Plate  XVII,  B) 
which  is  at  first  gray  and  gradually  becomes  darker  often  being  of  a  dirty 
olive-green  colour.  Membrane  is  sometimes  -seen  upon  the  lips,  or  in 
patches  in  the  mouth.  There  is  obstruction  to  nasal  respiration  from  the 
swelling  of  the  palate,  tonsils,  and  the  tissues  of  the  rhino-pharynx ;  the 
mouth  is  half  open,  the  breathing  noisy,  the  tongue  dry,  and  the  lips  are 
fissured  and  bleed  readily.  Occasionally  large  nasal  hemorrhages  occur 
which  may  necessitate  plugging  the  nares.  Both  nostrils  are  generally 
blocked  by  the  swelling  and  the  false  membrane  ;  the  discharge  excoriates 
the  upper  lip,  and  frequently  has  a  fetid  odour.  During  the  second  week 
there  is  often  regurgitation  of  fluids  through  the  nose,  owing  to  paralysis 
of  the  palate.  The  lymph  glands  at  the  angle  of  the  Jaw  swell  rapidly ; 
in  severe  cases  they  are  very  prominent,  and  there  may  also  be  extensive 
infiltration  of  the  cellular  tissue  about  them,  although  this  is  ,more  char- 
acteristic of  the  cases  of  mixed  infection.  The  local  symptoms  are  the 
cause  of  much  discomfort,  especially  the  copious  discharge  of  mucus  and 
the  nasal  obstruction. 

The  constitutional  symptoms  usually  increase  steadily  with  the  exten- 
sion of  the  membrane.  In  the  most  severe  cases  the  system  is  overwhelmed 
with  the  poison,  and  all  the  evidences  of  intense  toxaemia  are  present  by 
the  second  or  third  day  of  the  disease.  This  is  shown  by  great  muscular 
weakness  and  prostration,  by  a  feeble,  rapid  pulse,  and  a  mental  state  of 
complete  apathy  or  stupor,  sometimes  alternating  with  great  restlessness. 
It  is  more  frequent  for  the  constitutional  symptoms  to  develop  gradually, 
and  not  to  reach  their  height  before  the  fifth  or  sixth  day.  The  pulse 
becomes  I'apid,  weak,  and  compressible,  sometimes  irregular ;  and  there  is 
a  great  and  steadily  increasing  amemia.  The  course  of  the  temperature  is 
irregular,  and  bears  no  constant  relation  to  the  severity  of  the  other  symp- 
toms. Its  usual  range  is  from  101°  to  103°,  but  in  some  of  the  worst 
cases  it  may  never  go  above  101°  F.  It  fluctuates  irregularly  with  the 
development  of  complications,  and  sometimes   without  apparent  cause. 


PLATE   XVII. 


The  Diphtheritic  Membrane. 

A.  Typical  tonsillar  diphtheria. 

B.  Severe  pharyngeal  diphtheria  (fatal  ease). 

C.  Pseudo-diphtheria.  The  specimen  is  seen  from  behind,  the  larynx  and  trachea 
having  been  laid  open,  and  shows  an  extensive  membrane  involving  the  epiglottis  and 
the  entire  lower  pharynx,  but  extending  into  the  larynx  only  a  short  distance.  It  is 
also  seen  upon  the  posterior  surface  of  the  uvula  and  soft  palate,  the  tonsils  being  onlv 
partially  covered.  The  colour  of  the  membrane  is  not  characteristic  of  pseudo-diph- 
theria, as  the  same  appearance  is  often  seen  in  true  diphtheria,  particularly  of  the 
septic  type. 


DIPHTHERIA.  957 

By  the  second  or  third  day  the  urine  regularly  shows  the  presence  of 
albumin,  and  by  the  end  of  the  first  week  the  quantity  is  often  large. 
Granular  and  h3faline  casts,  and  occasionally  blood  in  small  quantities, 
are  also  found.  The  amount  of  urine  secreted  is  not  noticeably  dimin- 
ished, and  dropsy  is  rare.  There  is  complete  anorexia,  and  often  vomit- 
ing and  diarrhoea  are  present ;  in  some  of  the  cases  they  are  prominent. 
Nervous  symptoms  are  seen  in  all  the  very  severe  cases.  There  may  be 
duiness  and  complete  indifference  to  surroundings,  but  more  frequently, 
owing  to  the  discomfort  arising  from  local  symptoms,  there  is  extreme 
restlessness  and  excitement,  sometimes  followed  by  delirium. 

At  any  time  during  the  first  week,  but  not  often  after  that  time,  symp- 
toms may  arise  indicating  that  the  disease  has  extended  to  the  larynx. 
The  first  signs  of  laryngeal  invasion  usually  appear  from  the  second  to  the 
fifth  day  of  the  disease.  There  are  at  first  hoarseness,  a  croujoy  cough, 
and  slight  dyspnoea.  In  the  severe  cases  these  symptoms  steadily  increase 
until  all  the  signs  of  laryngeal  stenosis  are  present.  The  symptoms  of 
diphtheria  of  the  larynx,  whether  it  begins  there  or  follows  disease  of  the 
pharynx,  have  already  been  described  in  the  chapter  on  Diseases  of  the 
Larynx  (page  446).  The  severe  symptoms  are  due  to  membrane  in  the 
larynx  ;  the  milder  ones  may  arise  from  catarrhal  laryngitis. 

The  local  process  in  the  pharynx  seems  to  be  a  self-limited  one.  By 
the  fifth  or  sixth  day  it  has  usually  reached  its  height,  and  after  that  the 
appearances  do  not  change  essentially  for  two  or  three  days.  From  the 
seventh  to  the  tenth  day,  in  favourable  cases,  the  diphtheritic  membrane 
begins  to  loosen  and  separate  from  its  attachment.  It  hangs  loosely  from 
the  palate  or  uvula,  and  can  often  be  pulled  away  in  large  masses.  The 
detachment  is  frequently  rapid,  and  in  two  or  three  days  from  the  time 
when  the  first  improvement  is  seen,  the  tonsils  and  pharynx  may  be  almost 
free  from  membrane.  The  mucous  surface  left  behind  is  of  a  bright-red 
colour  and  bleeds  easily.  The  separation  of  the  membrane  in  the  nose 
and  rhino-pharynx  takes  place  more  slowly.  From  the  former  it  may  dis- 
integrate gradually  or  come  away  en  masse.  With  the  disappearance  of 
the  membrane  the  local  symptoms  abate  rapidly, — the  discharge  ceases, 
the  swelling  of  the  lymph  glands  subsides,  deglutition  becomes  easy  and 
natural,  and  nasal  breathing  is  re-established.  Simultaneously  with 
these  changes  in  the  throat  the  constitutional  symptoms  improve,  but 
much  more  slowly.  Convalescence  is  often  protracted.  The  anemia  and 
muscular  weakness,  and,  most  of  all,  the  feeble  heart  action,  may  persist 
for  weeks.  The  more  severe  the  local  disease  has  been,  the  slower  is 
recovery. 

Instead  of  the  usual  course  just  described,  the  diphtheritic  membrane 
may  persist  for  two  or  even  three  weeks.  In  rare  cases  relapses  occur,  the 
membrane  forming  again  after  it  has  entirely  or  partially  disappeared. 

The  early  course  of  the  disease  in  the  fatal  cases  often  does  not  differ 


968  THE  SPECIFIC  INFECTIOUS  DISEASES. 

from  that  of  the  severe  cases  which  end  in  recovery  except  in  the  malig- 
nant form,  which  kills  in  twenty-four  or  forty-eight  hours,  and  which, 
after  all,  is  rare.  Death  most  frequently  occurs  at  the  height  of  the  local 
process  in  the  throat,  usually  from  the  fifth  to  the  tenth  day.  It  may  be 
due  to  progressive  asthenia  the  result  of  diphtheritic  toxoemia,  such  cases 
being  characterized  by  steadily  increasing  prostration,  great  anaemia,  feeble, 
irregular  pulse,  vomiting,  refusal  to  take  food  or  stimulants,  and  mental 
apathy  or  stupor.  Death  is  frequently  due  to  heart  failure,  which  may 
be  quite  sudden  and  occur  early  or  late.  In  other  cases  death  is  due  to 
complications,  particularly  broncho-pneumonia,  rarely  to  nephritis  or  haem- 
orrhages, and  in  still  others  to  invasion  of  the  larynx. 

Even  after  the  throat  has  cleared  off  completely  the  disease  may  end 
fatally  from  the  occurrence  of  late  pneumonia  or  nephritis  or  from  sudden 
heart  paralysis.  Cases  of  the  variety  last  mentioned  are  particularly  dis- 
tressing ones,  and  not  infrequent.  It  often  happens  that  the  patient  is  re- 
garded as  convalescent,  and  the  great  vigilance  of  the  previous  days  or 
weeks  has  been  relaxed.  The  physician  has  ceased  his  frequent  visits  and 
looks  in  only  once  a  day  to  satisfy  himself  that  the  patient  is  doing  well, 
and  all  congratulate  themselves  that  the  danger  is  over.  If  the  pulse  is 
carefully  watched,  it  is  one  day  discovered  that  it  is  weaker  than  formerly, 
and  occasionally  there  is  slight  irregularity.  It  is  usually  slower,  but  may 
be  more  rapid  than  normal.  On  inquiry,  it  is  found  that  the  patient  does 
not  take  his  food  so  well,  that  he  has  refused  stimulants,  and  perhaps  has 
vomited  once  or  twice.  Slight  dyspnoea  is  noticed,  and  the  face  is  paler 
than  usual.  '  Sometimes,  within  twenty-four  hours  from  the  beginning  of 
such  symptoms,  the  patient  is  dead.  The  changes  for  the  worse  occur 
very  rapidly.  The  pulse  becomes  weaker,  more  irregular,  often  abnormally 
slow,  but  very  rapid  on  slight  exertion,  and  there  may  be  a  sense  of  prse- 
cordial  weakness  or  distress.  There  are  dyspnoea  without  cyanosis,  anx- 
iety, and  great  restlessness,  but  the  mind  is  clear.  There  is  vomiting  if 
food  or  stimulants  are  taken.  The  extremities  are  cold.  Auscultation 
shows  feeble  and  indistinct  heart  sounds,  but  no  murmur.  The  pallor  is 
extreme.  Death  results  from  sudden  syncope,  sometimes  during  an  at- 
tempt to  administer  food,  sometimes  from  such  slight  exertion  as  turning 
in  the  crib. 

Instead  of  such  a  rapid  course,  the  same  symptoms  may  develop  more 
gradually  during  three  or  four  days,  the  significance  of  the  earlier  symp- 
toms not  being  appreciated.  Sometimes  no  premonitory  symptoms  are 
present,  and  the  child  falls  dead  after  walking  across  the  room,  or  sud- 
denly sitting  up  in  bed,  or  after  some  other  muscular  effort,  or  possibly 
as  a  consequence  of  passion  or  excitement. 

Although  such  symptoms  are  more  often  seen  after  severe  cases,  they 
may  occur  after  those  of  only  moderate  intensity,  and  even  when  the 
patient  has  been  considered  well  enough  to  be  up  and  about  or  out  of 


DIPHTHERIA.  959 

doors.     One  little  girl  was  considered  well  enough  to  go  coasting,  and  died 
suddenly  after  the  exertion. 

The  explanation  of  sudden  heart  failure  during  or  after  diphtheria  is 
not  always  the  same.  When  it  occurs  at  the  height  of  the  disease  it  is 
sometimes  due  to  cardiac  thrombosis,  probably  always  associated  with 
changes  in  the  muscular  walls.  When  it  occurs  late  and  follows  some 
sudden  muscular  effort  or  excitement  without  premonitory  symptoms  of 
any  sort,  it  is  probably  the  result  of  changes  in  the  muscular  walls — d. 
toxic  myocarditis.  When  prodromal  symptoms  are  present,  and  particu- 
larly when  it  is  accompanied  by  vomiting,  abdominal  pain,  and  disturbed 
respiration,  it  is  probably  the  result  of  a  toxic  neuritis  affecting  either  the 
pneumogastric  or  the  cardiac  nerves,  and  is  to  be  regarded  as  a  form  of 
post-diphtheritic  paralysis.  In  many  cases,  no  doubt,  changes  are  present 
both  in  the  nerves  and  in  the  myocardium.  The  other  forms  of  diph- 
theritic paralysis  which  may  result  fatally,  are  discussed  in  the  chapter  on 
Diseases  of  the  Peripheral  Nerves. 

Cases  of  mixed  infection  or  septic  diphtheria. — The  symptoms  are 
usually  severe  from  the  outset.  The  exudation  in  these  cases  is  generally 
of  a  yellow  or  dirty-gray  or  olive  colour,  sometimes  being  almost  black 
from  the  presence  of  blood.  The  membrane  is  usually  extensive,  cover- 
ing the  entire  pharynx,  often  extending  to  the  nose  and  the  middle  ear, 
and  occasionally  spreading  to  the  buccal  cavity.  There  is  great  swelling 
of  the  tonsils  and  uvula,  and  it  is  often  impossible  to  obtain  a  view  of 
the  pharynx ;  all  the  evidences  of  inflammation  are  usually  more  marked 
than  in  the  severe  uncomplicated  cases.  Sometimes  the  inflammation  is 
of  a  necrotic  character,  and  there  may  be  extensive  sloughing  of  the 
tonsils,  the  uvula,  or  the  soft  palate.  The  nasal  discharge  is  generally 
abundant,  and  often  very  offensive.  There  is  marked  swelling  of  the 
cervical  lymph  glands,  and  frequently  extensive  infiltration  of  the  cellular 
tissue  of  the  neck,  so  that  the  head  is  thrown  back  to  relieve  the  pressure 
upon  the  larynx  and  trachea.  The  swelling  sometimes  forms  a  distinct 
collar,  reaching  from  ear  to  ear  and  filling  out  the  whole  space  beneath 
the  jaw.  The  pressure  upon  the  jugular  veins  leads  to  congestion  and 
swelling  of  the  face  and  congestion  of  the  brain. 

The  general  symptoms  are  those  of  a  severe  septicsemia.  The  tem- 
perature is  usually  higher  than  in  simple  diphtheria  ;  it  follows  no  regular 
course,  but  is  generally  high  and  widely  fluctuating,  ranging  from  101°  to 
106°  F.  Dr.  Biggs  informs  me  that  in  the  Willard  Parker  Hospital,  in 
the  cases  characterized  by  such  high  temperatures,  where  bacteriological 
examinations  have  been  made  piost  mortem,  there  have  been  uniformly 
found  either  a  general  streptococcus  or  pneumococcus  infection,  usually 
the  former.  The  pulse  is  weak,  rapid,  and  compressible.  The  peripheral 
circulation  is  poor,  the  extremities  are  often  cold,  there  is  extreme  mus- 
cular prostration,  and  both  vomiting  and  diarrhoea  are  frequent.     There 


970  THE  SPECIFIC  INFECTIOUS  DISEASES. 

may  be  excitement,  restlessness,  and  active  deli;ium,  or  dulness,  apathy, 
and  stupoi".  Nephritis  is  very  frequent  and  is  often  severe ;  the  urine 
contains  a  large  amount  of  albumin  "and  casts  of  all  varieties,  but  rarely 
blood.  Dropsy  is  not  usually  present,  and  suppression  of  urine  is  seldom 
seen.  In  a  large  proportion  of  the  children  under  three  years  old  broncho- 
pneumonia develops.  This  is  indicated  by  the  accelerated  breathing, 
higher  temperature,  and  cough,  and  often  occurs  even  when  the  larynx 
is  not  involved.  The  spleen  is  usually  enlarged,  and  frequently  the  liver 
also.  Such  severe  symptoms  continue  for  from  two  days  to  a  week ;  the 
patient  may  die  from  the  sudden  invasion  of  the  larynx,  or  there  may  be 
suppression  of  urine  and  uremic  convulsions;  but  more  frequently  the 
cause  of  death  is  asthenia  or  broncho-pneumonia.  Death  usually  occurs 
while  the  local  disease  is  at  its  height.  Occasionall}'  it  comes  later  from 
heart  failure,  where  the  signs  of  local  improvement  may  have  begun. 

Eecovery  from  this  type  of  the  disease  is  rare,  and  those  who  manage 
to  escape  the  dangers  of  the  acute  period  have  still  others  to  encounter. 
Among  the  latter  may  be  mentioned  :  extensive  sloughing  in  the  throat  or 
of  the  cellular  tissue  of  the  neck,  which  may  be  followed  by  severe  or 
even  fatal  hemorrhage,  diffuse  suppuration  of  the  same  region,  nephritis, 
which  may  develop  as  late  as  the  end  of  the  second  or  even  the  third 
week  and  may  prove  rapidly  fatal,  late  pneumonia  or  pleurisy,  and  finally 
paralysis  of  the  heart  or  respiration,  as  in  the  severe  uncomplicated  cases. 

Complications  and  Sequelae. — Most  of  the  complications  of  diphtheria 
have  already  been  mentioned  either  under  the  head  of  Lesions  or  Symp- 
toms.    It  only  remains  to  consider  their  clinical  association. 

Otitis  is  not  very  frequent.  It  occurs  particularly  in  the  rhino- 
pharyngeal  cases,  and  is  sometimes  due  to  the  diphtheria  bacillus  alone, 
but  more  often  to  mixed  infection.  The  type  of  inflammation  is  usually 
a  severe  one,  and  it  may  be  accompanied  by  necrotic  changes  in  the  drum 
membrane  which  resemble  those  of  scarlet  fever. 

Broncho-pneumonia  is  the  most  frequent  complication  in  young  chil- 
dren. It  occurs  especially  in  laryngeal  cases,  and  in  those  of  a  septic 
type  whether  the  larynx  is  involved  or  not.  Pneumonia  usually  develops 
at  the  height  of  the  disease,  although  it  is  occasionally  seen  late  and  even 
during  convalescence.  Other  pulmonary  complications  are  infrequent. 
Pleurisy  with  a  serous  effusion  may  occur  in  connection  with  severe 
nephritis,  and  empyema  in  septic  cases.  Emphysema  is  a  complication  of 
laryngeal  diphtheria ;  it  is  nearly  always  vesicular,  sometimes  interstitial, 
and  may  become  general,  extending  into  the  cellular  tissue  of  the  neck 
and  afterward  that  of  the  entire  body.  Pericarditis,  endocarditis,  and 
meningitis  are  all  very  rare  and  are  seen  chiefly  in  septic  cases  of  the  most 
severe  type.  Myocarditis  is  much  more  frequent,  and  is  present  to  a 
greater  or  less  degree  in  nearly  all  severe  c^ses,  although  in  but  a  small 
proportion  of  these  does  it  give  rise  to  distinct  symptoms.     It  is  closely 


DIPHTHERIA.  9YI 

connected  pathologically  with  degeneration  of  the  cardiac  nerves,  and  it 
may  be  a  cause  of  sudden  death  at  any  time  during  the  acute  period  of 
the  disease  or  during  convalescence. 

Thrombosis  and  embolism  are  among  the  less  frequent  complications.  If 
cerebral,  they  may  cause  hemiplegia,  aphasia,  and  sometimes  convulsions ;  if 
peripheral,  they  usually  affect  one  of  the  lower  extremities,  where  they  may 
cause  sudden  pain,  numbness,  and  coldness  of  the  limb,  followed  by  partial 
paralysis,  oedema,  and  sometimes  even  by  gangrene.  Thrombosis  of  the  pul- 
monary artery  or  of  the  heart  may  be  a  cause  of  sudden  death,  the  symptoms 
being  dyspnoea  and  prascordial  distress,  with  pallor  or  cyanosis.  Both  throm- 
bosis and  embolism  are  associated  with  a  very  feeble  action  of  the  heart,  and 
generally  they  are  preceded  by  degenerative  changes  in  its  muscular  walls. 

Hsemorrhages  are  usually  nasal,  and  while  in  most  cases  they  are  not 
serious,  they  may  necessitate  plugging  of  the  posterior  nares.  Bleeding 
from  any  other  mucous  membrane  may  occur,  but  it  is  rare  except  from 
the  mouth.  Subcutaneous  haemorrhages  are  not  very  infrequent,  and  are 
evidence  of  a  very  high  degree  of  diphtheritic  toxaemia.  They  usually  oc- 
cur as  small  petechial  spots,  but  are  sometimes  extensive.  They  may  be 
seen  upon  almost  any  part  of  the  body,  most  frequently  upon  the  abdomen 
and  lower  extremities ;  but  the  most  extensive  extravasation  I  have  ever 
seen  was  in  the  neck,  reaching  from  the  clavicle  almost  to  the  ear  and 
covering  nearly  one  lateral  half  of  the  neck. 

Albumin  is  present  in  the  urine  of  almost  every  case  of  moderate 
severity,  usually  depending  upon  acute  degeneration  of  the  kidney.  Severe 
nephritis  is  most  frequently  seen  in  septic  cases.  It  usually  develops  at 
the  height  of  the  local  disease,  but  may  come  during  convalescence.  The 
most  common  form  is  acute  exudative  nephritis,  in  which  there  are  albu- 
min and  casts  in  the  urine,  but  rarely  dropsy  or  signs  of  uremia.  It  is 
seen  in  most  of  the  fatal  septic  cases  except  those  due  to  laryngeal  ob- 
struction, but  it  is  seldom  a  cause  of  death.  Less  frequently  acute  diffuse 
nephritis  occurs,  with  dropsy,  scanty  urine  or  even  suppression,  vomiting, 
and  all  the  usual  symptoms  of  acute  uraemia.     It  may  be  a  cause  of  death. 

Funxitional  disturbances  of  the  stomach  are  very  frequent,  and  are  in 
fact  present  in  most  of  the  severe  cases,  but  lesions  of  the  mucous  mem- 
brane are  rare.  While  diarrhoea  is  often  seen  without  intestinal  lesions, 
the  latter  are  of  frequent  occurrence.  The  most  characteristic  form  of 
inflammation  is  a  follicular  ileo-colitis,  which  seldom  goes  on  to  ulcera- 
tion. It  is  extremely  rare  that  the  membranous  form  is  seen,  and  then 
it  is  generally  associated  with  the  presence  of  streptococci,  not  diphtheria 
bacilli.  The  intestinal  symptoms  usually  begin  while  the  process  in  the 
throat  is  at  its  height,  but  often  continue  for  some  time  after  the  throat 
has  cleared.  Although  severe  intestinal  inflammation  is  rare,  it  is  a  most 
serious  complication  when  it  occurs,  which  is  generally  in  infants  and  very 
young  children. 


972  THE  SPECIFIC  INFECTIOUS   DISEASES. 

Diphtheria  is  usually  followed  by  a  severe  aud  often  persistent  anaemia 
which  may  continue  for  weeks.  Pneumonia,  nephritis,  and  cardiac  disease 
may  first  show  themselves  during  convalescence,  and  so  be  ranked  as 
sequelae.  The  most  important  sequel  of  diphtheria,  however,  is  multiple 
neuritis  or  post-diphtheritic  paralysis  (page  790). 

Diagnosis. — The  diagnosis  of  diphtheria  rests  upon  two  kinds  of  evi- 
dence— clinical  and  bacteriological.  While  the  bacteriological  diagnosis 
is,  on  the  whole,  more  exact,  it  should  not  be  depended  upon  to  the  exclu- 
sion of  the  clinical  diagnosis.  The  prevailing  tendency  to  disregard  the 
clinical  evidences  of  the  disease  and  rely  wholly  upon  bacteriology,  is 
greatly  to  be  deprecated.  These  means  of  diagnosis  are  not  mutually  ex- 
clusive, "but  complementary.  Bacteriology  applied  to  the  diagnosis  of 
diphtheria  has  rendered  incalculable  service,  but  it  has  its  limitations.  As 
has  well  been  said  by  Welch,  the  mere  presence  of  the  diphtheria  bacilli  in 
the  throat  of  a  patient  no  more  proves  that  he  has  diphtheria,  than  the 
presence  of  the  pneumococcus  in  his  saliva  establishes  the  fact  that  he  has 
pneumonia.  Again,  the  case  may  be  one  of  undoubted  diphtheria  and 
yet  the  bacilli  may  not  be  found  at  the  first  examination,  although  they 
are  found  at  subsequent  examinations — a  thing  which  has  repeatedly  hap- 
pened in  my  own  experience.  The  delay  thus  occasioned  in  the  applica- 
tion of  early  treatment  is  a  matter  of  the  greatest  importance,  especially  in 
connection  with  serum  therapy.  Finally,  because  of  the  occasional  presence 
in  the  throat  of  a  non-virulent  diphtheria  bacillus  and  of  the  so-called 
pseudo-diphtheria  bacillus,  even  a  positive  report  by  the  bacteriologist  may 
be  misleading ;  but  after  all  this  will  seldom  be  the  case  in  actual  practice. 
While  in  no  way  detracting  from  the  immense  advantage  of  having  bac- 
teriological assistance  in  making  the  diagnosis,  I  insist  that  the  clinical 
manifestations  of  diphtheria  must  be  observed  by  the  physician  with  the 
same  care  as  heretofore,  particularly  since  the  great  body  of  the  profession 
are  as  yet  compelled  by  circumstances  to  rely  solely  upon  a  clinical  diag- 
nosis. Every  one  who  has  seen  much  of  the  two  methods  of  diagnosis 
studied  side  by  side  will,  1  think,  admit  that  in  fully  four  fifths  of  the 
cases  an  accurate  clinical  diagnosis  can  be  made  after  twenty-four  hours' 
observation,  and  in  a  considerable  proportion  of  these  in  a  shorter  time ; 
the  remaining  one  fifth  require  either  a  longer  period  of  observation  or 
continue  doubtful  to  the  end.  The  great  majority  of  the  cases  of  this 
group  are  of  the  mildest  variety  and  terminate  in  recovery.  In  them  an 
accurate  diagnosis  is  of  importance  more  for  the  sake  of  others  than  for 
the  patient  himself. 

1.  The  Clinical  Diagnosis. — In  arriving  at  this,  there  must  be  con- 
sidered, first,  the  patient  and  his  surroundings ;  secondly,  the  constitutional 
or  general  symptoms ;  thirdly,  the  local  evidences  of  disease.  The  chances 
of  diphtheria  are  greatly  increased  if  the  patient  is  a  child  under  ten  years 
of  age,  if  his  home  is  in  a  tenement  house  or  an  institution,  if  he  attends 


DIPHTHERIA.  973 

a  public  school  where  he  mingles  with  children  coming  from  all  sorts  of 
homes,  and  if  there  are  other  cases  in  the  family  or  in  the  neighbourhood. 
On  the  contrary,  the  chances  are  much  lessened  if  the  patient  is  over  ten 
years  old,  if  he  lives  in  a  private  house,  if  there  is  no  diphtheria  in  the 
neighbourhood,  and  if  he  does  not  mingle  with  children  who  come  from 
doubtful  or  infected  localities.  In  tonsillitis  a  history  of  repeated  attacks 
is  often  obtained,  and  is  of  some  value.  If  the  throat  symptoms  occur 
with  measles  or  scarlet  fever,  the  time  of  their  development  is  of  much 
importance ;  when  they  precede  the  eruption  or  appear  while  the  fever  is 
at  its  height,  the  disease  is  rarely  true  diphtheria ;  while,  if  they  develop 
at  a  later  period  or  after  defervescence,  diphtheria  is  highly  probable. 

The  mode  of  onset  and  the  constitutional  symptoms  are  of  some  im- 
portance in  diagnosis,  but  diphtheria  develops  in  such  a  variety  of  ways 
that,  taken  by  themselves,  the  constitutional  symptoms  prove  little.  The 
onset  of  diphtheria  is  more  frequently  gradual,  and  the  initial  temperature 
is  more  often  low,  than  is  the  case  with  other  throat  inflammations;  but 
the  exceptions  are  many.  Diarrhoea,  vomiting,  coated  tongue,  and  an- 
orexia, count  for  little  on  either  side.  The  presence  of  a  nasal  discharge, 
especially  if  abundant,  ichorous  and  tinged  with  blood,  the  early  develop- 
ment of  the  symptoms  of  croup,  the  rapid  enlargement  of  the  cervical 
lymph  glands,  and  the  early  appearance  of  albumin  in  the  urine, — all  point 
strongly  to  diphtheria.  Later  symptoms  which  are  especially  diagnostic 
are  marked  angemia,  progressive  asthenia,  intense  toxaemia  often  with  a 
low  temperature,  A^ery  feeble  pulse  which  is  sometimes  slow,  sometimes 
rapid,  sudden  attacks  of  syncope,  nasal  haemorrhages,  nasal  regurgitation 
from  paralysis  of  the  soft  palate,  contagion,  and,  finally,  the  development 
of  post-diphtheritic  paralysis  of  the  muscles  of  the  throat,  eye,  or  extremi- 
ties, with  paralysis  of  the  heart  or  respiration. 

For  early  diagnosis  much  more  reliance  is  to  be  placed  upon  the  local 
appearances  than  upon  the  general  symptoms.  The  characteristic  mem- 
brane of  diphtheria  appears,  in  the  great  majority  of  cases,  first  upon  the 
tonsils  usually  as  a  gray  film,  which  gradually  becomes  more  dense  and 
white,  and  often  has  the  look  of  being  plastered  on.  The  colour  of  older 
membrane  is  gray,  greenish-yellow,  brown,  sometimes  black.  Beginning 
as  a  small  patch,  it  soon  spreads  so  as  to  cover  the  tonsils.  It  frequently 
affects  one  tonsil  twenty-four  or  thirty-six  hours  before  the  other,  and 
occasionally  it  is  confined  to  one  side.  In  exceptional  cases  it  begins  in 
the  crypts  of  the  tonsil  and  appears  as  isolated  dots,  which  may  coalesce 
to  form  a  continuous  patch  like  that  already  described,  or  it  may  remain 
isolated  like  the  exudate  of  an  ordinary  follicular  tonsillitis.  When  the 
membrane  is  removed  it  usually  requires  some  force,  and  the  entire  patch 
may  come  away,  leaving  bleeding  points,  but  it  reforms  in  most  cases 
within  twenty-four  hours.  More  important  still  for  diagnosis  is  the  fact 
tliat  the  membrane  spreads  from  the  original  seat,  and  also  the  manner  of 


974  THE  SPECIFIC   INFECTIOUS  DISEASES. 

its  spreading.  If  it  extends  from  the  tonsils  to  the  faucial  pillars  and  the 
uvula,  it  is  alinost  surely  diphtheria ;  so  also  in  most  cases  when  it  extends 
to  the  lateral  walls  of  the  pharynx.  Doubtful  patches  on  the  tonsils  or 
fauces  followed  by  symptoms  of  croup,  may  be  considered  as  diphtheria 
with  almost  absolute  certainty.  The  rapidity  of  the  spreading  varies 
much  in  the  different  cases,  depending  upon  the  intensity  of  the  infec- 
tion ;  but  the  gradual  extension  beyond  the  tonsils,  as  shown  by  observa- 
tions made  at  intervals  of  eight  or  twelve  hours,  usually  settles  the  diag- 
nosis in  the  primary  cases.  However,  if  the  throat  symptoms  complicate 
measles  or  scarlet  fever  the  above  rules  do  not  apply.  Such  cases  are  to  be 
judged  by  the  time  at  which  the  membrane  appears,  as  already  stated. 

In  pure  diphtheria  there  is  a  notable  absence  of  oedema  of  the  faucial 
pillars  and  uvula,  so  common  in  throat  inflammations  due  to  cocci.  In 
fact,  whenever  there  are  seen  in  the  throat  evidences  of  a  very  high  degree 
of  inflammation,  it  points  either  to  mixed  infection  or  to  false  diphtheria. 
The  same  is  true  of  a  very  friable  membrane,  yellow  in  colour  from  the 
presence  of  pus  cells,  and  also  of  deep  sloughing  of  the  tonsils  or  the  pil- 
lars of  the  fauces. 

Primary  membranous  inflammation  of  the  larynx  may  always  be  safely 
regarded  as  diphtheria ;  but  if  there  is  no  visible  membrane,  the  diagnosis 
is  rendered  positive  only  by  a  bacteriological  examination.  This  may  be 
true  of  many  nasal  cases  where  the  only  symptoms  are  a  discharge  of  the 
character  previously  described.  Such  cases  may  continue  for  weeks  with 
no  symptoms  other  than  the  discharge.  Some  of  them  are  examples  of 
catarrhal  diphtheria;  in  others,  membrane  is  present  in  the  post-nasal 
space  or  in  the  nose  itself. 

The  most  characteristic  clinical  differences  between  diphtheria  and 
other  inflammations  accompanied  by  an  exudation  upon  the  throat  or  in 
the  nose — i.  e.,  pseudo-diphtheria — are  shown  in  the  following  table : 

DIPHTHERIA.  PSEUDO-DIPHTHERIA. 

1.  Often  a  history  of  exposure  to  a  pre-  1.  Usually  none, 
vious  case.  • 

2.  Prevails  epidemically.  2.  It  is  questionable  if  it  ever  does. 

3.  Onset  often  gradual,  with  low  tem-  3.  Onset  usually  abrupt,  with  high  tem- 
perature and  slight  constitutional  symp-  perature  and  quite  marked  constitutional 
toms.  symptoms. 

4.  Previous  attacks  rare.  4.  Often  a  history  of  repeated  attacks. 

5.  Often  begins  in  the  larynx.  5.  Seldom  if  ever  does  so  when  primary. 

6.  If  pharyngeal,  often  shows  a  strong  6.  This  tendency  is  much  less  marked, 
tendency  to  extend  to  the  larynx. 

7.  Primary  cases  frequently  severe.  7.  Rarely  severe  unless  secondary,  par- 

ticularly to  measles  or  scarlet  fever. 

8.  When  it  complicates  measles  or  scar-  8.  Usually  occurs  at  the  height  of  the 
let  fever  it  often  develops  late,  after  pri-  primary  disease,  sometimes  even  preceding 
mary  fever  has  subsided.                                  the  eruption. 


DIPHTHERIA. 


975 


DIPHTUERIA. 

9.  The  middle  ear  not  so  often  involved. 

10.  Occasionally  limited  to  the  nose 
(croupous  rhinitis). 

11.  Adenitis  constant;  not  much  sur- 
rounding inflammation,  except  in  cases  of 
mixed  infection  ;  suppuration  is  rare. 

13.  Albuminuria  the  rule,  except  in  the 
mildest  cases. 

13.  Nasal  regurgitation  from  paralysis 
of  the  palate  in  the  second  week  or  later. 

14.  Toxic  symptoms  common ;  asthe- 
nia ;  great  anaemia  after  the  fourth  or  fifth 
day ;  later,  sudden  heart  paralysis,  respira- 
tory paralysis,  or  post-diphtheritic  paraly- 
sis of  throat,  eyes,  or  extremities. 

15.  The  membrane  usually  thicker  and 
more  adherent ;  can  often  be  removed  in 
large  masses. 

16.  Greater  tendency  to  spread  from  its 
original  seat. 

17.  Longer  duration  noticeable,  espe- 
cially in  mild  cases,  where  it  may  last  five 
to  ten  days. 

18.  Usually  less  evidence  of  inflamma- 
tion of  mucous  membrane  and  in  surround- 
ing parts. 

19.  After  removal  of  membrane  a  red 
surface  left;  ulceration  slight  and  super- 
ficial ;  rarely  a  tendency  to  sloughing. 

20.  A  very  extensive  membrane  of  a 
white  or  pearl-gray  colour,  covering  ton- 
sils, uvula,  fauces,  pharynx,  and  nose,  is 
almost  invariably  true  diphtheria,  if  pri- 
mary. 

21.  A  thick  gray  membrane,  not  re- 
movable without  force,  with  little  or  no 
inflammation,  and  although  confined  to 
the  tonsils  lasting  five  or  six  days,  is  al- 
most invariably  true  diphtheria. 


22.  A  membrane  on  the  tonsils,  similar 
to  that  described,  with  isolated  adherent 
patches  on  the  uvula  or  anywhere  in  the 
pharynx,  is  usually  diphtheria:  doubtful 
patches  iipon  the  tonsils  followed  by  croup, 
almost  invariably  diphtheria. 
03 


PSEUDO-DIPHTHERIA. 

9.  Much  more  frequently;  in  scarlet 
fever  almost  invariably. 

10.  Doubtful  if  it  ever  is  so. 

11.  Adenitis  often  slight  or  absent  in 
primary  cases :  in  scarlet  fever,  marked  in- 
flammation which  extends  to  tissues  around 
the  glands ;  frequently  suppurates. 

12.  Rarely  seen  in  primary  cases,  and 
sometimes  not  in  secondary  form,  even 
though  the  symptoms  are  severe. 

13.  Never  seen. 

14.  Septic  symptoms  frequent,  but  the 
peculiar  toxic  symptoms  are  never  seen. 


15.  Thinner,  more  friable,  and  less  ad- 
herent ;  rarely  removed  in  large  masses. 

16.  Tendency  much  less;  in  most  pri- 
mary cases  membrane  limited  to  tonsils. 

17.  Shorter  duration  ;  three  to  five  davs. 


18.  Evidence  often  of  intense  inflam- 
mation. 

19.  In  bad  cases,  often  marked  ulcera- 
tion with  deep  sloughing  and  suppuration. 

20.  An  exudation  of  isolated  yellow 
dots  which  never  coalesce,  confined  to  the 
tonsils,  with  considerable  swelling  and  evi- 
dence of  inflammation  and  usually  with 
a  high  temperature,  is  seldom  true  diph- 
theria. 

21.  An  exudation  of  soft,  yellow  patches, 
changing  to  a  dirty  green,  which  can  be 
partly  or  entirely  wiped  off  without  haem- 
orrhage, whether  confined  to  the  tonsils 
or  extending  to  the  pillars  of  fauces  and 
lasting  only  three  or  four  days,  is  seldom 
true  diphtheria. 

22.  Cases  with  much  general  inflamma- 
tion of  the  tonsils  and  pharynx,  with  small 
patches  of  a  yellow  exudate,  are  seldom 
true  diphtheria.. 


976  ^'HE  SPECIFIC  INFECTIOUS  DISEASES. 

The  difficulties  of  diagnosis  are  greatest  in  the  mild  cases  and  in  the 
early  stage.  There  are  very  few  cases,  except  those  of  the  mildest  type,  in 
which  a  diagnosis  is  not  possible  by  the  course  of  the  disease;  but  there 
are  very  many,  in  which  an  early  diagnosis  is  impossible  without  cultures. 

It  is  not  often  difficult  to  distinguish  diphtheria  from  any  other  dis- 
ease ;  but  the  exudation  upon  the  pharynx  or  tonsils  may  be  confounded 
with  thrush  or  herpes.  This  mistake  can  scarcely  be  made  by  one  who 
examines  a  case  with  any  degree  of  care.  The  appearance  of  the  tonsils 
on  the  second  or  third  day  after  tonsillotomy  has  been  performed,  may 
be  easily  mistaken  for  diphtheria  by  one  who  is  unfaniiliar  with  the  ap- 
pearance of  the  wound. 

Diphtheria  of  the  mouth  may  be  mistaken  for  herpetic  or  ulcerative 
stomatitis.  It  is,  however,  much  more  common  for  these  latter  affections 
to  be  called  diphtheria  than  for  the  opposite  mistake  to  be  made.  Diph- 
theria'of  the  mouth  alone  is  so  rare  that  it  may  almost  be  dropped  from 
consideration.  As  a  rule,  this  is  seen  only  in  the  worst  cases  of  pharyn- 
geal diphtheria. 

It  is  sometimes  difficult  to  distinguish  cases  of  scarlet  fever  in  which 
the  throat  symptoms  are  severe  and  appear  early,  from  cases  of  primary 
diphtheria.  In  many  of  these  cases  the  eruption  appears  late,  and  is  not 
characteristic.  Much  importance  is  to  be  attached,  as  pointing  toward 
scarlet  fever,  to  a  prevailing  epidemic,  a  history  of  exposure,  a  sudden 
onset  with  severe  symptoms,  vomiting,  prostration,  very  high  temperature, 
and  to  a  very  active  inflammation  in  the  pharynx.  In  all  cases  with  a 
sudden  onset,  in  which  from  the  throat  symptoms  one  is  inclined  to  make 
a  diagnosis  of  diphtheria,  the  possibility  of  scarlet  fever  should  not  be 
forgotten ;  and  one  should  never  omit  to  examine  the  patient  thoroughly 
for  an  eruption.  The  diagnosis  of  primary  di^^htheria  of  the  larynx  has 
already  been  considered  (page  447). 

2.  The  Bacteriological  Diagnosis.* — The  technique. — In  many  cases  an 
immediate  diagnosis  may  be  reached  by  smearing  a  cover-glass  with  a 
swab  which  has  been  drawn  over  the  diphtheritic  membrane ;  the  cover- 
glass  is  then  dried  and  stained.  Although  in  the  hands  of  an  expert  this 
method  is  fairly  exact,  it  is  not  adapted  to  general  use,  as  bacilli  directly 
from  the  throat  are  much  less  typical  than  those  from  cultures,  and  the 
chances  of  contamination  are  much  increased.  Furthermore,  the  mouth 
often  contains  bacilli  which  somewhat  resemble  the  Loeffler  bacillus ;  so 
that  on  the  whole  the  result  is  more  likely  to  be  doubtful  than  if  cultures 
are  made. 


*  I  am  greatly  indebted  for  many  facts  in  these  pages  to  the  Scientific  Bulletin 
No.  1,  of  the  New  York  Health  Department,  in  whose  bacteriological  laboratory,  under 
the  supervision  of  Drs.  H.  M.  Biggs  and  W.  11.  Park,  some  of  the  best  work  in  the 
world  in  the  bacteriological  diagnosis  of  diphtheria  has  been  done. 


PLATE   XVIII. 


1 


''MM?jJ^Sii';^^il-?^Mi 


Diphtheria  Bacilli  and  their  Associates. 

1  and  3,  colonies  of  diphtlieria  bacilli  under  a  low  and  a  high  ] tower :  3,  4,  5,  char- 
acteristic diphtheria  bacilli  x  1,000 ;  5,  showing  the  short  even-stained  diphtheria 
bacilli ;  6,  pseudo-diphtheria  bacilli  ;  7.  streptococci  from  a  serum  culture  ;  8,  strep- 
tococci from  a  smear  directly  from  tiie  throat.  (After  Park.) 


DIPHTHERIA.  977 

In  making  cultures  there  is  required  a  sterilized  swab  and  a  tube  or 
plate  of  Loeffler's  blood-serum  (page  952).  The  swab  is  made  from  a 
piece  of  wire  roughened  at  one  end  where  it  is  wound  with  absorbent 
cotton.  In  taking  a  culture  from  the  throat,  the  tongue  should  be  de- 
pressed and  the  tonsils,  pharynx,  or  other  seat  of  visible  membrane  rubbed 
firmly  with  a  swab,  which  is  then  rubbed  over  the  surface  of  the  culture- 
medium  in  the  tube  or  on  the  plate.  In  laryngeal  cases  the  culture  should 
be  taken  from  the  posterior  wall  of  the  pharynx,  and  in  nasal  cases  from 
the  nostril.  The  tube  or  plate  is  then  placed  in  an  incubator  for  twelve 
or  fourteen  hours  and  kept  at  a  temperature  of  about  100°  F.  (37°  C.),  at 
the  end  of  which  time  the  colonies  (Plate  XVIII,  1  and  2)  may  be  exam- 
ined. A  sterilized  platinum  needle  is  dipped  into  a  colony  and  washed 
off  in  a  drop  of  sterilized  water  upon  the  cover-glass,  dried  in  the  air,  and 
then  heated  by  passing  several  times  over  an  alcohol  flame  and  stained  for 
ten  minutes  with  Loeffler's  solution  of  alkaline  methyl  blue,  without  heat- 
ing; after  which  it  is  rinsed,  dried,  and  mounted  in  balsam.  Examina- 
tion with  an  oil-immersion  lens,  in  the  great  majority  of  cases,  shows 
either  a  great  number  of  diphtheria  bacilli  (Plate  XVIII,  3,  4,  and  5) 
and  a  few  cocci,  or  only  cocci  in  pairs  or  short  chains  (7  and  8) ; 
exceptionally,  the  cocci  and  bacilli  may  be  present  in  nearly  equal 
numbers. 

Although  the  first  slide  may  seem  conclusive,  a  positive  opinion  should 
not  be  given  without  examining  at  least  three  colonies  from  different 
parts  of  the  specimen.  The  diagnosis  is  completed  by  testing  the  viru- 
lence of  the  bacilli  found.  This  is  usually  done  by  injecting  a  guinea-pig 
with  a  pure  broth-culture.  When  death  occurs  within  seventy-two  hours, 
the  bacilli  are  said  to  be  fully  virulent. 

Tlie  reliance  to  he  placed  upon  bacteriological  diagnosis. — Many  mis- 
leading statements  have  been  published  in  regard  to  the  relative  frequency 
of  cases  of  membranous  inflammation  due  to  the  diphtheria  bacillus  and 
to  other  bacteria.  My  own  experience  coincides  fully  with  the  state- 
ments made  by  Welch  and  Baginsky,  that  in  the  great  proportion,  fully 
ninety-five  per  cent,  of  the  cases  in  which  one  would  unhesitatingly  make 
the  diagnosis  of  diphtheria  by  clinical  symptoms,  the  Loeffler  bacillus  is 
found,  provided  proper  precautions  are  observed.  It  will  almost  invari- 
ably be  found:  (1)  if  there  is  visible  membrane  in  the  pharynx;  (2)  if 
the  culture  is  made  during  the  period  in  which  the  membrane  is  form- 
ing; (3)  if  no  antiseptics  have  been  applied  shortly  before  using  the 
swab ;  (4)  if  the  culture  has  been  made  with  sufficient  care  to  avoid  con- 
tamination. 

The  diphtheria  bacillus  sometimes  disappears  early ;  hence  cultures 
made  while  the  membrane  is  loosening  may  be  negative.  If  the  mem- 
brane has  disappeared,  or  if  none  has  been  present,  it  may  be  necessary,  as 
has  been  shown  by  Koplik,  to  go  into  the  tonsillar  crypts  with  probe  or 


978  '-THE  SPECIFIC  INFECTIOUS  DISEASES. 

spoon  to  discover  bacilli.*  It  is  therefore  important  in  all  cases  to  con- 
sider the  duration  of  the  disease  before  drawing  a  conclusion  from  a  nega- 
tive culture.  If  the  case  is  one  of  laryngeal  disease  without  pharyngeal 
exudation,  a  negative  culture  from  the  pharynx  in  the  early  stage  is  not 
uncommon,  although  a  little  later  bacilli  may  be  coughed  up  and  found 
in  the  pharynx  in  abundance.  Hence  negative  results  are  most  frequent 
late  in  pharyngeal  and  early  in  laryngeal  cases.  A  single  negative  culture 
is  never  to  be  taken  as  conclusive,  although  in  most  conditions  other  than 
those  mentioned  it  may  be  so  regarded. 

The  next  question  for  consideration  is  how  far  one  is  justified,  from 
the  microscopical  appearances  of  bacilli  and  from  their  mode  of  growth, 
in  deciding  that  they  are  virulent,  without  resorting  to  the  test  of  animal 
inoculations.  The  consensus  of  opinion  among  bacteriologists  at  the  pres- 
ent time  is  that,  for  diagnostic  purposes,  all  bacilli  present  in  suspicious 
throats,  having  the  morphological  and  cultural  characteristics  of  diph- 
theria bacilli  are  to  be  regarded  as  virulent  unless  the  contrary  is  proved, 
the  latter  being  very  infrequent.  This  is  equally  true  of  bacilli  from  both 
mild  and  severe  cases,  for  it  is  well  known  that  the  most  virulent  bacilli 
are  often  found  in  cases  clinically  of  a  mild  type. 

Noji-virulent  bacilli  resembling  the  Loeffler  bacillus. — There  may  be 
found  in  throats  two  forms  of  bacilli  which  resemble  the  diphtheria  bacil- 
lus and  which  may  occasionally  be  a  source  of  error.  The  first  is  the  non- 
virulent  diphtheria  bacillus,  a  form  which  corresponds  in  every  other 
characteristic  with  the  Loeffler  bacillus,  but  which  lacks  virulence  as  shown 
by  animal  tests.  The  exact  status  of  this  form  is  not  yet  fully  determined. 
The  view  most  widely  accepted  is  that  of  Roux  and  Yersin — viz.,  that  they 
are  simply  diphtheria  bacilli  which  have  lost  their  virulence.  The  other 
form,  though  in  many  particulars  resembling  the  Loeffler  bacillus,  differs 
from  it  in  being  shorter,  plumper,  and  more  uniform  in  size,  and  in  pro- 
ducing an  alkali  in  broth  cultures ;  to  this  the  term  pseudo-dipJitlieria 
bacilhis\  (Plate  XVIII,  6)  has  been  given.  It  is  more  frequently  seen 
than  the  form  just  described  and  like  it  is  non-virulent.  Both  these  forms 
of  bacteria  are  rare  in  throats  where  a  suspicion  of  diphtheria  exists. 

The  presence  of  virulent  bacilli  in  the  throats  of  healthy  persons. — 
That  virulent  bacilli  maybe  harboured  for  an  indefinite  period  in  the  throat 

*  Dr.  Martha  Wollstein,  pathologist  to  the  Babies'  Hospital,  has  reported  to  me  the 
following  case  illustrating  this  point :  The  first  swab  from  a  doubtful  exudate  upon 
the  tonsil  revealed  the  Loeffler  bacillus.  The  case  was  reported  to  the  Board  of  Health, 
who  a  day  or  two  later  took  a  culture  from  the  throat,  the  exudate  having  at  that  time 
disa[)peared,  and  reported  the  case  as  negative.  On  the  following  day  Dr.  Wollstein 
made  a  second  culture  from  the  tonsillar  crypts,  finding  as  before  the  Loeffler  bacilli 
in  great  numbers.  Such  cases  indicate  how  great  caution  must  be  observed  in  drawing 
conclusions  from  negative  cultures,  especially  if  made  late. 

f  An  unfortunate  term,  as  this  bacillus  has  nothing  to  do  with  the  form  of  angina 
classed  as  pseudo-diphtheria,  which  is  generally  due  to  the  streptococcus. 


DIPHTHERIA.  979 

or  nose  of  a  healthy  person  is  proved  by  many  observations.  In  Escherich's 
well-known  case,  the  throat  of  an  apparently  healthy  nurse,  under  whose 
care  a  number  of  cases  of  diphtheria  had  developed,  was  found  to  contain 
numerous  virulent  bacilli  which  remained  for  weeks.  In  a  case  observed 
by  Park,  virulent  bacilli  were  found  for  months  in  the  nose  of  an  apparently 
healthy  infant,  and  this  child  communicated  diphtheria,  it  was  believed, 
to  two  other  members  of  the  family,  without  itself  ever  suifering  from  the 
disease.  Similar  instances  have  been  reported  by  Feer,  Loeffler,  and 
others;  but  they  are  to  be  regarded  as  very  exceptional.  However,  the 
presence  of  bacilli  in  the  nose  or  throat  of  a  child  who  has  recently  been 
exposed  to  diphtheria  is  of  very  common  occurrence.  The  Xew  York 
Health  Department  made  observations  upon  forty-eight  children  in  four- 
teen families  in  which  one  or  more  cases  of  diphtheria  had  occurred,  and 
where  no  attempt  at  isolation  had  been  made.  In  one  half  these  cases 
bacilU  were  found,  and  animal  tests  showed  them  to  be  virulent  in  every 
one  of  six  cases  tested,  although  four  of  the  children  did  not  develop 
diphtheria.  Of  the  entire  number,  forty  per  cent  subsequently  developed 
diphtheria.  My  own  experience  in  two  institutions  where  diphtheria 
lias  been  endemic,  fully  confirms  the  observation  that  bacilli  of  all  degrees 
of  virulence  are  very  frequently  found  in  the  noses  or  throats  of  such 
exposed  children,  although  a  large  proportion  of  them  never  develop 
the  disease.  Outside  of  institutions  and  infected  tenement  houses,  how- 
ever, such  a  condition  is  extremely  rare.  In  a  series  of  three  hundred 
and  thirty  cases  studied  by  Park,  in  which  no  exposure  to  diphtheria  was 
known,  virulent  bacilli  were  found  in  but  eight  persons,  two  of  whom 
subsequently  developed  the  disease.  In  twenty-four  of  this  series,  non- 
virulent  diphtheria  bacilli  were  found,  and  in  twenty-seven  the  pseudo- 
diphtheria  bacillus.  Any  person,  but  especially  a  child  who  has  been  in 
contact  with  a  case  of  diphtheria,  may  receive  bacteria  into  the  throat, 
where  they  may  be  present  for  days  or  weeks  before  the  disease  develops, 
and  such  persons  may  convey  the  disease  to  others,  although  they  them- 
selves may  never  have  it. 

Summary. —  1.  For  ordinary  diagnostic  purposes  the  discovery  in  the 
throat  of  a  case  of  suspected  diphtheria,  of  bacilli  having  the  appearance  of 
the  Loeffler  bacillus,  may  be  regarded  as  conclusive  evidence  of  diphtheria. 

2.  Cultures  may  yield  negative  results  late  in  pharyngeal  cases  when 
the  membrane  is  separating  or  after  it  lias  disappeared,  or  early  in  laryn- 
geal cases;  but  in  no  instance  is  a  single  negative  culture  to  be  regarded 
as  conclusive. 

3.  Both  the  local  appearance  of  the  throat  and  the  stage  of  the  disease 
are  always  to  be  considered  in  connection  with  the  bacteriological  report. 

4.  A'irulent  bacilli  are  frequently  found  in  the  noses  or  throats  of 
children  exposed  to  diphtheria,  apart  from  all  throat  lesions.  Such  a  find- 
ing is  not  in  itself  evidence  that  these  persons  have  diphtheria,  although. 


980  THE  SPECIFIC  INFECTIOUS  DISEASES. 

inasmuch  as  they  may  infect  others  and  as  a  considerable  proportion  of 
them  subsequently  develop  diphtheria  themselves,  they  should  be  re- 
garded with  suspicion  and  if  possible  kept  under  observation. 

5.  Non-virulent  bacilli  are  occasionally,  and  virulent  bacilli  are  rarely, 
found  in  the  throats  of  healthy  persons  where  there  is  no  history  of  expos- 
ure to  diphtheria. 

6.  The  existence  of  a  membranous  inflammation  in  the  nose  or  phar- 
ynx, associated  with  the  presence  of  diphtheria  bacilli,  is  conclusive  evi- 
dence of  the  existence  of  diphtheria. 

7.  The  presence  of  such  bacilli,  associated  with  marked  evidences  of 
catarrhal  inflammation  of  the  mucous  membrane,  is  likewise  evidence  of 
diphtheritic  infection. 

Prognosis. — There  is  no  disease  in  which  it  is  more  difficult  to  foretell 
the  outcome  than  in  diphtheria,  and  none  in  the  course  of  which  unex- 
pected dangers  more  often  arise.  So  many  possibilities  exist  that  even  the 
mildest  case  must  be  regarded  as  serious  and  carefully  watched,  since  we 
can  never  know  when  unfavourable  symptoms  may  develop.  Jacobi  puts 
it  well  when  he  says,  "  The  physician  will  often  be  deceived,  and  more 
frequently  in  mild  cases  than  in  severe  ones."  In  perhaps  the  majority 
of  cases  it  is  impossible  to  tell  how  severe  the  attack  will  prove  before  the 
third  or  fourth  day  of  the  disease. 

The  factors  to  be  considered  in  the  prognosis  of  any  given  case  are :  the 
age  and  previous  condition  of  the  patient ;  the  time  when  treatment  is 
begun  ;  the  extent  of  the  membrane  and  the  rapidity  with  which  it  is 
spreading  ;  the  degree  of  diphtheritic  toxaemia  as  shown  by  the  condition 
of  the  pulse  and  the  nervous  symptoms;  whether  or  not  the  membrane  has 
invaded  the  larynx  ;  and  the  presence  or  absence  of  complications,  espe- 
cially nephritis  and  broncho-pneumonia.  Pure  diphtheria  has  usually  a 
better  prognosis  than  cases  of  mixed  infection. 

So  many  circumstances  modify  the  death-rate  of  diphtheria  that  figures 
are  of  no  value  for  comparison  unless  their  source  is  considered.  There 
must  always  be  taken  into  account,  the  age  of  the  patients  treated  and 
whether  the  statistics  are  drawn  from  private  or  hospital  practice  ;  if  the 
latter,  what  sort  of  cases  are  received  at  the  hospital  and  the  treatment 
employed.  Diphtheria  is  very  fatal  during  the  first  two  years  of  life, 
from  two  causes:  first,  from  its  strong  tendency  to  invade  the  larynx  and 
lower  air  passages ;  and  secondly,  from  the  frequency  with  which  broncho- 
pneumonia occurs  as  a  complication,  both  with  and  without  membrane 
in  the  larynx  and  trachea.  Of  eighty-five  consecutive  cases  under  twenty- 
six  months  of  age  observed  in  the  New  York  Infant  Asylum,  in  a  period 
extending  over  two  years,  the  mortality  was  68  per  cent ;  in  over  two 
thirds  of  the  fatal  cases  the  disease  involved  the  larynx.  In  diphtheria 
hospitals,  where  most  of  the  mild  cases  included  in  the  above  statistics 
would  probably  not  have  been  admitted,  the  mortality  in  children  under 


DIPHTHERIA.  981 

two  years  has  varied  from  60  to  80  per  cent ;  in  private  practice  it  has 
ranged  for  this  age  from  30  to  60  per  cent — i.  e.,  without  antitoxine. 

After  the  second  year  there  is  a  steady  fall  in  the  mortality  up  to  pu- 
berty. From  a  comparison  of  many  statistical  tables  it  may  be  stated  that, 
under  the  same  conditions,  the  mortality  from  two  to  five  years  is  two 
thirds  the  mortality  of  the  first  two  years  ;  while  that  from  five  to  ten 
years  is  one  half,  and  that  from  ten  to  fifteen  years  about  one  fifth  the 
mortality  of  the  first  two  years.  Series  of  cases  from  different  sources  and 
treated  by  different  methods  show  very  nearly  this  relative  mortality. 

In  some  seasons  a  mild  type  of  the  disease  prevails,  the  number  of 
laryngeal  cases  is  small,  and  the  mortality  therefore  is  less  than  half  that 
which  is  usually  seen.  In  other  seasons,  with  the  opposite  conditions,  the 
mortality  may  be  trebled.  The  influence  of  the  method  of  treatment 
upon  the  mortality  will  be  considered  in  the  pages  devoted  to  treatment. 

There  has  been  considerable  discussion  as  to  what  influence  the  gen- 
eral introduction  of  bacteriological  diagnosis  has  had  upon  diphtheria 
statistics.  While  many  cases  of  pseudo-diphtheria,  most  of  which  recover, 
have  been  excluded,  there  have  been  included  many  cases  formerly  re- 
garded as  examples  of  simple  tonsillitis.  According  to  the  data  collected 
by  the  N'ew  York  Health  Department,  there  are  excluded  by  bacteriology 
more  cases  than  are  included.  In  April,  1896,  there  were  reported  to  the 
Department  as  diphtheria  (without  a  bacteriological  examination)  107  cases 
which  were  proven  by  cultures  to  be  pseudo-diphtheria ;  while  during  the 
same  month  there  were  80  cases  returned  as  doubtful  or  as  pseudo-diph- 
theria, which  by  bacteriological  examination  were  proven  to  be  true 
diphtheria.  The  results  obtained  in  several  other  months  were  very 
similar. 

It  can  not  be  too  often  emphasized  that  the  danger  from  diphtheria  is 
not  over  when  the  throat  has  cleared  off.  The  most  frequent  cause  of 
death  after  this  time  is  heart  paralysis,  which  may  come  very  suddenly. 
This  danger  exists  after  every  severe  case  and  it  occasionally  occurs  after 
those  in  which  the  early  symptoms  were  only  of  moderate  severity.  Less 
frequently  death  late  in  the  disease  is  due  to  paralysis  of  respiration,  to 
nephritis,  or  to  broncho-pneumonia. 

Prophylaxis. — In  no  infectious  disease  can  so  much  be  accomplished 
in  the  way  of  prevention  as  in  diphtheria. 

Public  funerals  of  children  dying  from  diphtheria  should  at  all  times 
be  prohibited.  Schools  should  be  closed  whenever  the  disease  is  epidemic. 
Children  from  families  where  diphtheria  exists  should  not  be  allowed  to 
attend  school,  not  only  ordinary  day  schools,  but  Sunday  schools,  dancing 
s jhools,  and  the  like ;  first,  for  the  reason  that  they  may,  while  healthy, 
be  the  carriers  of  the  disease,  but,  what  is  even  more  important,  that  they 
may  mingle  with  other  children  while  themselves  suffering  from  diphthe- 
ria in  an  early  stage  or  in  a  mild  form.     Such  children  should  be  kept 


982  THE  SPECIFIC  INFECTIOUS  DISEASES. 

from  school  for  at  least  two  weeks  after  the  recovery  of  the  last  case  in 
the  family. 

In  every  large  city,  hospitals  for  diphtheria  patients  should  be  estab- 
lished, not  only  for  the  poor,  but  with  private  rooms  for  cases  developing 
in  hotels,  boarding  houses,  or  in  any  place  where  isolation  is  impossible. 
The  removal  of  diphtheria  patients  from  tenement  houses  to  a  hospital 
should  be  insisted  upon  whenever  there  are  other  children  in  the  family. 
Every  city  should  be  provided  with  a  steam  disinfecting  plant,  where  car- 
pets, blankets,  bedding,  etc.,  can  be  sent  from  the  sick-room  for  disinfec- 
tion. It  is  also  desirable  that  the  board  of  health  in  every  city  have  a 
bacteriological  laboratory,*  where  the  diagnosis  in  all  doubtful  cases  may 
be  settled  by  means  of  cultures,  in  order  that  proper  and  necessary  means 
of  prophylaxis  may  be  taken  in  every  case  of  true  diphtheria,  even  though 
it  is  mild,  and  also  that  unnecessary  expense  and  trouble  be  not  imposed 
in  cases  of  pseudo-diphtheria. 

Quarantine. — Not  only  every  undoubted  case  of  diphtheria,  but  every 
suspected  case,  should  be  immediately  isolated.  Quarantine  for  the  latter 
should  continue  until  the  diagnosis  is  settled  either  by  a  bacteriological 
examination  or  by  the  course  of  the  disease.  Positive  and  suspected  cases 
should  not  be  isolated  together.  The  quarantine  in  every  instance  must 
be  complete ;  no  person  should  be  allowed  in  the  room  except  the  attend- 
ants and  the  physician.  The  meals  and  everything  else  required  by  the 
patient  should  be  left  outside  the  door. 

Bacteriology  has  furnished  some  very  definite  data  from  which  the 
necessary  duration  of  the  period  of  quarantine  may  be  determined.  In 
this  the  physician  is  to  be  guided  by  the  time  that  the  bacilli  remain  in 
the  throat,  for  the  patient  is  to  be  considered  as  dangerous  while  they  per- 
sist. This  point  was  investigated  by  the  New  York  Health  Department 
in  605  cases :  In  304  of  these  the  bacilli  had  disappeared  by  the  third 
day  after  the  membrane  was  gone ;  and  in  301  they  persisted  for  a  longer 
time, — in  176,  for  seven  days;  in  64,  for  twelve  days;  in  36,  for  fifteen 
days ;  in  12,  for  twenty-one  days ;  in  4,  for  twenty-eight  days ;  in  4,  for 
thirty-five  days ;  and  in  2,  for  sixty-three  days.  While  it  is  unquestion- 
ably true  that  in  a  certain  number  of  cases  these  persistent  bacilli  have 
been  found  non-virulent,  the  opposite  has  been  frequently  shown.  Of  15 
caseg  in  which  the  virulence  was  tested,  virulent  bacilli  were  found  in  9 
at  periods  varying  from  eight  to  twenty-five  days  after  the  membrane  was 
gone.  Tobiesen  found  that  of  46  patients  leaving  the  hospital  under 
ordinary  rules,  virulent  bacilli  were  present  in  24  at  the  time  of  their  dis- 
charge.    The  general  rule  should  be  to  continue  quarantine  until  a  cul- 

*  The  example  of  the  New  York  Health  Department  in  establishing  a  ninnicipal 
laboratory  for  the  bacteriological  diagnosis  of  diphtheria  has  now  been  followed  by 
nearly  every  large  city  in  this  country. 


DIPHTHERIA.  933 

ture  shows  the  throat  to  be  free  from  bacilli;  in  the  absence  of  the 
culture  test,  quarantine  should  be  continued  in  mild  cases  for  ten  days, 
and  in  severe  cases  for  three  weeks,  after  tlie  membrane  has  disap- 
peared. The  danger  after  this  period  in  either  instance  is  very  slight ; 
for  even  where  virulent  bacilli  are  found  long  after  the  membrane  has 
disappeared,  their  number  is  usually  small.  The  rules  above  given 
should  be  followed  with  reference  to  children  returning  to  school  or 
mingling  with  other  children,  and  adults  who  are  throAvn  into  close  con- 
tact with  children. 

Treatment  of  suspected  cases. — During  an  epidemic  of  diphtheria  every 
sore  throat  should  be  looked  upon  with  suspicion,  and  every  such  case  iso- 
lated as  soon  as  any  exudation  appears  upon  the  tonsils,  or  a  watery  nasal 
discharge  begins.  In  institutions  it  is  desirable  that  cultures  be  made 
from  suspicious  cases  of  pharyngitis,  even  though  no  membrane  is  pres- 
ent. All  such  patients  should  be  separated  from  the  other  inmates  of  the 
home  or  the  institution,  and  while  waiting  for  the  results  of  the  bac- 
teriological examination  or  for  positive  symptoms,  antiseptic  gargles  should 
be  used.  If  there  are  patches  on  the  tonsils,  the  case  should  be  treated  as 
true  diphtheria,  in  order  that  no  time  may  be  lost.  If  the  bacteriological 
examination  shows  the  disease  not  to  be  true  diphtheria,  the  patient  may 
be  released  from  quarantine  in  two  or  three  days,  provided  the  throat 
symptoms  disappear.  It  is,  of  course,  important  that  the  conditions  laid 
down  with  reference  to  bacteriological  diagnosis  shall  have  been  fulfilled. 
Should  symptoms  continue,  however,  a  second  culture  should  be  taken, 
since  the  bacilli  at  the  first  examination  may  have  been  so  few  as  to  have 
escaped  the  swab. 

Treatment  of  children  exposed. — When  a  case  of  diphtheria  occurs  in 
a  family  or  an  institution  every  child  that  has  been  exposed  should  receive 
an  immunizing  dose  of  antitoxine.  Although  many  points  regarding 
immunization  are  still  unsettled,  there  can  be  no  doubt  that  for  a  limited 
time,  probably  about  a  month,  the  serum  confers  almost  complete  pro- 
tection. 

Some  of  the  most  striking  evidences  of  the  value  of  the  serum  for 
immunization  have  been  obtained  in  New  York  institutions,  especially 
in  the  Nursery  and  Child's  Hospital  and  the  New  York  Infant  Asylum, 
both  of  which  have  been  under  my  own  observation.  The  results  in  these 
institutions,  together  with  those  obtained  elsewhere,  are  shown  in  the  ac- 
companying table,  which  was  prepared  by  Biggs.* 

In  the  two  institutions  first  named  in  the  table,  many  infants  under 
three  months  old  were  injected,  and  several  under  a  week  old,  without  any- 
thing more  than  transient  disturbances.  In  one  of  these  institutions  21 
pregnant  women  and  8  women  in  the  puerperal  state  were  injected ;  there 

*  The  Medical  News,  November  30,  1895. 


984 


THE  SPECIFIC  INFECTIOUS  DISEASES. 


was  no  reaction  in  any  of  them,  and,  tliough  the  urine  was  examined 
daily  for  a  week,  in  none  did  albumin  appear. 

Table  Showing  the  Results  of  Antitoxine  Injections  for  Immunization. 


Place  of  Observation. 

Chil- 
dren 
immu- 
nized. 

Cases  of  diph- 
theria develop- 
ing among 
those  immu- 
nized between 
1  and  30  days. 

Cases 
devel- 
oping 
within 
24  hrs. 

Cases  devel- 
oping after 
30  days. 

Number 

of  cases  of  diphtheria 

that  occurred  in 

the  institutions  previous 

to  immunization. 

New  York  Infant  Asyhim 
(1st  immunization.) 

New  York  Infant  Asylum 
(2d  immunization). 

Nursery  and  Child's  Hos- 
pital. 

New  York  Juvenile  Asy- 
lum. 

New  York  Catholic  Pro- 
tectory. 

Bellevue  Hospital 

Health   Department   in- 
spectors. 

224 
245 

ll36 

114 

11 

^232 

1  mild  on  the 
19th  day. 

1  mild  on  the 
12th  day. 

0 

0 
0 

0 

1  mild  on  the 
lyth  day. 

0 
0 

0 
0 

1 

0 
3 

6 
4 

0 

0 
0 

0 

(  1,  80th. 

3  \  1.  31st. 

(  1,  55th. 

107  cases  in  108  days. 

6  eases  in  12  days. 

(  46  cases  in  90  days. 
]  15  cases  in  18  days. 

1  12  cases ;  3  cases  in 
\      2  days. 

5  cases  in  3  days. 

2  cases  in  10  days. 
One  or  more  cases  in 

more  than  90  fam- 
ilies. 

Total 

1,043 

3 

4 

13 

In  the  Bulletin  of  the  New  York  Health  Department  are  brought 
together  twenty-nine  reports,  covering  15,986  injections  of  antitoxine  in 
exposed  persons  for  the  purpose  of  immunization.  The  number  attacked 
with  diphtheria  during  the  thirty  days  following  injection  was  but  79,  or 
0-5  per  cent.  Nearly  all  of  these  had  a  mild  form  of  the  disease,  only  one 
case  being  fatal.  Many  of  these  injections  were  made  in  the  early  days  of 
antitoxine,  and  doses  now  regarded  as  insufficient  were  given. 

The  dose  for  immunization  is  from  50  to  350  units,  the  former  being 
that  required  for  an  infant  under  three  months,  and  the  latter  for  a  child 
of  twelve  or  fourteen  years ;  for  one  from  five  to  ten  years  the  usual  dose 
is  200  to  300  units.  With  the  strongest  serum,  the  larger  dose  can  now 
be  administered  in  a  volume  of  ten  minims. 

If  possible,  cultures  should  be  made  from  the  throats  of  all  exposed 
children,  and  those  having  no  bacilli  should  be  sent  away  from  the 
house.  Children  whose  throats  contain  bacilli  should  be  separated  from 
others,  but  not  necessarily  confined  in-doors.  Those  who  are  old  enough 
should  use  a  gargle  of  bichloride,  1  to  5,000.  For  very  young  children  it 
is  wise  to  spray,  or  better,  to  syringe  the  nose  with  either  Seller's  or  a 
simple  saline  solution,  two  or  three  times  a  day.  The  throats  of  all  such 
children  should  be  carefully  inspected  twice  a  day.  In  a  hospital  the  same 
general  rules  should  be  adopted. 

Nurses. — Those  in  charge  of  diphtheria  cases  should  receive  an  im- 
munizing dose  of  antitoxine  of  300  or  400  units.     As  diphtheria  is  con- 


DIPHTHERIA.  985 

tracted,  not  from  the  breath  of  the  patient  or  the  air  of  the  room,  but  by 
receiving  the  bacilli  into  the  month  or  air  passages,  all  possible  means 
should  be  taken  to  destroy  the  bacilli  discharged,  and  to  secure  absolute 
cleanliness  in  everything  about  the  sick-room.  Nurses  should  never  be 
allowed  to  eat  or  sleep  in  the  sick-room,  and  an  antiseptic  gargle  should 
be  used  four  or  five  times  a  day.  The  hands  should  be  kept  clean,  and 
only  such  dresses  worn  as  can  be  readily  washed  and  disinfected.  It  is 
the  nurse  who  is  most  likely  to  contract  the  disease,  on  account  of  the  con- 
tinued exposure.  Hence,  these  measures  should  be  rigorously  insisted 
upon.     She  should  be  allowed  a  few  hours  in  the  open  air  every  day. 

Physicians. — The  physician  should  take  the  same  precautions  as  in 
scarlet  fever  (page  907).  A  pocket  tongue-depressor  should  not  be  used 
for  the  examination  of  the  throat,  but  a  spoon  which  is  kept  in  a  solution 
of  carbolic  acid,  1  to  40.  In  order  to  prevent  the  coughing  up  of  mucus 
or  membrane  in  the  face  of  the  physician,  a  pane  of  ordinary  window  glass 
may  be  held  in  front  of  the  patient's  face  during  inspection  of  the  throat. 

The  sick-room. — The  car^Dets,  hangings,  upholstered  furniture,  every- 
thing in  fact  not  necessary  for  the  patient's  welfare,  should  be  removed, 
especially  books,  toys,  cushions,  etc.  The  room  should  be  a  large  one,  if 
possible  with  an  open  fireplace,  well  ventilated,  and  fresh  air  should  be 
allowed  in  abundance.  The  floor  should  be  washed  once  a  day  with  a 
solution  of  bichloride,  1  to  2,000,  and  dusted  often  wuth  cloths  moistened 
in  the  same  solution.  All  handkerchiefs,  bed  linen,  and  clothing  removed 
from  the  patient  should  be  treated  as  in  a  case  of  scarlet  fever.  Pieces 
of  membrane  and  other  matters  discharged  from  the  patient  should  be 
put  into  a  solution  of  carbolic  acid,  1  to  20,  or  of  bichloride,  1  to  1,000. 
Pieces  of  old  muslin  or  absorbent  cotton  should  be  used  to  cleanse  the  nose 
and  mouth  of  the  patient  and  burned  immediately.  All  vessels  for  the 
reception  of  expectoration  or  other  discharges  should  contain  bichloride, 
1  to  2,000.  The  bed-linen  should  be  very  frequently  changed,  and  every- 
thing kept  scrupulously  clean.  In  the  room  should  be  a  large  bowl  of 
carbolic  acid,  1  to  40,  or  some  similar  solution  for  the  cleansing  of  hands, 
and  a  tray  of  the  carbolic  solution  for  spoons,  syringes,  or  other  things 
used  in  the  treatment  of  the  patient.  All  spoons,  cups,  or  other  dishes 
used  by  the  patient  should  be  carefully  sterilized  by  boiling  for  twenty 
minutes.  No  milk  or  other  food  should  be  allowed  to  stand  about  the 
room.  There  is  no  objection  to  the  hanging  of  sheets  moistened  in  car- 
bolic, bichloride,  or  other  disinfectant  solutions  before  the  door,  but  neither 
this  nor  hanging  them  about  in  the  sick-room  is  to  be  regarded  as  having 
any  value  in  disinfecting  the  air  of  the  room.  They  create  a  false  sense 
of  security,  and  often  lead  to  the  neglect  of  thorough  cleanliness,  which, 
after  all,  is  the  essential  thing. 

Disinfection  of  apartments  after  an  attack  should  be  done  as  after 
scarlet  fever  (page  907). 


986  THE  SPECIFIC   INFECTIOUS  DISEASES. 

Treatment. — General  measures. — It  is  important  in  every  case  that 
there  should  be  plenty  of  fresh  air  in  the  room  throughout  the  attack. 
Where  it  is  possible,  it  is  desirable  to  have  two  rooms  for  the  patient,  so 
that  he  can  be  changed  from  one  to  the  other  every  day,  giving  time  for 
thorough  cleanliness  and  airing.  In  hospital  wards,  patients  should  never 
be  crowded  together.  Small  wards,  containing  three  or  four  beds,  are 
much  to  be  preferred  to  very  large  ones.  Even  in  mild  cases  the  patient 
should  be  kept  in  bed  throughout  the  entire  attack,  and  in  severe  cases 
this  should  be  continued  for  some  time  during  convalescence.  It  is  espe- 
cially important  where  there  have  been  symptoms  of  cardiac  depression 
during  the  acute  stage. 

Nursing  infants  may  be  fed  on  breast  milk  obtained  by  a  breast  pump, 
but  should  not  be  put  to  the  mother's  breast.  The  feeding  of  older  cliil- 
dren  must  be  managed  very  much  as  in  other  cases  of  severe  illness  (page 
191).  Milk  is  the  main  reliance  ;  it  should  usually  be  diluted,  and  for 
younger  infants  often  partially  peptonized.  The  greatest  difficulty  in 
feeding  is  seen  in  the  latter  part  of  the  disease,  when  the  patients  are 
septic  and  have  a  strong  aversion  to  food,  when  vomiting  is  easily  excited 
and  when  swallowing  is  difficult  on  account  of  the  swelling  and  pain.  It 
is  then  that  forced  feeding  by  means  of  gavage  is  most  valuable.  This  is 
much  more  successful  with  children  under  three  years  old  than  is  rectal 
feeding.  In  children  of  five  or  six  years,  who  struggle  against  the  tube  in 
the  mouth,  it  may  be  passed  through  the  nose  with  very  little  difficulty. 
The  results  are,  as  a"  rule,  extremely  satisfactory,  and  gavage  may  be  used 
with  advantage  in  many  intubated  cases. 

Stimulants. — There  is  no  question  in  regard  to  the  value  of  alcohol  in 
diphtheria.  It  is  altogether  the  most  powerful  drug  we  possess  to  com- 
bat the  effects  of  the  disease  upon  the  nervous  centres  and  the  heart. 
Stimulants  should  be  begun  as  soon  as  the  depressing  effects  of  the  poison 
of  diphtheria  are  shown  upon  the  pulse  and  general  condition  of  the 
patient.  In  most  cases,  therefore,  they  are  not  needed  until  the  third  or 
fourth  day ;  in  a  few  they  may  be  required  from  the  outset,  and  in  some 
they  may  not  be  required  at  all.  The  indications  for  alcoholic  stimulants 
are  marked  prostration,  a  feeble  pulse,  and  a  weak  first  sound  of  the 
heart.  In  regard  to  the  quantity,  one  ounce  of  whisky  or  brandy  in 
twenty-four  hours  is  enough  to  begin  with,  for  a  child  four  years  old. 
This  should  be  diluted  with  at  least  six  parts  of  water.  In  very  bad 
cases  five  or  six  times  as  much  may  be  given  ;  the  only  limit  to  the 
quantity  is  the  tolerance  of  the  stomach.  The  method  of  administration 
should  be  the  same  as  in  other  severe  acute  diseases  (page  49).  Usually 
stimulants  should  not  be  combined  Avith  food.  A  child  is  more  apt 
to  rebel  against  the  stimulants  than  the  milk,  and  it  is  important  that 
nothing  be  done  to  interfere  with  the  taking  of  proper  nourishment. 
Other  heart  stimulants  than  alcohol,  though  inferior  to  it,  are  of  value 


DIPHTHERIA.  987 

in  some  cases.  The  most  useful  one  is  strychnine,  which  should  be 
given  as  in  pneumonia  (page  510).  Camphor  and  carbonate  of  am- 
monia are  valuable  for  rapid  effect  in  syncopal  attacks,  and  digitalis  in 
other  cases  where  the  pulse  is  weak  and  arterial  tension  low,  but  it  is 
not  wise  to  give  it  in  large  doses.  In  cases  of  threatened  heart  paralvsis 
occurring  late  in  the  disease  or  during  convalescence,  nothing  is  so  valu- 
able as  morphine  hypodermically.  Full  doses  must  be  given  and  repeated 
every  two  to  four  hours,  so  that  the  child  may  be  kept  completely  under 
its  influence. 

Except  for  stimulation  or  the  control  of  special  symptoms  such  as 
vomiting  or  diarrhoea,  all  internal  medication  would  better  be  omitted ; 
for  there  is  yet  wanting  proof  that  drugs  influence  the  course  or  the  result 
of  the  disease. 

Local  treatment. — Since  the  introduction  of  antitoxine,  medical  opinion 
has  undergone  a  decided  change  with  reference  to  local  treatment.  While 
it  is  not  desirable  that  it  should  be  entirely  abandoned,  still  it  has  assumed 
a  position  of  secondary  importance ;  and  under  conditions  where  it  can  be 
carried  out  only  with  great  difficulty  and  the  use  of  considerable  force,  as 
in  the  case  of  very  young  or  intractable  children,  it  is  often  wise  not  to 
attempt  it  systematically. 

The  purpose  of  local  treatment,  it  is  now  generally  agreed,  should  be 
cleanliness,  and  not  the  destruction  of  bacilli.  Cleanliness  of  the  nose, 
mouth,  and  pharynx  is  important,  inasmuch  as  one  of  the  chief  dangers  of 
the  disease  is  the  aspiration  of  bacteria  contained  in  the  abundant  secre- 
tions of  these  parts,  into  the  larynx  and  bronchi.  Our  aim  should  there- 
fore be  to  keep  the  parts  as  clean  as  possible  without  too  severely  taxing 
the  strength  of  the  child.  Harm  often  results  from  attempting  to  do  too 
much. 

For  cleansing  the  nose  and  rhiiio-pharynx  only  syringing  can  be  de- 
pended upon.  Nasal  syringing  is  indicated  when  there  is  much  nasal 
discharge,  whether  membrane  is  visible  in  the  anterior  nares  or  not,  unless 
there  is  so  much  resistance  on  the  part  of  the  child  that  it  can  not  be 
done  without  a  good  deal  of  force.  In  such  cases  more  harm  than  good 
may  result.  However,  in  septic  cases  with  a  profuse  fetid  discharge  it 
may  be  necessary  to  syringe  the  nose,  no  matter  how  strongly  the  child 
resists.  Whether  it  shall  be  done  forcibly  in  such  a  case,  will  depend  upon 
the  condition  of  the  patient's  strength  and  his  pulse.  The  purpose  in 
syringing  is  not  so  much  to  clear  the  nose,  from  which  absorption  is  slow 
and  imperfect,  although  this  is  useful,  as  to  flush  the  rhino-pharynx,  from 
which  absorption  is  always  very  active.  Only  bland  solutions  should  be 
employed,  such  as  a  common-salt  solution,  strength  of  one  per  cent,  or  a 
boric-acid  solution,  one  to  four  per  cent  strength. 

For  ordinary  cases,  the  syringe  and  the  method  described  on  page  57 
may  be  used.     For  some  cases  a  fountain  syringe  possesses  manifest  ad- 


988  THE  SPECIFIC  INFECTIOUS  DISEASES. 

vantages,  and  it  is  rather  more  convenient  for  hospital  purposes.  All 
solutions  should  be  used  lukewarm,  and  in  sufficient  quantity  to  irrigate 
the  parts  thoroughly,  a  few  such  irrigations  being  much  better  than  a 
great  many  partial  ones.  By  a  skilful  nurse  syringing  can  in  most  cases 
be  done  with  comparatively  little  disturbance  to  the  child. 

Slight  nasal  hemorrhages  may  necessitate  less  frequent  syringing,  and 
a  free  haemorrhage  may  oblige  us  to  stop  it  altogether.  Astringent  solu- 
tions of  alum,  Monsel's  solution,  lemon  juice,  etc.,  are  sometimes  bene- 
ficial in  such  cases,  but  they  must  be  largely  diluted.  In  children  who  are 
old  enough  to  use  them,  the  mouth  and  pharynx  should  be  kept  clean  by 
gargles.  A  solution  of  boric  acid,  listerine,  or  Dobell's  or  Seller's  solution 
much  diluted,  may  be  employed. 

In  cases  with  a  moderate  nasal  discharge  it  is  usually  sufficient  to 
syringe  three  or  four  times  a  day;  but  in  those  of  the  most  severe  or 
septic  type,  with  very  abundant  discharge,  syringing  should  be  repeated 
as  often  as  every  two  hours  during  the  day  and  every  four  hours  at 
night. 

External  applications  to  the  throat  have  practically  no  effect  upon  the 
disease,  but  are  often  useful  to  relieve  pain  and  tension  in  the  swollen 
lymph  glands.  In  very  young  children  heat  is  to  be  preferred  to  cold, 
and  may  be  applied  either  by  means  of  poultices,  or,  better,  spongio- 
piline  Avrung  from  very  hot  water,  covered  with  cotton  and  then  with 
oiled  silk;  prolonged  poulticing  should  not,  however,  be  allowed.  For 
older  children  an  ice-bag  may  be  used,  and  this  frequently  gives  great 
relief. 

The  Serum  Treatment. — This  has  been  the  outcome  of  a  long  series  of 
experiments  in  which  many  men  have  had  a  share  ;  but  it  is  to  Behring 
pre-eminently  that  the  credit  belongs  for  the  development  of  the  princi- 
ples of  serum-therapy.  It  will  be  sufficient  here  to  indicate  the  more  im- 
portant steps  which  have  led  to  this  discovery.  In  December,  1890,  Beh- 
ring and  Kitasato  published  experiments  which  demonstrated  that  it  was 
possible  for  the  blood  of  an  immunized  animal  (one  which  had  been  in- 
jected with  the  toxines  of  a  disease  in  gradually  increasing  doses,  until  a 
condition  was  reached  when  such  injections  produced  no  reaction)  when 
injected  into  another  animal  to  convey  immunity,  and  also  cure  the  disease 
if  artificially  produced.  This  was  first  shown  to  be  true  of  tetanus.  In 
August,  1892,  Behring  further  showed  that  the  blood  of  an  immunized 
animal  had  the  power  both  of  protecting  and  curing  susceptible  animals 
which  had  been  inoculated  either  with  the  toxines  or  with  the  bacilli  of 
diphtheria.  Early  in  the  same  year  he  produced  from  animals  his  so-called 
"  normal "  serum,  which  was  used  in  his  animal  experiments,  this  being 
one  sixtieth  of  the  strength  of  his  No.  1  serum  now  employed.  The 
further  steps  consisted  in  gradually  increasing  the  strength  of  the  serum 
by  the  use  of  stronger  toxines  for  injection.     Up  to  this  time  small  ani- 


DIPHTHERIA.  989 

mals  had  been  used,  and  the  serum  produced  only  in  limited  quantity. 
Later,  Roux  conceived  the  idea  of  using  horses  for  injection,  and  from  this 
time  they  were  generally  employed.  In  the  latter  part  of  1893  the  serum 
was  first  tried  upon  diphtheria  patients  in  the  Berlin  hospitals,  and, 
although  it  was  still  very  weak,  encouraging  results  were  observed.  At 
the  International  Congress  held  at  Rome  in  March  and  April,  1894,  Heub- 
ner  reported  his  results  in  cases  treated  by  the  serum,  followed  the  same 
month  by  a  report  from  Ehrlich,  Kossel,  and  Wassermann,  with  two  hun- 
dred and  twenty  cases,  which  up  to  that  time  had  been  treated  with  anti- 
toxine,  showing  a  decided  reduction  in  the  death-rate.  The  results  im- 
proved steadily  with  the  strength  of  the  serum  employed.  By  August, 
1894,  the  beneficial  results  of  the  serum  were  considered  sufficiently 
established  to  warrant  placing  Behring's  serum  on  sale.  The  new  treat- 
ment attracted  but  little  notice  until  the  Congress  at  Buda-Pesth  in  the 
summer  of  1894,  where  Roux  presented  a  report  of  three  hundred  cases 
treated  at  Paris  under  his  supervision,  with  results  so  striking  that  the 
interest  of  the  entire  medical  profession  was  at  once  aroused.  Since  the 
beginning  of  1895  the  serum  treatment  has  been  tested  on  a  large  scale 
all  over  the  world. 

Regarding  the  nature  of  the  antitoxine  and  its  mode  of  action  but 
little  is  as  yet  definitely  known.  Two  theories  have  been  advanced :  one, 
that  its  action  is  a  chemical  one,  directly  neutralizing  the  toxine  of  diph- 
theria ;  the  other,  that  its  effect  is  rather  a  vital  one,  rendering  the  cells 
tolerant  of  the  diphtheria  toxine.  Without  being  in  any  sense  germi- 
cidal in  its  effect,  the  antitoxine  produces  a  condition  in  the  blood  which 
arrests  the  growth  of  the  diphtheria  bacillus  and  the  membranous  inflam- 
mation which  this  excites. 

Following  the  plan  of  Roux,  the  dijihtheria  antitoxine  is  produced  at 
the  present  time  from  the  blood-serum  of  the  horse.  This  is  drawn  into 
sterilized  vessels  and  preserved  in  small  sterilized  bottles,  each  of  which  is 
designed  to  contain  a  sufficient  quantity  for  a  single  dose.  It  is  preserved 
by  the  addition  of  carbolic  acid  (Behring),  camphor  (Roux,  New  York 
Health  Department,  and  others),  or  some  other  antiseptic.  Properly  pre- 
pared, it  will  keep  without  deterioration  for  from  three  to  six  months; 
but  after  one  year  it  loses  somewhat  of  its  antitoxic  properties,  this 
amounting,  according  to  the  experiments  of  Park,  to  perhaps  one  third 
of  its  original  strength.  It  should  be  kept  in  a  cool,  dark  i^lace,  and  after 
a  bottle  has  been  opened  it  should  be  used  within  a  few  days.  The  effort 
to  prepare  and  preserve  the  antitoxine  in  a  dry  form  has  not  thus  far  been 
very  successful. 

The  strength  of  the  serum  is  measured  in  antitoxine  units,  the  unit 
being  an  arbitrary  one  and  representing  the  ability  to  neutralize  a  definite 
quantity  of  diphtheria  toxine.  The  improvements  in  the  production  of 
the  serum  have  thus  far  consisted  in  increasing  its  strength.      Behring's 


990  THE   SPECIFIC   INFECTIOUS   DISEASES. 

normal  serum  as  first  used  contained  in  each  cubic  centimetre  (15  minims) 
one  antitoxine  unit ;  that  sold  as  Behring's  No.  3  contains  150  units 
in  each  cubic  centimetre.  Several  American  manufacturers  have  now 
placed  on  sale  a  serum  containing  500  units  in  each  cubic  centimetre,  and 
have  produced  one  containing  750  units  in  each  cubic  centimetre.  There 
may  now  be  obtained  also  an  "extra-potent"  Behring's  serum  which  con- 
tains 500  units  in  each  cubic  centimetre.  The  stronger  serum  has  been 
produced  by  the  use  of  stronger  toxines  for  animal  injections,  those  at 
present  employed  being  many  times  stronger  than  those  formerly  regarded 
as  the  strongest  possible. 

The  concentration  of  the  serum  is  of  immense  advantage,  and  has  sim- 
plified many  things  in  connection  with  its  administration.  Horse-serum 
being  merely  the  vehicle  of  the  antitoxine,  and  itself,  it  is  believed,  capable 
of  producing  unpleasant  effects  when  large  quantities  are  injected,  it  is 
desirable  to  administer  the  dose  of  antitoxine  in  the  smallest  amount  of 
serum  possible.  There  seems  now  to  be  good  evidence  that  the  local  dis- 
comfort— oedema,  pain,  etc. — and  also  the  various  eruptions,  which  some- 
times follow  its  use,  have  depended  largely  upon  the  amount  of  horse- 
serum  injected.  With  the  concentrated  serum  now  available,  it  is  never 
necessary  to  use  more  than  5  cubic  centimetres  (75  minims)  for  a  single 
dose,  and  usually  but  half  this  quantity.  This  does  away  with  the  neces- 
sity for  large  and  special  syringes.  The  hypodermic  syringe  as  made  for 
veterinary  use,  holding  5  cubic  centimetres,  answers  every  purpose,  and 
is,  I  think,  to  be  preferred  on  account  of  the  smaller  size  of  the  needle. 
For  nearly  a  year  I  have  used  no  other  instrument.  The  syringe  should 
be  rinsed  with  alcohol  immediately  before  using,  and  the  needles  should, 
always  be  boiled.  Care  should  be  taken  that  all  air  is  expelled  from  the 
syringe  before  the  injection  is  made.  The  seat  of  injection  is  of  com- 
paratively little  importance  now  that  the  dose  of  antitoxine  can  be  given 
in  so  small  a  volume.  The  cellular  tissue  of  the  abdomen  or  the  thigh  is 
perhaps  the  best  location.  If  a  small  needle  is  used,  no  application  of 
adhesive  plaster  is  necessary;  but  the  needle  puncture  should  be  covered 
with  the  finger  for  a  few  moments. 

Rules  for  accurate  dosage  in  antitoxine  are  as  yet  impossible.  It  is 
desirable  to  give  in  every  case  enough  to  neutralize  the  amount  of  diph- 
theria toxine  present  in  the  blood,  but  Ave  have  no  very  exact  means  of 
determining  how  much  this  is.  It  depends  upon  the  virulence  of  the 
bacilli — which  may  be  judged  by  the  severity  of  the  attack  and  the  extent 
of  the  membrane — the  time  when  the  injection  is  made,  and  somewhat 
upon  the  age  of  the  patient.  The  general  experience  of  the  profession 
thus  far  is,  that  for  children  over  two  years  old  the  initial  dose  should  be 
from  1,500  to  2,000  units  in  all  severe  cases,  including  those  of  laryngeal 
stenosis,  this  dose  to  be  repeated  in  from  twelve  to  sixteen  hours  if  no 
improvement  is  seen,  and  again  in  twenty-four  hours  if  the  course  of  the 


DIPHTHERIA.  991 

disease  is  nnfavourable.  The  third  dose  is  rarely  necessary.  Exceptional 
cases  of  great  severity,  especially  when  seen  late,  should  receive  somewhat 
larger  doses  than  those  mentioned — i.  e.,  3,000  units.  Mild  cases  should 
receive  1,000  units  for  the  first  injection,  a  second  being  rarely  required. 
For  children  under  two  years  old,  the  initial  dose  in  a  severe  case  or  one 
of  laryngeal  stenosis  should  be  1,000  units,  to  be  repeated  as  above  indi- 
cated ;  in  a  mild  case,  600  units.  The  most  concentrated  serum  is  to  be 
preferred,  and  only  that  obtained  from  a  reliable  source  should  be  used. 
It  is  unfortunate  that  legal  restrictions  do  not  make  it  impossible  for  any 
other  to  be  sold.  My  own  experience  has  been  chiefly  with  the  serum  of 
Behring  and  that  of  the  New  York  Health  Department,  both  of  which 
are  absolutely  reliable,  as  are  also  the  serum  of  Mulford  and  that  of  Parke, 
Davis  &  Co. 

Xot  only  must  a  sufficient  dose  be  given,  but,  to  be  efficient,  the  anti- 
toxine  must  be  administered  early  in  the  disease  before  the  diphtheria 
toxines  have  done  their  work.  The  serum  can  not  undo  the  serious  dam- 
age already  done  to  the  cells  of  the  body,  and  this  at  the  time  of  injection 
may  be  so  great  that  death  will  result.  One  who  waits  until  his  cases 
have  grown  alarmingly  worse  under  other  treatment  and  gives  but  half 
doses,  will  see  little  benefit  from  antitoxine.  In  very  mild  cases,  with 
older  children,  one  may  wait  for  the  result  of  a  bacteriological  examination 
where  such  examinations  are  possible,  but  never  in  a  severe  case  and  never 
in  a  young  child.  In  the  group  of  severe  cases  should  be  placed  every  one 
which  at  the  first  visit  shows  a  pharyngeal  exudate  covering  more  than  the 
tonsils,  also  all  cases  with  symptoms  of  laryngeal  invasion,  and  all  with  an 
exudate  in  the  pharynx  and  a  profuse  nasal  discharge.  If  in  a  doubtful 
case  twelve  hours'  observation  shows  that  the  membrane  has  spread  from 
its  original  seat,  no  further  delay  is  admissible.  Experiments  have  shown 
that  after  a  fatal  dose  of  diphtheria  toxiue,  an  animal  can  usually  be  res- 
cued if  the  antitoxine  is  administered  within  forty-eight  hours,  but  rarely 
after  that  time.  In  human  diphtheria  marked  benefit  usually  follows  in- 
jections, made  as  late  as  the  third  day ;  but  after  three  days  have  passed 
little  benefit  is  to  be  expected,  although  it  occasionally  follows  even  later 
injections.  On  the  other  hand,  in  very  severe  or  in  malignant  cases  irre- 
parable harm  may  be  done  by  the  disease  during  the  first  twenty-four 
hours. 

The  local  effects  of  the  injection  are  a  slight  redness,  pain,  and  usually 
some  transient  oedema.  General  eruptions  are  seen  in  a  considerable  num- 
ber of  cases,  from  five  to  forty  per  cent  according  to  various  observers. 
They  are  most  frequent  from  the  eighth  to  the  twelfth  day  after  injec- 
tion, usually  appearing  in  the  form  of  an  urticaria.  Although  in  most 
cases  slight  and  transient,  the  body  may  be  covered  and  the  urticaria  con- 
tinue to  be  most  annoying  for  several  days.  Various  forms  of  erythema 
have  been  occasionally  observed,  and  in  a  few  cases  swelling  of  the  joints. 
64 


992  THE  SPECIFIC  INFECTIOUS  DISEASES. 

There  appears  to  be  a  close  connection  between  the  amount  of  horse- 
serum  administered  and  the  occurrence  of  these  symptoms.  They  are 
certainly  much  less  frequent  since  the  use  of  more  concentrated  anii- 
toxine. 

The  effect  upon  the  diphtheritic  membrane  is  usually  noticeable  within 
twenty-four  hours  ;  it  first  stops  spreading,  and  soon  begins  to  soften  and 
loosen.  The  swelling  of  the  mucous  membrane  subsides  and  the  local 
disease  abates^  very  much  after  the  manner  seen  when  the  disease  runs 
its  usual  course.  The  striking  thing  after  the  use  of  antitoxine  is  the 
rapidity  with  which  these  changes  take  place,  and  the  abrupt  transition 
from  an  advancing  to  a  retrograde  process.  The  evidence  of  the  subsi- 
dence of  the  inflammatory  conditions  in  the  larynx  and  trachea  is  quite  as 
marked  as  in  the  pharynx.  The  symptoms  of  stenosis,  even  when  severe, 
often  diminish  in  a  few  hours  and  continue  to  improve,  making  operation 
unnecessary  in  a  very  large  number  of  cases  where  previously  it  seemed 
inevitable.  The  membrane  loosens  rapidly  in  the  larynx  and  trachea, 
sometimes  necessitating  the  frequent  removal  of  the  intubation  tube, 
where  operation  has  been  performed.  It  is  the  experience  of  McNaugh- 
ton  (Brooklyn),  and  of  some  other  operators,  that  the  tube  is  more  fre- 
quently coughed  up  after  the  use  of  antitoxine  than  formerly,  probably 
because  of  the  rapid  subsidence  of  the  swelling.  Improvement  is  also 
shown  by  the  cessation  of  the  nasal  discharge,  the  re-establishment  of 
nasal  respiration,  and  the  diminution  in  the  swelling  of  the  glands  of 
the  neck. 

The  effect  upon  the  constitutional  symptoms  is  not  less  striking.  In 
favourable  cases  there  is  seen,  often  in  twelve  hours,  a  fall  in  temperature 
and  improvement  in  the  pulse  and  in  the  nervous  condition  of  the  patient. 
Sometimes  the  change  in  the  general  symptoms  is  seen  earlier  than  in  the 
local  conditions. 

The  limitations  of  antitoxine. — It  is  important  that  these  should  al- 
ways be  kept  in  mind.  The  serum  must  be  given  early,  for  if  given  late 
it  can  not  undo  the  mischief  already  done  by  the  diphtheria  toxine.  Cases 
of  great  severity  have  often  passed  the  period  when  recovery  was  possible, 
before  the  antitoxine  is  given.  This  period  may  in  some  cases  be  three 
days,  in  others  it  may  be  less  than  twelve  hours.  The  tissues  most  sus- 
ceptible to  the  diphtheria  toxine  are  probably  the  nervous  structures,  the 
heart,  and  the  kidneys ;  and  the  consequences  of  its  action  may  be  seen  in 
the  jiroduction  of  nephritis,  in  sudden  heart  failure  at  the  height  of  the 
disease,  or  some  form  of  post-diphtheritic  paralysis,  in  spite  of  the  fact 
that  antitoxine  was  given  at  a  period  early  enough  to  avert  death  from 
local  disease  in  the  larynx  or  bronchi.  Again,  antitoxine  is  of  no  value  in 
cases  of  streptococcus  septicaemia.  The  early  arrest  of  the  inflammation 
excited  by  the  diphtheria  bacillus  is  unfavourable  to  the  spread  of  strepto- 
coccus infection,  yet  sometimes  the  latter  has  gained  such  headway  or  is 


DIPHTHERIA.  993 

of  such  intensity  as  to  involve  almost  the  entire  body.  Against  the  phleg- 
monous inflammation  of  the  throat  or  the  cellular  tissue  of  the  neck, 
broncho-pneumonia,  and  nephritis,  antitoxine  is  powerless;  and  just  in 
proportion  to  the  severity  of  these  inflammations  are  negative  results 
seen. 

Real  and  alleged  dangers  from  antitoxine  injections. — In  the  cases 
where  sudden  death  has  followed  antitoxine  injections,  the  evidence  that 
antitoxine  was  the  cause  of  death  is  not  conclusive.  That  only  three  or 
four  alleged  instances  of  this  have  occurred  among  the  hundreds  of  thou- 
sands of  antitoxine  injections  which  have  now  been  made,  is  sufficient  to 
establish  the  fact  that  the  serum  itself  is  harmless.  These  rare  accidents 
have  been  attributed  to  the  carbolic  acid  used  to  preserve  the  antitoxine, 
to  the  injection  of  air,*  to  the  shock  from  needle  puncture,  and  to  indi- 
vidual idiosyncrasy. 

Regarding  the  unfavourable  effects  upon  the  heart,  the  kidneys,  and 
the  blood,  attributed  to  antitoxine,  they  are  to  my  mind  not  proved.  In  a 
disease  like  diphtheria,  where  the  heart  and  kidneys  are  so  often  and  so 
seriously  affected,  and  where  cardiac  and  renal  symptoms  in  so  many  cases 
are  so  suddenly  manifested,  it  is  impossible  to  say,  even  when  such  symp- 
toms follow  the  injection  of  serum,  that  they  are  not  due  to  the  original 
disease.  They  were  seen  with  great  frequency  before  antitoxine  was  heard 
of.  It  is,  however,  not  impossible  that  in  a  very  young  or  delicate  child 
the  sudden  introduction  into  the  circulation  of  such  a  large  quantity  of 
horse-serum  as  was  first  used  (i.  e.,  20  or  30  cubic  centimetres)  might  in- 
tensify existing  cardiac  or  renal  disturbance — a  result  not  probable  and  I 
think  not  reported  with  the  concentrated  serum  now  in  use.  Observa- 
tions regarding  the  effect  of  the  serum  upon  the  blood  were  made  by 
Billings,  Jr.,  upon  twenty-nine  cases  of  diphtheria.  He  found  the  re- 
duction both  in  the  hsemoglobin  and  the  red  cells  to  be  much  less  than 
the  average  found  in  cases  of  diphtheria  of  similar  severity  not  treated 
by  the  serum. 

At  the  present  time,  after  the  serum  has  been  in  general  use  for  nearly 
two  years,  no  evidence  has  been  adduced  as  to  its  danger  or  injurious 
effects  which  should  deter  any  one  from  its  use.  Those  which  have  been 
reported  are  to  be  looked  upon  in  the  light  of  accidents  for  which  the 
antitoxine  was  probably  not  responsible. 

The  results  with  antitoxine  in  hospital  practice. — Guerard,  in  Bulletin 
No.  3  of  the  New  York  Health  Department,  has  collected  reports  of  9,893 
cases  treated  with  the  serum,  with  an  average  mortality  of  18-3  per  cent. 
Of  these  cases,  7,277,  in  which  the  mortality  was  20  per  cent,  were  re- 
turned by  53  hospitals ;  the  reports  from  the  same  hospitals  give  as  their 
previous  mortality  an  average  of  44:'3  per  cent.     The  accompanying  chart 

*  Seibert  and  Schwyzer,  Xew  York  Medical  Journal,  May  30,  1896. 


994 


THE  SPECIFIC  INFECTIOUS  DISEASES. 


(Fig.  16G)  shows  the  results  obtained  in  the  Children's  Hospital,  Berlin, 
with  and  without  the  serum. 


MORT- 
ALITY 

AGES 

80^ 
65^ 

mi 
^% 

20/. 

16% 

5% 

0-2 

2-4 

4-6 

6-8 

8-10 

10-12 

12-14 

1"^ 

, 

^i 

'fN 

\ 

1/ 

N, 

\ 

N, 

\ 

1/ 

> 

\ 

i 

\,     ^ 

a 

\ 

\ 

\ 

^^ 

i   * 

x!k. 

I     1  ^ 

N. 

^ 

NN 

'/ 

V 

-2l_ 

iih 

'*^^. 

i— - 

'It 

\ 

f 

C^^.- 



Fig.  166. — Chart  showing  the  percentage  mortality  from  diphtheria  in  theChildren's  Hospital, 
Berlin,  for  three  periods  :  a,  a,  for  four  years  before  the  introduction  of  the  serum  ;  b,  o,  for 
the  first  year  of  the  serum  treatment ;  c,  c,  for  two  months  during  that  year  when  the  supply 
of  serum  failed.    (After  Baginf^ky.) 

The  fact  that  during  August  and  September  of  the  first  antitoxine 
year,  when  the  supply  of  serum  became  exhausted,  the  death-rate  rose  at 
once  to  nearly  three  times  what  it  had  been,  and  fell  again  when  the  serum 
was  again  in  use,  is  one  of  the  most  striking  demonstrations  yet  published 
in  favour  of  the  serum.  Identical  experiences  are  reported  by  Korte, 
Heim,  and  Ganghofner,  all  showing  that  the  results  were  not  explained 
by  a  milder  form  of  the  disease,  for  when  antitoxine  was  omitted  the  same 
mortality  prevailed  as  had  been  formerly  observed. 

Results  in  private  practice. — The  largest  number  of  cases  from  this 
source  has  been  brought  together  in  the  Collective  Investigation  made  by 
the  American  Pediatric  Society.*  This  embraces  5,794  returned  by  G15 
physicians  from  114  cities  and  towns  in  America,  with  an  average  mortal- 
ity of  12-3  per  cent.  But  in  this  report  is  included  every  case  returned 
in  which  the  serum  was  given,  many  of  which  were  moribund  at  the  time 
of  injection,  the  serum  being  used  only  to  gratify  parents.  If  these  cases 
and  those  dying  within  twenty-four  hours  after  the  first  injection  be 
excluded,  there  remain  5,576  cases,  with  a  mortality  of  8"8  per  cent.  Of 
4,120  injected  during  the  first  three  days  the  mortality  was  7'3  per  cent, 
or,  excluding  moribund  cases  and  those  dying  twenty-four  hours  after  the 


*  Archives  of  Paediatrics,  July,  1896. 


DIPHTHERIA. 


995 


first  injection,  but  4-8  per  cent.  The  diagnosis  of  diphtheria  was  con- 
firmed by  a  bacteriological  examination  in  83  per  cent  of  these  cases ;  in 
the  remainder  it  rested  upon  the  clinical  symptoms. 

Influence  of  the  serum  upon  the  diphtheria  mortality  in  cities. — If 
Behring's  antitoxine  is  the  specific  remedy  for  diphtheria  that  it  is 
claimed  to  be,  its  general  use  should  produce  a  decided  fall  in  the  actual 
mortality  from  diphtheria.  We  will  take  the  figures  from  four  large 
cities — New  York,  Berlin,  Paris,  and  Chicago;  from  the  first  three  we 
have  full  reports  not  only  of  the  antitoxine  period,  but  of  several  years 
preceding. 

In  the  city  of  Paris,  during  the  six  years  preceding  the  use  of  antitox- 
ine (1889  to  1894  inclusive),  the  average  number  of  deaths  from  diph- 
theria and  croup  was  1,518 ;  the  minimum  number  was  1,009,  this  being 
in  1894,  during  the  last  four  months  of  which  antitoxine  was  in  general 
use.  During  the  first  year  of  antitoxine  (1895)  the  number  of  deaths  fell 
to  442,  or  considerably  less  than  one  half  the  mortality  of  any  previous 
year  during  the  period  considered. 

The  following  table  gives  the  number  of  deaths  per  month  for  the  first 
three  months  of  the  six  years  before,  and  the  two  years  after  the  introduc- 
tion of  the  serum  :  * 


City. 

Average 
monthly  mor- 
tality, 1889-'94, 
without  serum. 

Minimum 
monthly  mor- 
tality, same 
period. 

1895. 
With  serum. 

1896. 
With  serum. 

(  January 

160 
152 
180 
135 
117 
114 
317 
276 
236 

120  (1892) 
108  (1893) 
148  (1894) 

102  (1891) 

103  (1891) 
86  (1891) 

48 

47 

45 

79 

64 

88 

207 

171 

168 

47 

Paris \  February 

56 

(  March 

48 

(  January 

58 

Berlin -I  February 

54 

{  March 

47 

^vT       T-r    1     (  January 

181 

n«^.^^y^  February 

172 

(1894  only).|^^^^^j^_3;;  ;;;;;;•;;• 

165 

The  only  month  in  which  a  lower  mortality  occurred  without  anti- 
toxine than  with  it  was  in  Berlin,  in  March,  1891 ;  but  it  will  be  seen  that 
the  amount  of  diphtheria  in  the  city  that  year  was  much  less  than  the 
average,  as  is  indicated  by  the  figures  for  January  and  February. 

The  following  chart  (Fig.  167)  shows  even  better  than  the  table  the 
influence  of  the  introduction  of  antitoxine.  Had  the  serum  been  em- 
ployed to  the  same  extent  in  all  the  cities,  we  should  doubtless  see  a  cor- 
responding reduction  in  the  number  of  deaths  in  all.  But,  as  is  well 
known,  the  serum  was  much  more  generally  employed  in  Paris  than  in 
either  of  the  other  cities. 


*  These  figures  are  taken  from  the  advance  sheets  of  Bulletin  No.  3  of  the  New 
York  Health  Department,  placed  at  my  disposal  by  Dr.  H.  M.  Biggs. 


996 


THE  SPECIFIC   INFECTIOUS  DISEASES. 


1886         '87           '88          '89          '90           '91           '92           '93          '94           '95 

200 

190 

180 

170 

160 

150 

140 

130 

120 

110 

100 

90 

80 

70 

60 

50 

40 

30 

20 

/ 

\ 

200 

190 

180 

170 

160 

150 

140 

130 

120 

110 

100 

90 

80 

70 

60 

50 

40 

30 

20 

/ 

\ 

New 

York 

\ 

\ 

1 

\ 

\ 

y 

\ 

V 

V 

/ 

/ 

\ 

\ 

/ 

\ 

Berlin 

\ 

V 

\ 

•, 

\ 

\ 

\ 

New 

York 

\, 

/ 

\ 

> 

■~."»^^ 

\ 

/ 

Paris 

^'   \ 

-'' 

v. 

/ 

\ 

\     • 
N 

s 



\ 

N 

s 

s. 

Berlin 

\ 
\ 

\ 
\ 
\ 

N 

Paris 

1886          '87           '88           '89           '90           '91           '92           '93          '94           '95 

Fig.  167. — Chart  showing  deaths  from  diphtheria  and  croup  per  100,000  of  population  in  New 
York,  Berlin,  and  Paris.  During  the  last  half  of  1894  antitoxine  was  widely  used  in  Berlin, 
and  during  the  last  four  months  of  that  year  it  was  in  general  use  in  Paris,  it  will  be  noted 
that  the  only  time  during  the  period  when  the  lines  of  the  three  cities  correspond,  is  since 
the  use  of  the  antitoxine.    (From  Bulletin  No.  3,  New  York  Health  Department.) 


The  results  in  the  city  of  Chicago  are  quite  as  striking  as  those  in 
Paris,  and  are  shown  by  the  accompanying  chart  (Fig.  168),  which  dem- 
onstrates how  a  rapidly  rising  death-rate  was  checked  by  the  introduc- 
tion of  the  serum  in  October,  1895. 

The  lines  for  both  years  show  a  relatively  small  number  of  deaths  dur- 
ing the  summer,  but  a  rapid  increase  in  the  autumn  months.  It  will  be 
noted  that  during  every  month  of  the  second  year  up  to  and  including 
October,  there  was  an  increase  in  the  fatal  cases  over  the  previous  year, 


DIPHTHERIA. 


997 


and  that  in  October  the  daily  death-rate  was  8-1  a  day,  as  against  5-5  the 
previous  year.  The  epidemic  of  diphtheria  at  this  time  had  attained  such 
proportions  in  the  city  that  the  question  of  closing  all  the  public  schools 
was  considered.  In  the  latter  part  of  October  the  Health  Department 
brought  antitoxine  into  general  use  by  establishing  sixty  stations  through- 
out the  city  where  it  could  be  obtained,  and  organizing  a  special  corps  of 
physicians  to  visit  the  diphtheria  cases.  One  of  these  was  sent  to  every 
case  in  a  tenement  house,  and  the  serum  injected  unless  refused  by  the 
parents.  The  effect  upon  this  daily  death-rate  is  graphically  shown  in 
the  chart.  Of  1,468  cases  treated  by  the  inspectors,  the  mortality  was 
but  6-4  per  cent ;  and  of  1,113  cases  injected  during  the  first  three  days, 
but  2 "5  per  cent. 


DEATHS 
PER 
DIEM 

9 
8 

7 
6 
5 
4 
3 
2 

APRIL 

MAY 

vjNE 

JULY 

AUG. 

SEPT. 

OCT. 

NOV. 

DEC. 

JAN. 

FEB. 

MAR. 

/N 

/ 

Nt-- 

--  •-.. 

^ 

/ 

'N. 

\ 

t 

/ 

N. 

/ 

S, 

J 

• 

\ 

^  / 

N.^ 

"*.. 

^       , 

^ 

^ 

"*" 

,->^ 

^  ■•  CI 

» 

^^^ 

"^  *^ 

_.-• 

•' 

■ 

■"♦-"" 

^ 

Fig.  168. — Showiner  the  average  daily  mortality  from  diphtheria  in  Chicago  for  two  years.  The 
dotted  line,  5,  5,  indicates  the  mortality  from  April,  1894,  to  April,  1895;  the  line  a,  a.  the 
mortality  from  April,  1895,  to  April,  1896.  Antitoxine  was  introduced  at  the  close  of  Octo- 
ber.    (From  the  lieport  of  the  Cnicago  Health  Department.) 

Results  in  other  American  cities  have  been  no  less  striking.  In  the 
city  of  Newark,  K.  J.,  there  were  reported  to  the  Board  of  Health,  from 
June  20,  1895,  to  March  20,  1896,  939  cases  of  diphtheria ;  606  of  these 
were  treated  by  the  serum,  with  85  deaths,  a  mortality  of  14  per  cent ;  333 
cases  did  not  receive  the  serum,  and  among  these  there  were  138  deaths,  a 
mortality  of  41*4. 

In  the  city  of  Boston,  Ernst  reports  1,156  cases  treated  by  the  serum, 
with  165  deaths,  a  mortality  of  14-2  per  cent.  The  report  by  MacCullom 
from  the  diphtheria  wards  of  the  Boston  City  Hospital  shows  even  better 
results.  Of  844  cases  treated  by  the  serum,  there  were  96  deaths,  a  mor- 
tality of  11  per  cent;  the  previous  mortality  in  the  same  institution  with- 
out serum  was  40-  per  cent. 

The  results  as  modified  ly  the  time  of  injection  and  the  age  of  the 
patients. — The  statement  has  been  already  made  that  striking  imjDrove- 
ment  from  the  use  of  the  serum  is  seen  only  when  it  is  used  early.  In 
the  American  PaBdiatric  Society's  report  the  mortality  of  4,120  cases 
injected  during  the  first  three  days  was  7-3  per  cent,  including  even 
those  which  were  moribund  at  the  time  of  injection ;  of  758  cases  in- 


998  THE  SPECIFIC  INFECTIOUS  DISEASES. 

jected  on  the  fourth  day  the  mortality  was  20-7  per  cent;  and  of  690 
injected  later  than  the  fourth  day  it  was  35-3  per  cent.  The  figures 
are  from  private  practice.  The  statistics  from  diphtheria  hospitals  show 
approximately  the  same  variation,  but  the  percentages  are  all  slightly 
higher. 

It  has  been  the  experience  of  nearly  every  one,  that  the  greatest  reduc- 
tion in  mortality  is  seen  in  the  youngest  patients.  In  the  above  report 
the  mortality  of  867  cases  two  years  old  and  under,  was  23-3  per  cent ; 
while,  excluding  moribund  cases  and  those  dying  within  twenty-four  hours 
of  the  first  injection,  it  was  only  19-2  per  cent.  There  are  two  factors  in 
this  great  reduction  from  former  figures.  These  infants  are  patients  for 
whom  often  little  or  nothing  could  be  done  by  local  treatment,  and  in 
whom  broncho-pneumonia  was  almost  certain  to  follow  the  invasion  of 
the  larynx.  The  serum  enables  us  largely  to  dispense  with  local  treat- 
ment, and  when  used  early  in  the  great  majority  of  cases  it  prevents  the 
extension  of  membrane  below  the  larynx. 

The  results  in  laryngeal  cases. — The  allegation  that  the  favourable  re- 
sults obtained  with  the  serum  are  to  be  explained  by  the  mildness  of  the 
disease  can  not  be  applied  to  diphtheria  of  the  larynx.  These  cases  are  not 
mild,  nor  do  they  tend  to  spontaneous  recovery ;  furthermore,  the  results 
obtained  both  by  intubation  and  tracheotomy  without  antitoxine  are  well 
known.  Laryngeal  diphtheria  therefore  furnishes  the  crucial  test  of  the 
serum  treatment.  The  benefits  of  the  serum  are  seen,  first,  in  the  num- 
ber of  cases  that  recover  without  operation ;  secondly,  in  the  percentage 
of  recoveries  in  operative  cases  ;  thirdly,  in  the  shortening  of  the  time  that 
the  tube  is  necessary. 

It  is  not  yet  possible  to  give  exact  figures  regarding  the  proportion 
of  laryngeal  cases  that  recover  without  operation.  Baginsky  found  that 
during  the  two  months  in  which  the  serum  treatment  was  interrupted  in 
the  Childrens'  Hospital  in  Berlin,  because  the  supply  was  exhausted,  the 
proportion  of  cases  requiring  operation  was  55*2  per  cent,  while  with  the 
serum,  during  the  period  immediately  preceding  and  following  this,  it 
was  only  18-1  per  cent.  This  is  to  be  explained  partly  by  the  fact  that  by 
the  early  use  of  the  antitoxine  the  larynx  less  frequently  became  involved, 
and  partly  by  the  number  of  laryngeal  cases  recovering  without  opera- 
tion. 

In  the  Psediatric  Society's  report  there  were  1,256  laryngeal  cases,  of 
which  554  recovered  without  operation.  Welch's  paper*  contains  figures 
from  seven  European  observei's  with  reference  to  this  jDoint,  who  together 
report  in  401  laryngeal  cases,  27'2  per  cent  of  recoveries  without  opera- 
tion. The  improvement  in  the  results  of  operated  cases  are  even  more 
striking : 

*  Transactions  of  the  Association  of  American  Physicians,  1895. 


DIPHTHERIA.  999 

Results  from  Intubation  with  and  without  Antitoxine. 


Source. 


Ranke,  European  hospitals 

Welch,  European  hospitals 

McXaughton  and  Maddren,  private  prac- 
tice in  America 

American  Pa^diatric  Society's  Report,  pri- 
vate practice  in  America 

.Dillon  Brown,  private  practice,  with  calo- 
mel fumigations 

Reports  of  operators  with  experience  of  10 
cases  or  more,  in  American  Pa?diatric 
Society's  Report 


Cases. 


1,445 
343 

5,346 

533 

279 

280 


Mortality. 


63-5 

29-8 

69-4 
25-9 
49-4 

23-2 


Without  antitoxine. 
With 

Without 

With 

Without         " 

With 


O'Dwyer  says  of  his  last  100  operations,  tliat  the  first  70  without 
the  serum  gave  a  mortality  of  73  per  cent,  the  last  30  with  the  serum  a 
mortality  of  33-3  per  cent.  McNaughton  says  that  in  his  last  72  opera- 
tions without  serum  the  mortality  was  66-6  per  cent ;  the  first  72  with 
serum,  33-3  per  cent. 

It  is  useless  to  multiply  evidence,  for  from  all  parts  of  the  world  the 
testimony  is  the  same,  that  the  mortality  in  cases  of  laryngeal  diphtheria 
requiring  operation  has  been  reduced  at  least  one  half  by  the  introduction 
of  serum.  This  marked  improvement  is  due  to  two  causes :  the  serum 
shortens  very  materially  the  length  of  time  it  is  necessary  to  wear  the 
tube ;  and,  what  is  far  more  important,  it  prevents  the  extension  of  the 
membrane  downward  into  the  trachea  and  bronchi,  in  this  way  removing 
in  great  measure  the  danger  of  broncho-pneumonia. 

The  results  from  tracheotomy  have  likewise  been  greatly  improved  by 
the  serum,  although  not  to  the  same  degree  as  those  from  intubation.  A 
collection  of  23,941  tracheotomies  for  croup  by  Prescott  and  Goodthwait  * 
gives  a  mortality  of  71 '3  per  cent.  Of  873  tracheotomies  with  serum  f 
the  mortality  was  40-9  per  cent.  It  is  now  generally  conceded,  not  only 
in  America  but  all  over  the  continent  of  Europe,  that  as  a  primary  opera- 
tion intubation  should  always  be  performed,  tracheotomy  being  reserved 
for  the  rare  cases  in  which  intubation  has  failed  to  relieve  the  stenosis. 

Summary. — 1.  Behring's  antitoxine  is  a  specific  remedy  for  experi- 
mental diphtheria  in  animals. 

2.  Experience  is  now  sufficient  to  justify  the  statement  that  it  is  so  in 
man,  and  just  in  the  degree  to  which  we  can  fulfil  the  conditions  which 
are  essential  in  experimental  diphtheria. 

3.  These  conditions  are,  that  the  serum  must  be  administered  early — 
usually  within  forty-eight  and  certainly  within  seventy-two  hours — that 
the  dose  be  adequate,  and  the  case  be  one  of  pure  di]3htheria. 

*  Gillet,  Sero-therapie,  Paris,  1895. 

f  Guerard's  collection,  in  New  York  Health  Board  Bulletin. 


1000  '         THE  SPECIFIC  INFECTIOUS   DISEASES. 

4.  Experience  shows  the  serum  to  be  much  less  efficacious  in  cases  of 
so-called  mixed  infection  or  septic  diphtheria,  and  that  it  is  valueless  in 
membranous  inflammations  which  are  due  to  streptococci — i.  e.,  pseudo- 
diphtheria. 

5.  The  serum  itself  is  essentially  harmless  both  when  injected  in 
healthy  persons  for  immunization,  or  in  those  suffering  from  diphtheria. 
Serious  symptoms  following  injections  are  so  exceedingly  rare  that  they 
must  be  attributed  to  other  causes. 

C.  Unpleasant  symptoms,  rashes,  etc.,  have  a  close  relation  to  the 
volume  of  serum  injected,  and  with  the  concentrated  preparations  now 
available  they  have  become  much  less  frequent. 

7.  In  a  young  child  the  serum  should  be  injected  upon  a  clinical  diag- 
nosis of  diphtheria  without  waiting  for  a  bacteriological  confirmation. 

8.  In  older  children  one  may  wait  for  this  in  a  mild  case,  but  never  in 
a  severe  one,  particularly  a  laryngeal  case. 

9.  For  all  cases,  but  especially  for  young  children,  the  most  concen- 
trated preparation  of  antitoxine  which  can  be  obtained  should  be  employed. 

10.  From  the  most  trustworthy  statistics  which  are  now  available,  it 
appears  that  the  actual  mortality  from  diphtheria  (including  membranous 
croup)  has  been  reduced  at  least  one  half  by  the  general  adoption  of  the 
serum  treatment ;  and 

11.  That  in  cases  injected  during  the  first  two  days  the  mortality  is 
less  than  five  per  cent. 

12.  The  evidence  is  conclusive  that  in  laryngeal  diphtheria  the  serum 
in  sufficient  doses  largely  prevents  the  extension  of  membrane  into  the 
trachea  and  bronchi,  and  thus  prevents  broncho-pneumonia. 

13.  There  are  not  yet  sufficient  data  at  hand  to  enable  one  to  state  to 
what  degree  the  heart,  the  kidneys,  and  the  nervous  system  are  protected 
by  the  serum.  It  is,  however,  certain,  that  to  insure  protection  of  the 
nervous  system,  the  injection  must  be  made  very  early. 

14.  While  much  still  remains  to  be  learned  regarding  immunization, 
present  knowledge  justifies  the  statement  that  for  a  period — approximately 
a  month — the  protection  conferred  is  practically  complete.  Immunizing 
doses  should  therefore  be  given  to  every  child  in  an  infected  household  or 
institution. 

15.  Gratif3'ing  as  were  the  earlier  results  with  the  serum  treatment, 
they  have  been  constantly  improving,  and  there  is  every  reason  to  believe 
that,  with  larger  experience  both  in  its  preparation  and  its  use,  still  better 
results  will  yet  be  reached.  Certainly  there  is  no  remedy  for  any  disease 
that  has  more  testimony  in  its  favour  than  has  now  antitoxine  for  diph- 
theria. 

Other  treatment  in  connection  with  antitoxine. — In  the  mild  cases 
nothing  else  is  required  except  to  keep  the  child  in  bed  and  to  continue  a 
fluid  diet.     In  the  severe  cases,  heart  stimulants,  especially  alcohol  and 


DIPHTHERIA.  1001 

strychnine,  are  to  be  used  as  formerly,  according  to  the  condition  of  the 
pulse.  Nasal  injections  of  bland  fluids,  either  a  warm  salt  solution  or  five- 
per-cent  boric  acid,  should  be  used  every  three  or  four  hours  in  severe 
nasal  or  naso-pharyngeal  cases,  unless  the  child  is  very  young  or  intract- 
able, but  if  he  struggles  much  against  them  more  harm  than  good  is 
likely  to  result  from  their  continuance.  The  mouth  should  be  kept  clean 
by  the  use  of  an  antiseptic  mouth-wash,  such  as  Seller's  solution,  oi',  in 
the  case  of  older  children,  by  a  gargle  of  bichloride  1  to  10,000.  A  fluid 
diet,  careful  nursing,  and  absolute  quiet  are  the  only  other  measures  that 
can  be  regarded  as  essential.  The  use  of  strong  antiseptic  or  caustic 
applications,  whether  by  the  spray,  swab,  or  syringe,  for  the  purpose  of 
controlling  the  local  disease,  should  be  entirely  omitted.  The  heart  and 
the  kidneys  should  be  watched  in  all  cases,  not  only  during  the  disease 
but  for  some  time  after  it. 

Convalesce?ice. — After  a  severe  attack  of  diphtheria  convalescence  is 
always  slow  on  account  of  the  ana?mia  and  the  depressing  effects  of  the 
disease.  Patients  should  invariably  be  kept  in  bed  for  at  least  a  week 
after  the  throat  has  cleared,  and  longer  if  any  tendency  to  cardiac  weak- 
ness is  seen.  The  pulse  should  be  carefully  watched,  and  irregularitv, 
intermission,  dicrotism,  or  a  weak  first  sound  of  the  heart,  should  make 
one  apprehensive.  An  abnormally  slow  pulse  may  be  more  serious  than 
one  which  is  rapid.  Under  such  circumstances  the  patient  should  be  kept 
recumbent  and  absolutely  quiet,  since  sudden  and  even  fatal  syncope  may 
be  the  result  of  the  violation  of  these  rules. 

The  extreme  degree  of  anaemia  requires  that  iron  be  given  for  a  con- 
siderable time  during  convalescence,  to  be  followed  by  cod-liver  oil,  wine, 
and  other  tonics. 

Great  difficulty  is  occasionally  experienced  in  getting  rid  of  the  bacilli 
in  the  throat.  Inasmuch  as  it  is  now  generally  made  a  condition  of  re- 
lease from  quarantine  that  the  throat  shall  have  been  shown  by  cultures  to 
be  free  from  bacilli,  this  becomes  a  matter  of  much  importance.  The 
tonsillar  crypts  and  the  adenoid  tissue  of  the  rhino-pharynx  are  the  places 
where  bacilli  are  likely  to  remain.  The  most  efficient  means  appears  to 
be,  to  syringe  the  nose  four  or  five  times  daily  with  a  solution  of  bichloride, 
1  to  5,000,  to  which  one  eighth  glycerin  has  been  added,  and  to  use  the 
same  solution  as  a  gargle.  For  children  under  foiir  years  old  a  simple 
salt  solution,  or  a  dilute  Dobell's  solution,  should  be  substituted  and  the 
gargle  omitted. 


1002  THE  SPECIFIC  INFECTIOUS  DISEASES. 


PSEUDO-DIPHTHERIA. 

Synonyms:  False  diphtheria,  streptococcus  diphtheria,  scarlatinal  diphtheria, 
diphtheroid  inflammation,  croupous  tonsillitis. 

At  the  present  time  there  are  included  under  the  term  pseudo-diph- 
theria all  inflammations  of  the  throat  and  upper  air  passages  character- 
ized by  the  production  of  a  false  membrane,  in  which  the  Loeffler  bacil- 
lus is  not  found.  When  these  inflammations  are  primary  they  are  rarely 
serious ;  but  when  they  complicate  scarlet  fever  or  measles  they  may  be 
very  severe,  and  frequently  prove  fatal. 

Frequency. — Numerical  statements  regarding  the  relative  frequency  of 
this  disease  and  true  diphtheria  signify  very  little,  because  of  the  varia- 
ble conditions  under  which  observations  have  been  made.  From  the  in- 
vestigations of  Park,  Baginsky,  Martin,  Morse,  and  others,  it  would  appear 
that  in  from  twenty-five  to  thirty-five  per  cent  of  the  cases  formerly 
sent  to  hospitals  with  a  clinical  diagnosis  of  diphtheria,  the  disease  was 
pseud o-dijjhtheria.  Most  of  these  were  mild,  and  were  then  regarded 
by  many  physicians  as  simply  cases  of  tonsillitis,  the  exceptions  being 
those  which  were  secondary  to  scarlet  fever  or  measles. 

Of  the  membranous  inflammations  occurring  in  the  diseases  just  men- 
tioned, the  great  majority  are  examples  of  pseudo-diphtheria.  Of  seven 
cases  of  membranous  angina  in  measles  and  three  in  scarlet  fever,  studied 
by  Prudden,  all  were  proven  to  be  pseudo-diphtheria;  of  nineteen  occur- 
ring with  scarlatina,  studied  by  Park,  only  two  were  found  to  be  true 
diphtheria;  and  of  sixteen  occurring  with  scarlet  fever  and  three  with 
measles,  studied  by  Booker,  none  were  true  diphtheria.  The  observa- 
tions made  along  the  same  lines  by  Sorenson,  Wurtz  and  Bourges  and 
others  have  confirmed  the  results  obtained  upon  this  side  of  the  Atlantic. 
It  has  been  the  general  experience  of  all  writers  that  when  it  compli- 
cates the  diseases  mentioned,  pseudo-diphtheria  occurs,  as  a  rule,  at 
the  height  of  the  primary  disease,  sometimes  preceding  the  eruption, 
while  true  diphtheria  more  often  occurs  later,  even  during  convalescence. 

Etiology. — As  was  first  shown  by  Prudden  in  1888,  and  abundantly 
confirmed  by  others  since  that  time,  this  inflammation  is  usually  due  to 
the  streptococcus  pyogenes ;  it  may  be  found  alone,  or  associated  with 
the  staphylococcus  aureus  or  albus,  and  occasionally  the  staphylococcus 
may  be  found  alone. 

The  streptococcus  is  very  frequently  found  in  the  throats  of  healthy 
persons,  particularly  at  certain  seasons  in  cities,  and  in  children  who  live  in 
tenements  or  who  are  inmates  of  hosjiitals  or  other  institutions.  The  local 
conditions  in  the  mucous  membranes  during  an  attack  of  measles,  scarlet 
fever,  and  other  infectious  diseases,  are  especially  favourable  for  the  devel- 


PSEUDO-DIPHTHERIA.  1003 

opment  of  these  germs,  which  at  such  times  are  very  often  present  in  great 
numbers  even  when  no  membrane  is  seen. 

Bad  drainage  and  sewer-gas  poisoning  are  other  conditions  with  which 
this  form  of  sore  throat  often  exists,  and  a  predisposition  is  afforded  by 
unhygienic  surroundings  of  any  description.  From  the  fact  that  the 
streptococcus  is  so  widely  distributed,  attacks  of  pseudo-diphtheria  may 
occur  in  any  place  and  at  any  time,  irrespective  of  epidemic  influences  or 
even  the  occurrence  of  other  cases. 

To  what  degree  these  cases  are  to  be  regarded  as  communicable,  and 
what  precautions  regarding  isolation  and  disinfection  are  required,  are 
questions  of  much  importance.  The  most  extensive  investigations  upon 
these  points  are  those  made  by  the  New  York  Health  Department.*  As  a 
result  of  observations  upon  450  cases  which  were  followed,  the  conclusion 
was  reached  that  the  disease  was  so  slightly  contagious  (if  at  all),  and 
usually  so  mild,  that  strict  isolation  and  subsequent  disinfection  were  un- 
necessary. Of  113  cases  occurring  in  100  families,  in  only  14  was  there  a 
history  of  exposure  to  a  similar  case ;  and  in  only  9  was  there  another  case 
in  the  same  family.  In  many  of  the  latter,  a  common  origin  appeared 
more  probable  than  that  one  case  was  derived  from  another. 

At  the  present  time  the  general  opinion  of  the  profession  seems  to  be 
that  these  cases  are  to  a  slight  degree  communicable,  to  be  compared  in 
this  respect  to  ordinary  catarrhal  colds  or  possibly  to  pneumonia.  They 
are  probably  more  contagious  in  the  presence  of  the  poison  of  scarlet  fever 
or  measles. 

Lesions. — In .  the  primary  cases  the  membrane  is  generally  con- 
fined to  the  tonsils  or  is  chiefly  there,  there  being  only  small  deposits 
elsewhere.  In  the  secondary  cases,  the  entire  pharynx  may  be  covered  and 
the  disease  may  extend  to  the  nose,  the  mouth,  the  middle  ear,  and  occa- 
sionally to  the  larynx,  trachea,  and  bronchi.  . 

The  structure  of  the  membrane  resembles  that  of  true  diphtheria, 
and  it  is  impossible  by  a  microscopical  examination  alone  always  to 
separate  the  two  diseases.  In  many  cases  the  membrane  is  softer,  more 
friable,  and  contains  a  relatively  larger  number  of  cells  than  does  that  of 
true  diphtheria,  but  the  structure  of  the  latter  varies  so  much  that  it  is 
not  safe  to  draw  any  positive  conclusions. 

In  the  mild  cases  the  inflammation  of  the  mucous  membrane  is  a 
superficial  one  and  the  false  membrane  is  not  very  adherent.  In  the 
severe  cases,  chiefly  the  secondary  ones,  the  process  extends  much  deeper. 
There  are  usually  seen  only  congestion,  oedema,  and  cell  infiltration,  but 
deep  suppuration,  and  even  extensive  necrosis  may  take  place.  This  usu- 
ally occurs  in  the  tonsils,  palate,  uvula,  or  epiglottis ;  but  it  may  extend 
to  the  tissues  of  the  pharynx  and  into  the  cellular  tissue  of  the  neck.     The 

*  Scientific  Bulletin,  No.  1. 


1004  THE  SPECIFIC    INFECTIOUS   DISEASES. 

lymph  nodes  are  swollen  in  all  the  severe  cases,  and  often  the  inflamma- 
tion ends  in  suppuration. 

The  streptococci  are  found  in  the  false  membrane,  in  the  underlying 
mucous  membrane,  in  the  lymph  spaces  and  in  the  lymph  nodes.  In  the 
most  severe  cases  there  are  present  the  lesions  of  a  general  streptococcus 
infection.  The  blood  swarms  with  these  germs,  and  they  may  set  up  in- 
flammations in  any  of  the  organs,  but  especially  in  the  lungs  and  the 
kidneys,  less  frequently  the  serous  membranes.  Small  foci  of  suppura- 
tion may  be  found  in  any  of  the  viscera. 

Symptoms. — 1.  The  primary  cases. — The  onset  is  usually  sudden,  with 
well-marked  symptoms :  there  are  frequently  chilly  sensations,  headache, 
vomiting,  general  pains,  and  in  most  cases  the  child  complains  of  soreness 
of  the  throat  and  pain  on  swallowing.  There  are  first  seen  a  general  red- 
ness and  swelling  of  the  tonsils,  sometimes  of  the  entire  pharynx ;  shortly 
afterward  membranous  patches  appear  upon  the  tonsils.  These  vary 
greatly  in  appearance.  In  colour  they  are  yellow  or  gray,  often  changing 
later  to  a  dirty-olive  tint.  (Plate  XVII,  c.)  The  membrane  seems  loose- 
ly attached  and  can  frequently  be  wiped  oflf  with  a  swab.  It  is  soft  and 
friable,  very  rarely  thick,  firm,  or  tenacious.  It  is  often  irregular  in  its 
outline,  which  is  not  sharply  defined.  The  membrane  usually  remains 
but  three  or  four  days  and  disappears  rapidly.  As  a  rule,  it  is  limited  to 
the  tonsils,  and  does  not  spread  after  it  first  forms.  Occasionally,  how- 
ever, small  patches  are  also  seen  upon  the  fauces  or  the  pharynx.  The 
oedema  and  other  evidences  of  inflammation  in  the  throat  are  usually 
more  marked  than  in  true  diphtheria,  and  the  swelling  of  the  lymph 
nodes  behind  the  jaw  is  slight.  The  constitutional  symptoms  are  gener- 
ally more  severe  during  the  first  two  days,  and  the  temperature  may  be 
103°  or  104°  F.,  but  by  the  third  day  it  falls,  and  most  of  the  symptoms 
subside.  It  is  rare  for  the  disease  to  extend  either  to  the  nose  or  the 
larynx.     Generally  there  are  no  complications  and  no  sequelge. 

2.  Tlie  secondary  cases. — Some  of  these  are  mild,  and  do  not  differ 
from  those  Just  described,  but  most  of  the  severe  cases  are  included  in  this 
group.  The  clinical  picture  of  the  latter  is  that  of  scarlatina  anginosa, 
as  given  by  the  older  writers,  and  it  does  not  differ  in  any  essential  par- 
ticulars from  the  septic  form  of  true  diphtheria  (page  969).  The  local 
symptoms  are  those  of  severe  pharyngeal  diphtheria,  and  the  constitu- 
tional symptoms  those  of  septicaemia. 

When  the  disease  complicates  scarlet  fever,  the  symptoms  may  precede 
the  eruption,  but  they  usually  begin  at  the  height  of  the  primary  fever — i.  e., 
from  the  second  to  the  fourth  day — and  gradually  increase  in  severity, 
reaching  their  maximum  from  the  fifth  to  the  eighth  day  of  the  disease. 
In  measles  the  throat  symptoms  are  somewhat  later ;  they  begin  at  the 
height  of  the  primary  fever,  and  often  increase  while  the  eruption  fades. 
In  nearly  all  severe  scarlatinal  cases  the  disease  involves  the  nose  and  the 


PSEUDO-DIPHTHERIA. 


1005 


middle  ear.  In  measles  both  these  complications  are  less  frequent,  but 
there  is  a  much  greater  tendency  to  involve  the  larynx,  and  if  the  larynx 
in  a  young  child  the  process  is  almost  invariably  complicated  by  broncho- 
pneumonia. In  some  cases  the  larynx  is  invaded  when  there  is  no  mem- 
brane in  the  pharynx  ;  but  this  is  very  infrequent,  unless  the  disease  is  true 
diphtheria.  Catarrhal  laryngitis  in  a  young  child  may  produce  symptoms 
which  are  practically  identical  with  those  of  the  membranous  form,  and 
there  is  little  doubt  that  many  cases  complicating  measles  in  which  the 
latter  diagnosis  is  made  are  really  examples  of  catarrhal  laryngitis,  par- 
ticularly if  no  membrane  is  visible  in  the  throat. 

Secondary  cases  as  a  class  are  characterized  by  high  temperature  (Fig. 
169),  rapid,  feeble  pulse,  great  prostration,  and  delirium,  apathy  or  stupor, 
and  often  albuminuria.  In  fatal  cases  death  usually  occurs  at  the  height 
of  the  disease,  from  asthenia,  broncho-pneumonia,  or  nephritis,  sometimes 


DAY 

1 

2 

3 

i 

5 

0 

7 

8 

9 

10 

u 

12 

13 

u 

13 

10 

17 

18 

19 

20 

21 

22   1 

M     E 

«|e 

M 

E 

M 

E 

M 

E 

mIe 

MiE 

m|  e 

ME 

M 

E 

M 

E 

M     E 

M  1  E 

M  1  E 

M  1  E 

M  1  E 

mIe 

ME 

m!e 

m{e 

mIe 

M 

E 

106° 
105° 
104° 
103° 

— 
= 

1 

= 

1 

= 

E 

E 

E 

1 

1 

1 

:: 
-" 
i: 

E 

J 

I 

1 

1 

E 

I 

■ 

1 

1 1 

' — r- 
— t— 

J— 

1 

-^— 

^ 

— (— 

—^ — 

r 

— 

E 

E 
— 

E 

101° 
100° 
99° 
98° 

=f= 

i 

b 

— i— 

1 

— 
E 

— 

^ 

1 

— 

1 

= 

:^ 

= 

E 

= 

= 

E 

= 

—i — 

3 

— 1— 

y 

n 

t 

-  -r 

A 

— 1 — 

1 

E 

-+- 

i 

1 1 

1    1 

1       1   '1 

~~^   1 

a — ) 

[::ztn 

_ 

_ 

L_l — 1 

— I 1 

1 

1 

1 

...^ 

1 

1 

1 

Fig.  169. — Pseudo-diphtheria  followinor  measles.  The  chart  becrins  at  the  time  of  the  full  erup- 
tion in  a  severe  case  of  measles.  On  third  day  temperature  fell,  with  fading  eruption,  and 
child  seemed  convalescent.  With  secondary  rise  in  temperature,  the  tonsils,  which  before 
had  been  only  red,  showed  membranous  patches,  the  exudation  rapidly  spreading  until  the 
entire  pharynx  was  covered;  throat  symptoms  very  severe,  with  great  swelling  of  cervical 
glands,  but  the  membrane  did  not  extend  beyond  the  pharynx.  From  sixth  to  twelfth  day 
a  most  profound  septicsemia,  so  that  life  was  despaired  of.  The  patient  was  a  vigorous  child, 
and,  escaping  both  nephritis  and  pneumonia,  made  a  good  recovery.  Convalescence  quite 
rapid ;  no  sequelae.  Repeated  cultures  were  made  from  the  throat,  but  all  showed  only 
streptococci.     Patient  a  girl  four  years  old.     Case  observed  in  private  practice. 


from  laryngitis.  If  none  of  these  complications  develop,  patients  may 
withstand  the  toxic  symptoms  even  when  they  are  very  severe.  If  the  at- 
tack terminates  in  recovery,  the  local  disease  follows  very  much  the  same 
course  as  in  diphtheria.  The  subsequent  anaemia  is,  however,  less  severe, 
and  none  of  the  dangers  of  convalescence  connected  with  cardiac  or  respi- 
ratory paralysis  are  present. 

There  may  be  in  connection  with  the  local  process  in  the  throat,  deep 
sloughing  of  the  tonsils  or  adjacent  structures,  suppuration  of  the  lym- 


1006  THE  SPECIFIC   INFECTIOUS  DISEASES. 

phatic  glands  or  in  the  cellular  tissue  of  the  neck,  occasionally  followed  by 
serious  haemorrhage.  However,  all  these  complications  are  rare,  and  if  the 
patient  survives  the  danger  of  the  acute  stage  of  the  disease,  he  usually 
recovers. 

Diagnosis. — The  clinical  features  which  distinguish  pseudo-diphtheria 
from  true  di^jhtheria  have  already  been  considered  (page  974).  It  is  im- 
possible in  any  case  to  be  certain  of  the  diagnosis  except  by  cultures ;  for, 
although  by  clinical  symptoms  alone  one  may  in  the  great  majority  of 
cases  be  certain  that  a  given  case  is  one  of  true  diphtheria,  to  say  that  any 
membranous  inflammation  of  the  throat  is  not  diphtheria,  is  impossible. 
The  bacteriologists  have  taught  us  to  be  cautious  in  pronouncing  too 
positively  upon  even  the  mild  cases,  as  it  has  been  clearly  shown  that 
some  of  them  may  be  caused  by  the  most  virulent  of  diphtheria  bacilli 
(page  9G5). 

In  the  secondary  cases  the  diagnosis  by  clinical  symptoms  is  more 
accurate.  A  membrane  which  appears  in  the  throat  early  in  the  course 
of  measles  or  scarlet  fever,  or  at  the  height  of  the  primary  disease,  is  due 
to  the  streptococcus  in  at  least  four  cases  out  of  five ;  while  one  which 
develops  late  or  after  the  primary  fever  has  subsided,  is  generally  due  to 
the  diphtheria  bacillus. 

Prognosis. — There  is  no  more  striking  contrast  between  true  and 
pseudo-diphtheria  than  in  their  mortality  when  they  are  seen  side  by  side. 
Of  117  primary  cases  of  pseudo-diphtheria  observed  by  Park  in  the  Willard 
Parker  Hospital,  New  York,  the  mortality  was  3'5  per  cent ;  of  127  cases  of 
true  diphtheria  seen  in  the  same  institution  at  the  same  time,  the  mortality 
was  34'5  per  cent.  In  a  group  of  154  hospital  cases  reported  by  Baginsky, 
there  were  118  of  true  diphtheria,  with  a  mortality  of  38-2  per  cent,  and 
34  cases  of  primary  pseudo-diphtheria,  with  a  mortality  of  5-5  per  cent. 
From  the  same  hospital,  Philip  has  published  a  report  upon  376  cases : 
332  of  these  were  true  diphtheria,  with  a  mortality  of  37  per  cent ;  31  were 
cases  of  primary  pseudo-diphtheria,  with  no  mortality.  The  Bulletin  of 
the  New  York  Health  Department  contains  a  report  upon  324  cases  of 
pseudo-diphtheria  in  children,  with  a  mortality  of  9,  or  2*8  per  cent;  4  of 
the  fatal  cases  complicated  scarlet  fever ;  of  the  primary  cases,  the  mor- 
tality was  but  1-5  per  cent.  These  were  not  hospital  cases.  The  larynx 
is  very  seldom  involved  in  primary  cases,  and  unless  this  occurs,  they 
nearly  always  recover.  From  the  above  data  the  deduction  seems  war- 
ranted that  in  a  child  previously  healthy,  primary  pseudo-diphtheria  is 
not  a  serious  disease. 

Turning  now  to  the  secondary  cases,  we  find  a  very  diJfferent  state  of 
things.  Large  statistics  are  not  yet  available,  but  from  those  already 
published  it  would  appear  that  the  usual  mortality  of  pseudo-diphtheria, 
when  it  is  secondary  to  scarlet  fever  and  measles,  is  from  20  to  40  per  cent. 
However,  when  these  diseases   prevail  epidemically   in   institutions   for 


PSEUDO-DIPHTHERIA.  1007 

young  children,  the  mortality  not  infrequently  reaches  70  or  80  per  cent. 
Under  such  conditions  the  cases  complicating  measles  give,  as  a  rule,  a 
higher  mortality  than  those  complicating  scarlet  fever. 

Prophylaxis. — In  primary  cases  strict  quarantine  is  unnecessary  after 
the  question  of  diagnosis  has  been  settled.  However,  in  private  practice, 
healthy  children  should  be  excluded  from  the  sick-room  during  acute 
symptoms.  Cases  of  pseudo-diphtheria  occurring  in  measles  or  scarlet 
fever  should  certainly  be  separated  from  uncomplicated  cases.  By  way  of 
prevention,  something  can  be  done  in  these  diseases  by  keeping  both  nose 
and  throat  as  clean  as  possible  during  every  severe  attack,  by  the  use  of 
an  antiseptic  mouth-wash  or  gargle,  and  by  a  nasal  spray  or  even  nasal 
syringing.  For  young  children  only  weak  solutions  should  be  employed, 
such  as  a  diluted  Dobell's  or  Seller's  solution,  1 :  10,000  bichloride,  or  a  one- 
per-cent  solution  of  boric  acid.  For  those  who  are  older,  stronger  solutions 
may  be  used,  especially  as  a  gargle. 

Treatment. — Every  child  with  a  membranous  patch  on  its  throat  re- 
quires close  watching.  If  the  child  is  young — i.  e.,  under  ten  years  old — 
the  diphtheria  antitoxine  should  be  administered,  pending  the  result  of 
a  bacteriological  examination.  The  primary  cases  require  only  the  treat- 
ment of  attack  of  tonsillitis ;  the  child  should  be  put  to  bed,  the  bowels 
freely  opened,  and  the  diet  should  be  light  and  fluid.  If  old  enough 
he  should  gargle  five  or  six  times  a  day  with  some  one  of  the  solutions 
mentioned  above ;  but  with  younger  children  it  is  not  worth  while  to  per- 
sist in  any  attempts  at  local  treatment,  unless  the  case  is  manifestly  pro- 
gressing unfavourably,  when  the  treatment  should  be  the  same  as  in  the 
secondary  cases. 

The  occurrence  of  a  patch  upon  the  tonsil  of  a  child  with  scarlet  fever 
or  measles  should  be  the  signal  for  beginning  active  local  treatment.  If  the 
child  is  old  enough  so  that  it  can  be  done  without  force,  the  tonsils  should 
be  touched  three  times  a  day  with  a  solution  of  bichloride,  1  :  500,  with  a 
swab,  and  a  gargle  should  be  used  every  hour  during  the  day,  of  1  :  5,000 
bichloride,  or  a  saturated  solution  of  boric  acid.  If  there  is  a  nasal  dis- 
charge, the  nose  should  be  syringed  with  a  bland  solution,  as  in  true  diph- 
theria (page  987).  In  a  younger  child  forcible  swabbing  is  a  very  doubt- 
ful expedient.  It  is  usually  better  to  content  one's  self  with  syringing 
both  the  nose  and  the  mouth  with  bland  solutions.  The  frequency  with 
which  these  measures  are  used  will  depend  upon  the  severity  of  the  case. 
The  treatment  of  these  cases  by  the  "  streptococcus  antitoxine  "  has  not 
yet  reached  a  point  where  it  is  to  be  recommended. 

In  the  general  management  of  these  cases,  feeding,  stimulants,  etc.,  the 
same  plan  is  to  be  followed  as  in  diphtheria. 


65 


1008  THE  SPECIFIC   INFECTIOUS  DISEASES. 


CHAPTER   IX. 
TYPHOID  FEVER. 

Typhoid  fever  is  an  acute  infectious  disease  due  to  a  specific  germ — 
Eberth's  bacillus — which  is  abundantly  present  in  the  intestinal  discharges 
of  affected  persons.  It  is  very  rare  in  infancy,  but  is  not  infrequent  in 
childhood.  As  compared  with  the  same  disease  in  adults,  the  typhoid 
of  childhood  is  characterized  by  its  shorter  duration,  milder  course,  the 
infrequency  of  serious  complications,  and  its  low  mortality. 

Etiology. — Age. — I  have  never  seen  typhoid  fever  in  a  child  under 
two  years  old,  and  I  believe  it  to  be  very  rare,  although  undoubted  cases 
have  been  reported  even  during  the  first  year.  Murchison  records  one  only 
six  montlis  old,  and  Ogle  another  four  and  a  half  months  old,  the  diag- 
nosis being  confirmed  by  autopsy  in  both  instances.  No  case  of  typhoid 
was  seen  in  the  New  York  Infant  Asylum  during  my  eight  years'  service 
there,  about  ten  thousand  cases  of  illness  having  been  treated  during  the 
period,  and  over  seven  hundred  autopsies  made.  In  seven  years  but  one 
case  was  admitted  to  the  Babies'  Hospital,  this  being  in  a  child  over  two 
years  old.  In  over  two  thousand  autopsies — chiefly  upon  children  under 
two  years  old — made  at  the  New  York  Foundling  Asylum,  Northrup  did 
not  meet  with  a  single  case  of  typhoid,  nor  was  one  known  to  have  oc- 
curred in  that  institution  for  twenty  years.  The  exceptional  cases  in 
infancy  have  almost  invariably  been  observed  in  general  epidemics.  In 
an  epidemic  in  Montclair,  N.  J.,  in  1894,  115  persons  were  attacked,  3 
of  these  being  under  two  years  old.  In  a  severe  epidemic  in  Stamford,. 
Conn.,  in  1895,  406  persons  were  attacked,  4  being  children  under  two 
years  old. 

After  the  second  year  typhoid  is  by  no  means  rare,  but  it  is  not  until 
after  the  fifth  year  that  it  can  be  said  to  occur  frequently.  The  following 
figures,  embracing  groups  of  cases  reported  by  eight  writers,  represent 
perhaps  as  well  as  statistics  can  the  relative  frequency  with  which  the 
disease  is  seen  at  the  different  ages :  Of  970  cases,  8  per  cent  occurred 
under  five  years,  43  per  cent  between  five  and  ten  years,  and  50  per  cent 
between  ten  and  fifteen  years. 

Typhoid  is  almost  invariably  contracted  by  drinking  water  or  milk 
which  contains  the  germs  of  the  disease.  It  is  not  within  the  scope  of 
this  article  to  discuss  the  manifold  ways  in  which  this  may  occur. 
The  epidemics  of  Montclair  and  Stamford,  already  referred  to,  were 
definitely  traced  to  infected  milk.  The  infrequency  of  typhoid  in  in- 
fants is  explained,  in  part  at  least,  by  the  fact  that  most  of  the  water 
and  a  large  part  of  the  milk  taken  have  previously  been  boiled,  or  at 


TYPHOID   FEVER.  1009 

least  heated.  In  cases  where  the  period  of  incubation  could  be  deter- 
mined with  something  approaching  accuracy,  this  has  varied  between  five 
days  and  three  weeks. 

Lesions. — Typhoid  in  young  children  is  so  seldom  fatal  that  oppor- 
tunities for  a  study  of  the  lesions  have  been  limited.  In  a  general  way  the 
lesions  resemble  those  of  adults  except  in  severity.  There  is  acute 
swelling  of  Peyer's  patches,  especially  in  the  lower  ileum,  and  of  the  soli- 
tary follicles  of  the  small  intestine  and  the  colon,  which  may  be  followed 
by  ulceration.  There  are  frequently  present  the  evidences  of  a  mild  catar- 
rhal enteritis.  The  mesenteric  glands  are  swollen  and  the  spleen  is  enlarged 
and  soft. 

The  intestinal  lesions  are,  as  a  rule,  much  less  severe  than  in  adults; 
in  a  considerable  number  of  the  cases  this  process  does  not  go  on  to  ulcera- 
tion ;  and  when  ulcers  form  they  are  seldom  large  or  deep,  and  perforation 
is  very  rare.  MontmoUin  gives  the  following  facts  concerning  23  autop- 
sies, most  of  them,  however,  being  in  children  over  eight  years  old  :  ulcers 
were  present  in  17  cases;  they  were  situated  in  the  lower  ileum  in  16, 
and  in  10  they  were  only  there ;  in  the  ascending  colon  in  9,  and  only 
there  in  one  case ;  in  one  other  case  they  were  in  the  transverse  colon, 
and  in  another  they  extended  to  the  sigmoid  flexure ;  perforation  oc- 
curred in  3  cases,  in  every  instance  in  the  lower  ileum.  In  35  autopsies 
by  Reimer,  ulcers  were  noted  in  30,  and  in  3  there  was  perforation.  The 
autopsies  made  upon  young  children  show  even  less  severe  intestinal  lesions 
than  those  mentioned.  In  fact,  some  cases  in  which  the  clinical  diagnosis 
was  beyond  question,  have  shown  only  moderate  redness  and  swelling  of 
Peyer's  patches,  the  solitary  follicles  and  tlie  mesenteric  lymph  nodes, — 
lesions  which  are  exceedingly  frequent  in  cases  of  simple  diarrhoea, 
as  my  own  experience  has  abundantly  demonstrated.  It  should  be  empha- 
sized that  in  a  doubtful  case  such  jDost-mortem  findings  do  not  establish 
the  diagnosis  of  typhoid.  Indeed,  they  prove  nothing  unless  cultures 
from  the  intestinal  contents,  the  mesenteric  glands,  or  other  organs,  show 
the  typhoid  bacillus.  From  a  consideration  of  the  clinical  course  of  the 
disease,  it  seems  very  probable  that  in  a  large  proportion  of  the  cases  which 
recover,  ulceration  does  not  take  place.  Enlargement  of  the  spleen  is  prac- 
tically constant.  The  degenerative  changes  in  the  heart,  the  kidneys,  and 
the  liver  are  much  less  frequent  and  generally  less  severe  than  in  adults. 
The  lesions  of  other  organs  will  be  considered  under  Complications. 

Symptoms, — The  peculiar  features  of  typhoid  in  early  life  are  seen  only 
in  children  under  ten  years  old;  for  after  this  time  the  disease  does  not 
differ  essentially  from  the  adult  type.  In  brief,  the  typhoid  of  early  child- 
hood may  be  characterized  as  a  fever  more  often  with  nervous  symiatoms, 
than  with  intestinal  symptoms. 

Onset. — A  sudden  onset  with  well-marked  symptoms — fever,  prostration, 
vomiting,  etc. — is  not  uncommon ;  in  fact,  it  is  quite  as  frequently  seen  as 


1010  THE  SPECIFIC   INFECTIOUS  DISEASES. 

the  insidious  beginning  with  lassitude,  headache,  coated  tongue,  anorexia, 
and  gradual  rise  in  temperature.  In  cases  developing  abruptly  it  often 
appears  as  if  an  acute  indigestion  had  been  the  means  of  precipitating  the 
attack.  The  most  frequent  initial  symptom  is  vomiting ;  a  chill  is  rare. 
I  have  once  known  the  disease  to  be  ushered  in  by  convulsions,  but  this 
is  very  exceptional.  Epistaxis  occurs  as  an  early  symptom  rather  less  fre- 
quently than  in  adults. 

Co)idition  of  the  hoioels. — There  is  no  constant  relation  between  the 
severity  of  the  intestinal  lesions  and  the  condition  of  the  bowels.  Taking 
large  groups  of  cases  together,  diarrhoea  is  present  in  about  half  the  num- 
ber. Morse's  *  observations,  however,  upon  children  under  ten  years  old 
showed  that  constipation  was  present  in  two  thirds,  and  diarrhoea  in  only 
one  third  of  the  cases.  The  diarrhoea  is  rarely  profuse,  from  two  to  four 
discharges  a  day  being  the  average.  The  appearance  of  the  stools  is  sel- 
dom characteristic ;  they  are  usually  thin  and  fluid,  often  containing  mu- 
cus. Constipation  may  be  present  at  the  beginning  only,  or  it  may  persist 
throughout  the  attack.  Tympanites  is  generally  moderate  in  degree,  and 
is  often  entirely  absent ;  it  usually  accompanies  constipation.  Marked 
iliac  tenderness  and  gurgling  are  infrequent. 

Spleen. — By  the  end  of  the  first  week  this  is  almost  invariably  found 
to  be  enlarged  to  a  sufficient  degree  to  be  recognised  by  palpation  (page 
832),  unless  a  satisfactory  examination  can  not  be  made  owing  to  the 
presence  of  tympanites  or  the  extreme  irritability  of  the  childo  Usually 
the  spleen  extends  but  an  inch  or  an  inch  and  a  half  below  the  ribs,  but  at 
times  it  may  be  three  inches  or  more.  Swelling  of  the  spleen  is  an  impor- 
tant symptom  not  only  for  diagnosis,  but  also  for  prognosis  ;  its  persistence 
always  indicates  that  the  disease  is  not  at  an  end  even  though  the  tem- 
perature has  reached  the  normal,  and  a  relapse  should  be  exjiected. 

Eruption. — It  is  the  experience  of  nearly  all  who  have  seen  much  of 
typhoid  in  children  that  the  eruption  is  less  constant,  less  abundant,  and 
less  characteristic  than  in  adults.  Of  670  cases  in  Morse's  collection,  it 
was  noted  in  but  60  per  cent.  The  typical  eruption  consists  of  small, 
scattered,  rose-coloured  spots,  which  appear  chiefly  or  solely  upon  the 
abdomen  at  the  beginning  of  the  second  week.  They  come  in  successive 
crops,  each  one  of  which  generally  lasts  three  days,  the  whole  duration 
of  the  eruption  being  about  a  week.  The  eruption  reappears  in  most 
cases  in  which  relapses  occur. 

Prostration.,  emnciation,  etc. — As  a  rule  the  prostration  is  quite  suffi- 
cient to  keep  a  child  in  bed  after  the  first  few  days.  The  general  weak- 
ness after  this  time  is  in  direct  i:)roportion  to  the  height  of  the  tempera- 

*  Typhoid  Fever  in  Childhood,  with  an  Analysis  of  284  Cases ;  Boston  Medical  and 
Surgical  Journal,  February  27,  1896.  In  this  article,  to  which  I  am  indebted  for  many 
statistics,  will  be  found  quite  a  full  bibliography  of  the  subject. 


TYPHOID  FEVER. 


1011 


ture.     Loss  of  flesh  is  steady  and  usually  marked ;  and  in  a  prolonged 
attack  there  is  marked  emaciation. 

Temperature. — In  the  cases  with  a  gradual  onset,  the  typical  tempera- 
ture curve  is  one  which  rises  steadily  for  from  two  to  seven  days,  fluctuates 
within  the  limits  of  one  to  three  degrees  during  the  second  week,  and 
steadily  declines  during  the  third  week,  reaching  the  normal  on  the  aver- 
age at  the  end  of  the  third  week.  In  cases  with  an  abrupt  onset,  the  tem- 
perature rises  at  once  to  from  102-5°  to  105°  F.,  but  subsequently  may 
run  the  same  course  as  in  the  first  group. 

The  following  are  the  most  important  variations  from  the  temperature 
curve  of  adults :  The  initial  rise  is  much  more  frequently  rapid  ;  during 
the  second  week  the  re- 
mittent character  is  less 
marked,  this  probably  de- 
pending upon  the  fact  that 
ulceration  is  less  frequent 
and  less  extensive  ;  the  aver- 
age duration  is  shorter.  In 
young  children  the  propor- 
tion of  cases  in  which  the 
fever  lasts  only  from  eight 
to  fourteen  days  is  quite 
large  (Fig.  170).  In  Wol- 
berg's  *  277  cases,  the  dura- 
tion of  the  fever  was  four- 
teen days,  or  less  in  70  per 
cent  of  the  cases,  and  eight  days  or  less  in  2-8  per  cent.  Of  this  series, 
60  per  cent  of  the  children  were  eight  years  old  or  under.  In  a  series 
of  295  cases  reported  by  Montmollin,  most  of  which  were  in  children 
over  eight  years  old,  the  disease  lasted  over  three  weeks  in  30  per  cent. 
The  same  peculiarity  is  brought  out  by  Morse's  figures:  not  counting 
relapses,  the  average  duration  of  75  cases  under  ten  years  old  was  19-3 
days ;  of  202  cases  from  ten  to  fifteen  years  old,  it  was  22G  days.  After 
the  age  of  ten  years  the  type  of  the  fever  is  much  like  that  seen  in 
adults.  The  maximum  temperature  in  the  mild  cases  is  103°  or  104°  F. ; 
in  the  severe  ones  it  often  reaches  105°  or  106°  F.,  but  rarely  goes 
above  this  point.  The  range  is  usually  higher  than  in  adult  cases  of 
the  same  severity.  Typhoid  is  about  the  only  disease  where  the  tempera- 
ture runs  higher  in  older  than  in  younger  children.  At  the  beginning  of 
convalescence  a  subnormal  temperature  is  very  frequent,  and  by  many 
writers  is  considered  to  be  the  rule.  A  secondary  rise  is  most  frequently 
due  to  errors  in  diet,  but  may  occur  from  the  development  of  complica- 


DAY 

104° 
103° 

^102° 

z       ^ 

S  101 

I 

"-  100 

1 

2      3 

i 

5 

C 

7 

S 

9 

10 

11 

12 

13 

k 

T\ 

A 

/^ 

^ 

1 

V 

,  j 

f 

\ 

\ 

^ 

/ 

\ 

*^ 

99° 
98° 
97" 

1 

V 

V 

k 

\ 

L 

-^ 

\ 

Fig.  170. — Typhoid  fever  of  short  duration  in  a  child 
thirteen  mouths  old.  Spleen  enlarged ;  eruption  typi- 
cal ;  no  diarrh(jea  and  only  moderate  abdominal  dis- 
tention. Tliere  were  two  other  cases  in  the  family, 
all  beinsj  due  to  the  same  cause — infected  milk.  (After 
Northrup.) 


*  Jahrbuch  f  iir  Kiiiderheilkunde,  Bd.  xxvii,  S.  28. 


1012 


THE   SPECIFIC   INFECTIOUS   DISEASES. 


tions.     A  siulden  fall  indicates  either  perforation  or  intestinal  hasmor- 
rhage. 

Relapses  are  not  infrequent;  they  were  present  in  11  per  cent  of  284 
cases  reported  by  Morse,  and  in  8-4  per  cent  of  533  cases  collected  by  him. 
They  follow  about  the  same  course  as  in  adults.  The  interval  between  the 
attacks  varies  from  two  days  to  two  weeks.  The  relapse  is  usually  shorter 
than  the  primary  fever,  but  is  characterized  by  a  reappearance  of  the  erup- 
tion and  most  of  the  previous  symptoms  (Fig.  171). 


DAY         1  8  1  9  ]lO    n|l2]l3llJ    15|io|t7   18    10   2o[^M"i'^  2^jM|20j27|28|29|3u|3l|32|3J|3■l|3j|30    37    38|39|40|4l|42|43| 

b 

I 

z 

o: 

z 

^.....t.EME.E.t-    i-.-    e.e.,...    ,.    E-    £..>.■!-.-.-.   -e-    .-...-.«    E.l-    .-    t-.   -.«€-.-    . 

'!?o 

^"AS/Vr^I                                                           Jts^^     -. 

Z°      ^  ^r                ^^^^^Jsv   t  1  >-h 

iff              I     J              iV  ^^tt     A  iJlt 

Z\               X      7u                                   ^^tl\\ 

Z             4  ff-^v  a  ^                       ^/ '  H>v , 

i"          ^^     \    ^                   ir^M/v^^ 

\^       1'-                                      _y\p 

Fig.  171. — Typhoid  fever  with  relapse.  Child  two  and  a  half  years  old ;  early  temperature  high 
and  syiiiptoins  typical ;  natural  fall  on  fourteenth  day ;  rise  on  seventeenth  day  apparently 
due  to  otitis;  relapse  on  twenty-fourth  day,  with  fresh  eruption  and  return  of  splenic  swell- 
ing which  had  disappeared.  Temperature  was  subnormal  at  the  end  both  of  primary  and 
secondary  fever. 

Nervous  symptoms. — As  a  rule,  these  are  more  prominent  in  severe 
cases  than  the  intestinal  symptoms,  and  are  directly  proportionate  to  the 
height  of  the  temperature.  The  extreme  nervous  symptoms  belonging  to 
the  typhoid  state  in  adults — subsultus  tendinum,  carphologia,  and  coma 
vigil,  with  the  dry  glazed  tongue,  etc. — are  rare  in  childhood,  and  when 
present  are  generally  in  patients  over  ten  years  old.  Headache  and  mild 
delirium  at  night  are  very  frequent,  the  former  being  seen  in  the  majority 
of  cases.  Young  children  are  usually  dull,  apathetic,  and  often  in  a  state 
of  semi-stupor.  Occasionally  the  disease  may  closely  simulate  meningitis. 
There  may  be  general  hyperesthesia,  delirium  or  stupor,  opisthotonus, 
contracted  or  unequal  pupils  and  strabismus ;  but  very  seldom  convul- 
sions. The  nervous  symptoms  are  usually  most  severe  in  the  second,  or 
early  in  the  third  week,  and  subside  as  the  temperature  declines. 

Pulse. — This  is  increased  in  frequency,  but  not  to  the  degree  that 
is  seen  in  most  diseases  of  childhood  with  a  similar  elevation  of  tempera- 
ture. The  force  and  rhythm  of  the  pulse  are  usually  good,  irregularity, 
very  low  tension,  and  dicrotism  being  rare  as  compared  with  adults;  they 
may  occur  either  at  the  height  of  the  disease  or  during  convalescence. 
Functional  heart  murmurs  are  quite  frequent. 

Intestinal  hmmorrhage. — Of  946  collected  cases,  mainly  from  hospital 
reports,  intestinal  haemorrhage  occurred  in  30,  or  about  three  per  cent ; 
the  majority  of  these  were  in  children  over  ten  years  old.  Thus  Morse 
reports  that  in  77  cases  under  ten  years  old  there  was  no  case  of  haemor- 


TYPHOID   FEVER.  1013 

» 

rhage ;  while  in  204  cases  between  ten  and  fifteen  years  it  was  seen  in  9 
cases.  Tlie  most  frequent  time  of  its  occurrence  is  toward  the  end  of  the 
second  week.  Moutmollin  reports  14  cases  of  haemorrhage,  with  4  deaths ; 
in  Morse's  9  cases  there  were  5  deaths. 

Intestinal  perforation. — This  is  even  more  rare  than  hasmorrhage.  In 
1,028  collected  cases,  this  accident  occurred  but  twelve  times,  or  in  I'l 
per  cent.  Eight  of  these  proved  fatal.  Perforation  is  indicated  by  a  sud- 
den fall  in  the  temperature,  with  collapse ;  usually  there  is  vomiting  and 
the  rapid  development  of  tympanites.  The  infrequency  of  both  perfora- 
tion and  haemorrhage  is  explained  by  the  superficial  character  of  the  in- 
testinal lesions  and  the  absence  of  deep  ulceration. 

Complications  and  Sequelae. — The  complications  of  typhoid  in  early 
life  are  infrequent  and  usually  mild.  Bronchitis  is  present  in  most  of  the 
severe  cases.  Pneumonia  was  noted  in  9  per  cent  of  seven  hundred 
cases,  reported  by  various  authors.  Both  serous  and  purulent  effusions 
into  the  chest  are  occasionally  seen,  and  less  frequently  abscess  of  the  lung. 
Gangrene  of  the  lung,  and  severe  inflammation  or  ulceration  of  the  larynx 
are  extremely  rare. 

A  small  amount  of  albumin  is  found  in  the  urine  in  most  of  the  severe 
cases  at  the  height  of  the  disease,  but  a  marked  degree  of  nephritis  is  in- 
frequent. It  was  seen  but  three  times  in  295  cases  reported  by  'Mout- 
mollin. 

Complications  referable  to  the  nervous  system  are  not  very  frequent, 
but  are  of  much  interest.  Meningitis  is  extremely  rare.  Morse  has  col- 
lected twenty-one  cases  of  aphasia,  in  two  of  which  it  was  clearly  due  to 
embolism ;  in  the  remainder,  however,  it  apparently  was  not  dependent 
upon  any  organic  lesion.  In  two  thirds  of  the  cases  it  came  on  during 
convalescence,  and  in  nearly  all  complete  recovery  occurred  after  an  aver- 
age duration  of  three  weeks.  Aphasia  usually  follow^ed  a  severe  type  of 
the  disease,  and  in  most  of  the  cases  was  not  accompanied  by  any  other 
paralysis  or  by  mental  disturbance.  Insanity  is  a  rare  sequel  of  typhoid  in 
children,  the  usual  type  being  acute  mania.  Adams  (Washington)  has 
recently  reported  two  examples  of  this,  both  terminating  in  recovery. 
Chorea  is  not  an  infrequent  sequel,  and  is  seen  rather  oftener  than  after 
the  other  infectious  diseases.  In  most  of  the  series  of  reported  cases  no 
mention  is  made  of  multijile  neuritis  as  a  sequel  of  typhoid,  but  it  is  cer- 
tainly not  very  rare. 

Otitis  is  not  an  infrequent  complication,  occurring  much  oftener  than 
in  adults.  It  is  principally  seen  in  young  children  and  during  the  cold 
season.  Among  the  less  frequent  complications  may  be  mentioned  :  paro- 
titis, which  is  usually  suppurative  and  is  seen  in  septic  cases ;  abscess  of 
the  liver,  examples  of  which  have  been  reported  by  Bokai,  Asch,  and 
others;  gangrenous  inflammation  of  the  mouth  or  genitals;  pericarditis, 
endocarditis,  and   peritonitis,  suppurative  inflammations  of  joints,  mul- 


1014  THE  SPECIFIC  INFECTIOUS  DISEASES. 

tiple  abscesses  and  furunculosis.  Tuberculosis  of  the  luugs  or  bones  not 
infrequently  follows  tyjahoid. 

Diagnosis. — The  diagnostic  symptoms  of  typhoid  are  the  continuous 
fever,  the  eruption,  tympanites,  and  enlargement  of  the  spleen.  Unless 
the  first  two  are  present  the  case  must  be  regarded  as  doubtful.  One 
should  be  very  slow  to  make  the  diagnosis  of  typhoid  in  a  child  under 
three  years  old,  unless  the  disease  is  ej)idemic.  The  great  proportion  of 
sporadic  cases  reported  as  occurring  in  infancy  are  probably  not  typhoid. 
After  the  fifth  year  the  disease  is  more  frequent,  and  its  symptoms  in 
general  resemble  those  of  adults,  except  in  severity. 

The  diSerential  diagnosis  is  to  be  made  from  malarial  fever,  ileo-colitis, 
meningitis,  tuberculosis,  and  from  other  ill-defined  continuous  fevers  of 
unknown  origin.  From  malarial  fever  the  diagnosis  is  to  be  made  by  the 
temperature  curve,  the  plasmodium  in  the  blood,  and  the  effect  of  quinine. 
In  most  of  the  cases  of  malaria  the  temperature  will  be  found  to  touch 
the  normal  at  some  time  in  the  twenty-four  hours.  While  the  presence  of 
the  Plasmodium  in  the  blood  is  conclusive,  its  absence  is  not  so.  The 
administration  of  full  doses  of  quinine  is  a  diagnostic  test  of  much  prac- 
tical importance;  an  irregular  or  remittent  fever  which  yields  promptly 
to  quinine  is  most  certainly  not  typhoid. 

Ileo-colitis  and  typhoid  fever  are  not  often  confounded.  The  former 
is  almost  limited  to  the  first  three  years  of  life,  a  time  when  typhoid  is  ex- 
tremely rare.  The  intestinal  symptoms  of  ileo-colitis  are  marked  even 
though  the  temperature  is  not  high,  and  they  are  altogether  more  severe 
than  is  usual  in  typhoid  ;  while  enlargement  of  the  spleen,  tympanites, 
and  the  eruption  are  not  present. 

The  cerebral  symptoms  of  typhoid  may  be  difficult  to  distinguish  from 
meningitis,  unless  one  has  watched  their  development.  Irregular  respira- 
tion, a  slow,  irregular  pulse,  localized  paralysis  and  complete  coma  are 
seldom,  if  ever,  seen  in  typhoid,  and  a  retracted  abdomen  very  rarely,  while 
the  enlarged  spleen  and  the  peculiar  eruption  are  not  seen  in  meningitis. 
In  typhoid  with  pronounced  nervous  symptoms  the  temperature  is  usually 
higher  than  in  meningitis. 

General  tuberculosis  very  often  resembles  typhoid  so  closely  that  a 
differential  diagnosis  is  almost  impossible  until  local  signs  of  tuberculosis 
have  appeared,  usually  in  the  lungs.     (See  page  1036.) 

WidaVs  serum-test. — This  consists  in  the  "  clumping  "  and  immobiliz- 
ing of  typhoid  bacilli  in  broth  cultures,  caused  by  the  blood  serum  of  a 
person  sick  with  typhoid  fever.  This  blood  test,  although  but  recently 
introduced,  has  already  been  shown  to  possess  great  value  in  making  the 
diagnosis  of  typhoid,  the  characteristic  reaction  being  obtained  after  the 
first  week  in  the  great  majority  of  cases  of  this  disease.  As  it  has  been 
found,  although  very  exceptionally,  in  other  conditions,  it  can  not  be  re- 
garded as  an  infallible  test.     (See  Biggs  and  Park,  Amer.  Jour,  of  the 


TYPHOID  FEVER.  1015 

Med.  Sci.,  March,  1897  ;  also,  Brannan,  K  Y.  Med.  Jour.,  March  37, 1897, 
for  a  full  discussion  of  the  subject,  with  references  to  the  recent  literature.) 

Prognosis. — Of  2,G23  cases  collected  from  the  reports  of  twelve  differ- 
ent writers,  the  mortality  was  5'4  per  cent.  These  are,  however,  almost 
all  taken  from  hospital  reports,  where  as  a  rule  the  mildest  cases  are  not 
brought  for  treatment.  The  mortality  of  the  disease  in  children,  includ- 
ing all  cases,  probably  does  not  exceed  3  or  4  per  cent.  Death  seldom 
occurs  from  the  disease  itself,  but  usually  from  some  accident  or  compli- 
cation ;  the  most  frequent  causes  of  death  are  pneumonia  and  intestinal 
haemorrhage  or  perforation.  Occasionally  death  results  from  general  sep- 
sis with  2:)arotitis,  bed  sores,  nephritis,  meningitis,  or  heart  paralysis.  The 
most  fatal  period  is  the  third  week. 

Treatment. — The  low  mortality  of  this  disease  shows  how  successful  all 
methods  of  treatment  are  likely  to  be  considered.  In  the  great  majority 
of  cases  very  little  active  treatment  is  required.  Every  patient  with  ty- 
phoid should  be  put  to  bed  and  kept  there  during  the  febrile  period,  and 
a  few  days  beyond  it,  no  matter  how  mild  the  attack  may  be.  A  fluid  diet 
also  should  be  prescribed  in  every  case,  preferably  milk  which  should  be 
given  regularly  every  three  hours,  and  not  pushed  greatly  beyond  the  de- 
sires of  the  patient.  Milk  may  be  diluted  or  partially  peptonized,  and 
kumyss  or  matzoon  may  be  substituted  for  it  if  the  stomach  is  irritable. 
Plenty  of  water  should  be  allowed,  unless  it  disturbs  the  stomach. 

The  discharges  should  be  immediately  and  thoroughly  disinfected  by 
a  solution  of  carbolic  1 :  20.  If  the  movements  are  in  a  chamber  or  a 
bed-pan  they  should  be  covered  with  this  solution  for  at  least  six  hours 
before  they  are  thrown  into  the  water  closet.  If  napkins  or  diapers  are 
used,  they  should  be  soaked  in  some  efficient  antiseptic  solution  for 
twelve  hours  and  then  thoroughly  boiled.  Sheets  stained  by  discharges 
should  be  treated  in  the  same  way,  and  all  bed-linen  should  be  boiled 
for  two  hours  apart  from  the  washing  of  the  family.  Aside  from 
these  general  measures  the  treatment  of  the  disease  is  the  treatment  of 
symptoms. 

Diarrhoea  calls  for  treatment  only  when  the  movements  exceed  four  or 
five  in  twenty-four  hours.  If  no  more  than  tliis  number  are  present,  they 
should  not  be  interfered  with.  Opium  and  bismuth  are  undoubtedly  the 
best  means  for  controlling  excessive  diarrhoea,  but  care  should  be  taken 
that  they  are  not  pushed  to  the  degree  of  inducing  constipation. 

Constipation  may  be  relieved  by  small  doses  of  the  salines,  or  an  occa- 
sional dose  of  castor  oil,  but  all  active  purgation  should  be  avoided.  In 
many  cases  daily  irrigation  of  the  colon  with  tepid  water  is  better  than 
anything  else.  On  the  whole,  constipation  is  more  troublesome  to  con- 
trol than  diarrhoea. 

Tympanites  is  rarely  severe  enough  to  require  treatment;  it  may  be 
relieved  by  turpentine  stupes,  by  a  glycerin  suppository,  or  a  small  glycerin 


1016  THE  SPECIFIC   INFECTIOUS  DISEASES. 

injection  (one  teaspoonful  of  glycerin  to  two  ounces  water),  or,  better  still, 
by  the  use  of  the  rectal  tube. 

Whenever  the  temperature  goes  above  103°  F.,  antipyretic  measures 
are  indicated.  In  mild  cases,  sponging  with  cold  water  or  with  alcohol 
and  tepid  water,  equal  parts,  is  generally  sufficient.  In  cases  which  do 
not  yield  to  such  measures,  baths  should  be  employed.  For  young  chil- 
dren the  graduated  bath  (page  48)  should  be  used;  for  those  who  are 
older  the  bath  should  be  from  ?5°  to  85°  F.,  its  duration  depending  upon 
the  amount  of  reduction  affected.  The  body  should  be  actively  rubbed 
during  the  bath  to  prevent  shock  and  cardiac  depression.  The  only  contra- 
indications to  the  bath  are  extreme  prostration  with  great  cardiac  weak- 
ness, or  the  existence  of  intestinal  haemorrhage.  The  ease  with  which  the 
cold  bath  can  be  employed  in  children  makes  it  especially  valuable.  The 
cold  pack  (pages  47  and  48)  may  be  substituted  for  the  bath  where  circum- 
stances make  the  latter  impracticable.  The  bath  or  pack  should  be  repeated 
in  an  average  case  in  from  two  to  four  hours,  or  whenever  the  temperature 
has  risen  to  103°  F.  The  method  of  applying  cold  which  causes  the  least 
disturbance  to  the  patient  is  the  one  which  should  always  be  selected. 

The  milder  nervous  symptoms — headache,  restlessness,  sleeplessness, 
etc. — may  be  relieved  by  an  occasional  dose  of  phenacetine,  either  alone  or 
in  combination  with  the  bromides,  or  by  cold  or  tepid  sponging ;  the 
more  severe  ones  usually  occur  with  high  temperature,  and  are  best  con- 
trolled by  the  cold  bath. 

Stimulants  in  most  of  the  cases  are  not  called  for.  They  are  to  be 
given  according  to  the  indications  afforded  by  the  pulse,  the  first  sound 
of  the  heart,  and  the  child's  general  condition.  They  are  seldom  needed 
earlier  than  the  middle  of  the  second  week ;  they  should  be  well  diluted. 
Brandy  or  whisky  is  to  be  preferred  to  wines,  and,  unlike  the  milk,  they 
may  be  given  at  frequent  intervals  whenever  the  patient  will  take  them 
best.  Intestinal  haemorrhage  calls  for  absolute  quiet,  morphine  hypoder- 
mically,  and  turpentine  or  ergotine  by  the  mouth.  Intestinal  perforation 
is  to  be  treated  by  hypodermics  of  morphine. 


CHAPTER  X. 

TUBERCULOSIS. 

Tuberculosis  is  an  infectious  communicable  disease,  now  universally 
admitted  to  be  due  to  the  bacillus  tuberculosis  of  Koch.  It  may  be  local 
or  general,  and  may  involve  any  organ  and  almost  any  structure  in  the 
body. 

Etiology. — Frequency. — Miiller,  in  500  autopsies  upon  children  in 
Munich,  found   tuberculosis  in  40  per  cent  of  the  cases ;  in  30  per  cent 


TUBERCULOSIS.  1017 

death  was  due  to  tuberculosis,  and  in  the  remaining  10  per  cent  tubercu- 
losis was  found  at  autopsy  in  jiatients  dying  from  other  diseases.  I  do  not 
think  it  is  so  frequent  in  this  country,  for,  of  726  consecutive  autopsies  in 
the  New  York  Infant  Asylum,  tuberculosis  was  found  in  only  58,  or  8  per 
cent  of  the  cases ;  6  per  cent  of  the  deaths  were  due  to  tuberculosis,  and  in 
2  per  cent  the  children  died  from  other  diseases.  Of  319  consecutive  autop- 
sies in  the  Babies'  Hospital,  tuberculosis  was  found  in  44,  or  14  per  cent. 

Predisposing  causes. — The  predisposition  to  tuberculosis  is  general  or 
local.  General  predisposition  may  be  inherited  directly  from  parents  who 
have  themselves  suffered  from  tuberculosis,  or  from  those  who,  in  conse- 
quence of  syphilis,  alcoholism,  or  any  other  constitutional  vice,  have  trans- 
mitted a  feeble  constitution  to  their  children.  Inherited  predisposition  is 
exceedingly  common,  and  really  signifies  a  diminished  resistance  of  the 
cells  of  the  body  to  tuberculous  infection.  It  should  be  distinguished 
from  the  very  exceptional  condition  of  congenital  tuberculosis,  where  in- 
fection takes  place  before  birth.  General  predisposition  includes  the 
child's  surroundings,  in  so  far  as  they  affect  the  constitution  and  lower 
the  general  vitality.  Children  reared  in  the  city,  either  in  institutions 
or  in  crowded  tenements,  are  more  frequently  affected  than  those  who 
have  had  the  advantage  of  the  best  surroundings,  not  only  because  of  their 
increased  chances  of  exposure,  but  also  from  their  feebler  resistance. 
Marasmus,  intestinal  diseases,  and,  in  fact,  any  debilitating  general  or 
local  disease,  may  predispose  to  tuberculosis. 

A  local  predisposition  is  created  by  any  pathological  condition  of  the 
mucous  membranes  or  organs  most  exposed  to  infection.  The  most  im- 
portant are  repeated  attacks  of  bronchitis,  broncho-pneumonia,  or  pleurisy, 
and  chronic  catarrhal  inflammation  of  the  mucous  membrane  of  the  nose  or 
pharynx,  so  frequently  associated  with  enlarged  tonsils  or  adenoid  growths 
of  the  pharynx.  Much  less  frequently  the  local  predisposition  is  the  result 
of  some  previous  disease  of  the  intestines. 

The  role  played  by  other  diseases  in  the  development  of  tuberculosis  is 
an  important  one,  and  until  recently  but  little  understood.  In  a  very 
large  number  of  cases  tuberculosis  develops  as  a  sequel  of  one  of  the 
acute  infectious  diseases,  particularly  measles,  pertussis,  or  epidemic  in- 
fluenza. In  such  cases  there  has  probably  existed  previously  a  latent  tuber- 
culosis, usually  in  the  bronchial  lymph  nodes.  This  process,  sometimes 
long  quiescent,  under  the  stimulus  of  a  new  infection  may  be  awakened  to 
activity.  It  is  to  be  noted  that  it  is  the  infectious  diseases  that  are  in- 
timately associated  with  pulmonary  complications,  which  are  liable  to  be 
followed  by  tuberculosis. 

Age. — No  age  is  exempt  from  tuberculosis.  It  was  formerly  believed 
that  the  disease  was  rare  in  infancy,  but  recent  observations  have  shown 
that,  although  its  form  is  somewhat  different,  it  is  more  frequent  in  in- 
fancy than  at  any  period  of  later  childhood.     Statistics,  taken  chiefly  from 


1018  THE  SPECIFIC  INFECTIOUS  DISEASES. 

two  institutions  where  children  up  to  four  years  of  age  are  received,  give 

the  following  results,  the  diagnosis  being  confirmed  by  autopsy  in  nearly 
every  case  under  two  years  old : 

Under  three  months 5  cases 

From  three  to  six  months 21  " 

"       six  to  twelve  months 31  " 

"       twelve  to  eighteen  months 29  " 

"       eighteen  to  twenty-four  months 10  " 

•'       two  years  to  five  years 32  " 

Over  five  years 15 

Total 143    " 

It  will  be  seen  that  the  first  year  furnished  57  cases,  the  second  year 
39,  and  the  succeeding  three  years  but  32  cases. 

Mode  of  infection.— The  possibility  of  intra-uterine  infection,  or  the 
direct  transmission  of  tuberculosis,  has  been  demonstrated  by  cases  re- 
corded by  Birch-Hirschfeld,*  Lehmann,  Bar  and  Renon  and  others.  In 
the  case  first  referred  to,  the  organs  of  a  foetus,  taken  from  a  woman  dying 
from  general  tuberculosis,  were  found  to  contain  tubercle  bacilli,  although 
no  tuberculous  lesions  were  present ;  bacilli  were  found  in  the  capillaries 
of  the  liver ;  inoctilations  from  the  spleen  and  kidney  produced  the  dis- 
ease in  animals ;  and  the  placental  tufts  were  filled  with  bacilli.  In  Leh- 
mann's  case  there  were  tuberculous  lesions  in  the  placenta  as  well  as  in 
the  child's  organs. 

Intra-uterine  infection  is  highly  probable  in  many  of  the  cases  of  chil- 
dren born  of  tuberculous  mothers,  who  develop  the  disease  during  the 
first  few  montlis  of  life,  although  they  may  show  no  evidence  of  it  at 
birth.  Among  my  own  cases  there  were  five  which  died  of  tuberculosis 
during  the  first  three  months.  One  of  these  children  was  but  twenty 
days  old.  It  was  born  prematurely  of  a  mother  who  at  the  time  was  suf- 
fering from  advanced  tuberculosis,  and  died  from  that  disease  shortly 
after  the  child.  Besides  other  lesions,  the  autopsy  showed,  in  the  case  of 
the  mother,  tuberculosis  of  the  endometrium.  In  this  instance  the  infec- 
tion of  the  child  certainly  took  place  before  birth. 

In  another  case,  a  child  died  of  general  tuberculosis,  with  wide-spread 
lesions,  at  the  age  of  seven  weeks.  The  mother  of  this  infant  died  from 
tuberculosis  eleven  days  after  the  birth  of  the  child.  Intra-uterine  infec- 
tion must,  however,  be  considered  rare  in  comparison  with  the  frequency 
with  which  infection  takes  place  after  birth,  instead  of  being,  as  was 
formerly  supposed,  very  common. 

Tuberculosis  may  be  communicated  by  direct  inoculation,  as  in  the 
case  of  a  bite  from -a  person  suffering  from  the  disease,  several  instances 
of  which  are  on  record.     The  rite  of  circumcision  performed  by  a  rabbi 

*  Wiener  medicinische  Blatter,  No.  17,  1891. 


TUBERCULOSIS.  1019 

suffering  from  tuberculosis  is  also  known  to  have  caused  the  disease.  One 
of  the  most  striking  instances  of  direct  infection  is  that  reported  by 
Reich.*  In  a  town  of  about  1,300  inhabitants,  the  obstetric  practice  was 
divided  between  two  midwives.  Within  fourteen  months  no  less  than 
ten  infants,  who  had  been  delivered  by  one  of  these  women,  died  of  tuber- 
culous meningitis.  In  none  of  these  families  was  there  a  history  of  tuber- 
culosis. This  midwife  was  found  to  be  suffering  from  pulmonary  tuber- 
culosis, and  died  from  that  disease.  It  was  her  custom  to  remove  the 
mucus  from  the  mouth  of  the  newly-born  infants  by  direct  mouth-to- 
mouth  aspiration,  and  then  to  establish  respiration  by  blowing  into  the 
nose.  In  the  practice  of  the  other  midwife,  who  was  healthy,  no  cases  of 
tuberculosis  occurred,  although  she  treated  the  newly-born  infants  in  the 
same  fashion. 

The  following  instance  of  infection  has  recently  come  to  my  notice  : 
Two  little  girls  were  much  in  the  room  and  about  the  bed  of  a  young 
woman  who  was  suffering,  it  was  afterward  discovered,  from  pulmonary 
tuberculosis.  Within  three  months  of  that  time,  and  within  six  weeks  of 
each  other,  both  died  of  tuberculous  meningitis. 

Examples  might  be  multiplied  indefinitely  of  cases  where  children 
have  contracted  the  disease  from  a  close  exposure  to  nurses  or  other  per- 
sons in  the  household,  More  frequently,  however,  the  mode  of  infec- 
tion can  not  be  traced,  the  exposure  doubtless  being  in  most  of  these 
cases  long  antecedent  to  the  development  of  symptoms. 

Aside  from  accidental  inoculation  already  mentioned,  the  tubercle 
bacilli  may  gain  an  entrance  to  the  body  either  through  the  respiratory  or 
the  alimentary  tract  or  the  skin — the  last,  however,  being  so  very  rare  that 
it  need  only  be  mentioned.  In  infancy  and  early  childhood,  infection 
through  the  respiratory  tract  is  the  rule.  This  is  conclusively  shown  by  the 
situation  of  the  primary  lesions  (pages  361  and  1023).  The  source  of  the 
bacilli  in  the  inspired  air  is  mainly  the  sputum  of  patients  suffering  from 
pulmonary  tuberculosis,  which  dries  and  becomes  part  of  the  dust  of  the 
street,  of  the  railroad  car,  the  home,  or  the  hospital.  Bacilli  may  be  taken 
into  the  alimentary  tract  with  milk  from  tuberculous  cows  or  tubercu- 
lous women.     Infection  in  this  way  I  believe  to  be  very  rare.f     Unless 

*  Berliner  klinisehe  Wochenschrift,  No.  37,  1878. 

f  In  this  connection  the  following  incident  is  interesting  as  bearing  upon  the  other 
side  of  the  question  :  Xear  a  large  American  city  was  a  fancy  stock  farm  of  registered 
Jersey  cows,  which  supplied  milk  for  table  use  and  infant  feeding  to  a  large  number 
of  families  in  the  wealthiest  part  of  the  city,  for  a  period  of  over  ten  years.  At  the 
end  of  that  time  the  tuberculin  test  was  used  for  the  first  time,  and  45  per  cent  of 
these  cows  were  found  to  be  tuberculous,  and  were  killed  by  order  of  the  State  Board 
of  Health.  The  diagnosis  was  confirmed  by  autopsies  upon  the  animals  in  every 
instance.  An  investigation  was  instituted  among  the  children  who  had  been  fed 
upon  this  milk,  but  in  only  one  case  of  many  hundreds  could  it  be  learned  that  tuber- 
culosis had  developed,  and  in  this  instance  it  was  by  no  means  established  that  the 


1020  THE  SPECIFIC   INFECTIOUS  DISEASES. 

the  udder  is  the  seat  of  disease,  the  number  of  bacilli  in  cow's  milk  is  so 
small  that  the  chances  of  infecting  a  child  after  these  bacilli  have  passed 
the  stomach  are  exceedingly  small.  Its  possibility  even  is  questioned  by 
many  good  authorities.  The  same  may  be  said  regarding  the  transmis- 
sion of  tuberculosis  through  the  milk  of  a  nurse.  Infection  from  the 
meat  of  tuberculous  animals  is  doubtless  a  possibility,  but  hardly  more. 
Bollinger's  experiments  in  feeding  animals  with  the  expressed  juice  of 
such  meat  gave  negative  results. 

The  Various  Paths  of  Infection  adopted  by  the  Tubercle  Bacillus. — 
The  tubercle  bacilli  which  enter  the  body  with  the  inspired  air  are  ar- 
rested upon  the  mucous  membrane  of  the  upper  or  the  lower  respiratory 
tract ;  upon  which  one  of  these,  is  largely  determined  by  local  conditions 
in  the  various  mucous  membranes.  Both  clinical  experience  and  animal 
experiments  indicate  that  the  bacilli  may  pass  through  a  mucous  mem- 
brane without  inducing  in  it  a  tuberculous  disease,  but  that  penetration 
is  much  easier  if  the  mucous  membrane  is  the  seat  of  a  catarrhal  inflam- 
mation, or  if  the  epithelium  has  been  injured.  The  bacilli  are  taken  up 
by  the  lymphatics  from  the  surface  of  the  mucous  membrane  upon  which 
they  have  lodged,  and  are  carried  to  the  nearest  lymph  nodes,  where, 
for  a  considerable  time  at  least,  they  are  arrested.  It  has  long  been  a 
familiar  clinical  fact  that  tlie  great  majority  of  children  who  suffer  from 
tuberculosis  of  the  cervical  lymph  nodes  escape  general  tuberculous  in- 
fection, so  eminent  an  authority  upon  this  subject  as  Treves  considering 
this  to  be  a  very  exceptional  result. 

It  is  not  infrequent,  in  autopsies  both  upon  children  and  adults  dying 
from  various  non-tuberculous  diseases,  to  find  tuberculosis  limited  to  the 
bronchial  lymph  nodes.  In  a  series  of  135  autopsies  at  the  New  York 
Foundling  Asylum  upon  children  with  tuberculosis,  Northrup*  found 
13  such  cases,  these  being  children  who  had  died  from  acute  non- 
tuberculous  diseases.  Many  confirmatory  reports  have  been  published 
by  Bollinger  (Munich)  and  others.  I  have  myself  seen  it  in  a  number 
of  instances. 

H.  P.  Loomis  f  (New  York)  made  inoculation  experiments  with  the 
bronchial  lymjDh  nodes  taken  from  the  bodies  of  thirty  persons  dying  by 
violence  or  from  acute  disease,  in  whom  no  evidence  of  tuberculosis  in  any 
other  part  of  the  body  could  be  found  at  autopsy.  From  eight  of  the  cases 
he  produced  tuberculosis  in  animals  by  inoculation.     Arnold  has  shown 

milk  had  been  the  source  of  infection.  It  should  be  stated  that  this  was  before  the 
days  of  sterilizing  milk  for  infant  feeding.  Besides  the  families  who  took  the  milk 
in  the  manner  mentioned,  the  employees  at  the  farm  were  accustomed  to  drink  the 
skimmed  milk  in  large  quantities  daily  as  a  beverage  in  the  place  of  water.  Many  of 
them  continued  to  do  this  for  years,  and  yet  not  one  of  tliem  developed  tuberculosis. 

*  New  York  Medical  Journal,  February  21,  1891. 

t  The  Medical  Record,  December  20,  1890. 


TUBERCULOSIS.  1021 

by  experiments  with  dust  inhalation  in  animals,  that  in  a  short  time  the 
bronchial  lymph  nodes  were  filled  with  dust,  though  the  bronchi  and 
alveoli  were  free ;  but,  however  prolonged  the  inhalation,  dust  was  never 
found  in  the  lymphatic  vessels  beyond  the  nodes. 

Arriving  at  the  lymph  node,  the  bacilli  light  up  a  tuberculous  inflam- 
mation of  varying  degrees  of  intensity,  depending  upon  their  number 
and  upon  local  conditions.  This  inflammation  may  pass  through  the 
usual  changes  of  tuberculous  glands — congestion,  swelling,  cell  prolifera- 
tion and  caseation ;  or  the  process  may  be  arrested  at  any  point,  and  the 
products  of  inflammation  become  encapsulated  by  a  proliferation  of  fibrous 
tissue,  in  which  condition  they  may  remain  latent  in  the  body  for  an  in- 
definite number  of  years — possibly  for  a  lifetime.  This  is  what  occurs  in 
older  and  more  vigorous  children,  and  it  is  consistent  with  every  outward 
sign  of  health ;  but  it  is  a  smouldering  ember  which  at  any  time  may  be 
fanned  into  flame  under  the  stimulus  of  an  inflammation  excited  by  some 
other  cause. 

In  infants  and  young  children,  the  tendency  is  always  for  the  bacilli  to 
lodge  first  in  the  bronchial  lymph  nodes,  probably  on  account  of  the 
favourable  conditions  for  entrance  existing  in  the  bronchi  and  lungs.  In 
those  who  are  delicate  and  have  but  little  resistance,  the  process  in  the 
lymph  nodes  is  likely  to  go  on  to  caseation  and  softening,  and  secondarily 
to  this  process  in  the  glands,  the  lung  may  become  infected.  Of  91  cases 
observed  by  Northrup,  in  which  the  mode  of  infection  could  be  pretty 
accurately  traced,  in  88  it  was  primarily  in  the  bronchial  lymph  nodes. 
The  manner  of  the. extension  of  the  disease  to  the  lung  is  not  always  easy 
to  trace  ;  but  in  many  instances  it  has  been  shown  to  be  the  result  of 
the  softening  of  one  of  these  small  tuberculous  lymph  nodes,  which  then 
ulcerates  through  the  wall  of  one  of  the  small  bronchi  or  a  blood-vessel, 
in  this  way  distributing  its  bacilli  through  the  lung. 

Although  this  is  the  course  usually  taken  by  bacilli  when  they  are  in- 
haled, it  is  not  always  the  case.  Lesions  in  the  lungs  are  occasionally 
found  where  the  lymph  nodes  are  not  involved  ;  and  there  are  other  cases 
in  which  advanced  changes  exist  in  the  lung,  while  only  the  earlier  ones 
are  seen  in  the  lymph  nodes.  In  these  cases,  which  perhaps  are  to  be 
considered  as  exceptional,  the  tuberculous  process  probably  begins  in 
the  walls  of  the  small  bronchi,  the  alveoli,  or  in  the  connective-tissue 
septa. 

Tubercle  bacilli  entering  the  alimentary  tract  rarely  cause  lesions  of 
the  gastric  mucous  membrane,  or  through  it  reach  the  lymphatic  circula- 
tion. In  the  intestines,  however,  more  favourable  conditions  exist.  It  is 
possible  for  the  bacilli  to  reach  the  mesenteric  lymph  nodes  without  caus- 
ing disease  of  the  intestinal  mucous  membrane,  but  I  believe  it  to  be  ex- 
ceedingly rare ;  for  by  careful  search  I  have  never  yet  failed  to  find  in- 
testinal ulceration  where  the  lymph  nodes  were  manifestly  tuberculous. 


1022 


THE  SPECIFIC  INFECTIOUS  DISEASES. 


Lesions. — In  the  following  table  are  given  the  different  lesions  of  tu- 
berculosis as  they  were  found  in  119  autopsies,  of  which  I  have  notes. 
These  represent  the  lesions  of  infancy  and  early  childhood,  66  per  cent  of 
these  children  being  two  years  old  or  under.  There  are  introduced  for 
comparison,  the  statistics  of  131  autopsies  from  the  Pendjebury  Hospital 
Keports  (Manchester,  England),  Very  few  of  the  cases  in  this  series  were 
under  three  years,  the  hospital  admitting  only  older  children  : 

Frequency  of  the  Different  Visceral  Lesions  of  Tuberculosis. 


Organs. 

Personal  cases  ; 

119  autopsies  (chiefly  under 

three  years). 

Pendlebury  Hospital  Reports  ; 

131  autopsies  (chiefly  over 

three  years). 

LxingsT 

117 

69 

108 

40 

77 

88 

46 

5 

40 

38 

10 

7 

1 

3 

2 

3 

99-0  per  cent. 
58-0       " 
96-0       " 
37-0       " 
65-0       " 
75-0       " 
39-0       " 

4-0       " 
37  0       " 
350       " 

90       " 

6  0       " 

0-8       " 

2-5       " 

1-7       " 

2-5       " 

122 

100 

91 

60 

86 

76 

54 

1 

65 

77 

37 

4 

2 

93-0  per  cent. 

Pleura  

76-0       " 

Bronchial  lymph  nodes 

Brain 

70-0       " 
46-0       " 

Liver  

65-0       " 

Sp)  een 

58-0       " 

Kidneys 

41-0       " 

Stomach 

Intestines     

0-8       « 
50-0       " 

JMesenteric  lymph  nodes 

Peritonasum 

59-0 

28-0       •' 

Pericardium 

3-0       " 

Suprarenal  capsules 

1-6       " 

The  varieties  of  tuberculosis  seen  at  different  ages. — During  the  first 
two  years  of  life,  tuberculosis,  with  great  uniformity,  involves  first  the 
bronchial  lymph  nodes  and  the  lungs.  It  is  most  frequently  the  pul- 
monary process  which  is  the  cause  of  death,  and  next  to  the  lungs,  death  is 
due  to  tuberculosis  of  the  brain.  It  is  rare  for  any  other  local  tuberculous 
process  to  be  fatal  at  this  time  of  life.  Of  73  cases  of  tuberculosis  in  the 
first  two  years  of  life,  in  which  the  exact  nature  of  the  lesions  was  deter- 
mined by  autopsy,  the  lungs  were  extensively  involved  in  all;  but  death 
was  due  to  meningitis  in  13,  in  only  one  to  tuberculous  peritonitis,  and  in 
one  to  hsemorrhage  from  a  tuberculous  ulcer  of  the  intestine.  During 
infancy,  meningitis  is  rare  except  when  associated  with  pulmonary  tuber- 
culosis ;  but  after  the  second  year,  meningitis  is  relatively  more  frequent. 
Of  the  deaths  from  tuberculosis  during  the  third  year,  meningitis  Avas 
present  in  over  one  half  the  number.  After  this  time  it  frequently  exists 
with  few  and  sometimes  with  no  lesions  in  the  lungs,  it  being  often  sec- 
ondary to  tuberculosis  of  the  bones  or  lymph  nodes. 

Beginning  with  the  third  year,  tuberculosis  of  the  bones,  cervical  and 
mesenteric  lymph  nodes,  peritoneum,  and  intestines,  becomes  more  frequent, 
and  in  any  of  these  organs  it  may  occur  as  the  principal  lesion,  although 
at  autopsy  the  lungs,  even  at  this  age,  are  rarely  found  free  from  infection. 


TUBERCULOSIS.  1023 

Pulmonary  Lesions. — As  compared  with  adults,  the  pulmonary  tuber- 
culosis of  children  is  more  widely  diffused,  and  the  predominance  of  cases 
in  which  the  lesion  is  at  the  upper  lobes,  though  less  marked,  still  exists. 
The  peculiarities  are  principally  seen  in  children  under  two  years.  In 
those  who  have  passed  the  sixth  or  seventh  year,  the  pathological  processes 
resemble  those  of  adult  life.  In  my  own  autopsies  the  oldest  lesions  were 
found  G9  times  in  one  of  the  upper  lobes  (left  35,  right  34) ;  23  times  in 
the  right  middle  lobe,  and  35  times  in  one  or  other  of  the  lower  lobes 
(left  24,  right  11).  Although  localized  tuberculous  processes  are  frequently 
met  with  in  patients  dying  from  other  diseases,  those  who  die  from  tuber- 
culosis usually  show  wide-spread  lesions  of  the  lungs,  and  the  younger  the 
child  the  more  diffuse  they  are. 

1.  Miliary  tuberculosis  of  the  lungs. — In  nearly  every  case  of  pulmo- 
nary tuberculosis,  miliary  tubercles  are  found  in  some  part  of  the  lung; 
usually  they  are  seen  upon  the  surface  and  in  scattered  areas  in  the 
vicinity  of  some  older  process.  Occasionally  in  older  children,  but 
very  rarely  in  infants,  they  are  distributed  through  nearly  the  whole  of 
both  lungs. 

In  some  places  the  lung,  with  the  exception  of  these  gray  granulations, 
appears  quite  normal ;  in  others  it  is  congested,  and  shows  between  the 
tubercles  the  lesions  of  simple  broncho-pneuraonia  in  its  various  stagey. 
There  is  also  an  acute  bronchitis  of  the  middle-sized  and  smaller  bronchi. 
The  microscope  shows  that  the  tubercles  usually  develop  in  the  walls  of 
the  small  bronchi  or  the  blood-vessels,  or  very  close  to  these  structures. 
In  their  gross  appearance,  the  lungs  in  these  cases  resemble  those  in  ordi- 
nary acute  broncho-pneumonia,  with  the  exception  that  everywhere  upon 
the  surface  and  throughout  the  substance  of  the  lung  are  seen  the  small 
gray  granulations,  and  in  most  cases  some  small  yellow  tuberculous  nod- 
ules. The  pleura  is  usually  normal  except  for  the  presence  of  the  tuber- 
cles. This  form  of  the  disease  represents  the  rapid  dissemination  of 
tubercle  bacilli  throughout  the  lungs,  the  miliary  tubercles  being  the 
result  of  the  inflammation  excited  by  their  presence. 

2.  Tuberculous  broncho-pneumonia. — This  is  the  most  frequent  and 
the  most  characteristic  form  of  tuberculosis  in  infants  and  young  chil- 
dren, and  it  is  the  one  which  at  this  age  usually  causes  death.  In  this 
form  of  disease  there  are  produced  in  the  lung,  caseous  nodules,  or  larger 
caseous  areas,  some  of  which  have  usually  undergone  softening  by  the 
time  the  case  comes  to  autopsy.  The  process  generally  runs  a  somewhat 
subacute  course.  With  the  lesions  mentioned  there  are  always  associated 
those  of  simple  broncho-pneumonia. 

The  pleura  is  involved  in  almost  every  case.     There  may  be  ^simply 

dense  connective-tissue  adhesions  which  bind  the  lung  firmly  to  the  chest 

wall,  or  the  pleura  may  be  greatly  thickened  and  contain  caseous  deposits. 

Occasionally  empvema  is  seen,  but  it  is  almost  always  sacculated  and  small. 
6fi 


1024  THE  SPECIFIC  INFECTIOUS  DISEASES. 

Both  lungs  are  usually  involved,  but  one  to  a  much  greater  degree  than 
the  other.  There  are  found  large  areas  of  consolidation  which  some- 
times involve  an  entire  lobe,  but  more  often  areas  are  seen  in  several  lobes. 
These  portions  of  the  lung  appear  much  firmer  and  harder  than  in  ordi- 
nary pneumonia.  The  upper  lobes  are  more  often  affected  than  the 
lower,  and  especially  that  part  of  the  lobe  which  is  near  the  root  of  the 
lung,  on  account  of  its  frequent  association  with  tuberculosis  of  the 
bronchial  glands ;  the  disease  very  often  extends  forward  from  this  point 
to  the  middle  lobe  of  the  right,  or  the  corresponding  part  of  the  left  lung. 
On  section  the  affected  part  of  the  lung  usually  shows  many  caseous 
nodules  varying  in  size  from  a  pin's  head  to  a  walnut,  which  appear  of  a 
pale  yellow  colour,  and  resemble  caseous  lymph  nodes.  They  contain  giant 
cells  and  are  usually  filled  with  bacilli,  those  which  have  softened  con- 
taining yellow  pus.  There  is  nearly  always  seen  in  some  part  of  the 
lung  a  large  caseous  area;  and  not  infrequently  there  may  be  diffuse 
caseation  of  almost  an  entire  lobe  (Fig.  172).  Sometimes  no  spot  of 
softening  is  seen  even  in  these  large  areas,  but  in  the  great  majority 
of  them  there  are  found  cavities  of  variable  size  with  ragged  but  not 
dense  walls. 

Softening  and  excavation  represent  the  final  stages  of  the  process  in 
tuberculous  pneumonia.  It  has  been  shown  by  Prudden  that  these  changes 
are  chiefly  or  entirely  due  to  other  pathogenic  organisms — usually  the 
streptococcus  or  staphylococcus — and  not  to  the  tubercle  bacillus.  Soften- 
ing usually  begins  in  the  centre  of  a  caseous  part,  often  at  several  points 
at  the  same  time.  Areas  of  excavation  large  enough  to  deserve  the  name 
of  cavities  were  present  in  thirty-five  of  seventy  two  autopsies  upon  tuber- 
culous patients,  two  years  old  and  under.  They  are  found  in  the  great 
majority  of  the  cases  in  which  continuous  pulmonary  symptoms  have  been 
present  till  death.  They  vary  in  size  from  a  cherry  to  a  hen's  egg,  and 
sometimes  a  much  larger  one  is  seen  (Fig.  173).  They  are  usually  rather 
deeply  seated,  and  partially  or  entirely  filled  with  caseous  masses  or  pus, 
but  very  seldom  perforate  the  pleura,  causing  pneumothorax  or  pyo-pneu- 
mothorax.  It  is  rare  in  a  young  child  to  find  cavities  surrounded  by  dense 
fibrous  walls  such  as  are  seen  in  older  children  or  in  adults;  for  in  infancy 
the  process  of  softening  once  begun  usually  advances  steadily  until  the 
death  of  the  patient. 

It  is  very  frequent  to  find  at  autopsy  small  cavities  surrounded  by 
larger  areas  of  caseous  pneumonia,  and  these  in  turn  surrounded  by  a 
zone  of  simple  pneumonia  through  which  are  scattered  many  miliary 
tubercles.  Often  the  lesions  mentioned  will  be  present  in  one  lobe,  while 
the  other  lobe  or  the  opposite  lung  will  show  only  the  changes  of  a  simple 
pneumonia. 

The  bronchial  lymph  nodes  are  in  these  cases  invariably  found  to  be 
tuberculous,  and  not  only  those  at  the  root  of  the  lung,  but  if  a  dissection 


TUBERCULOSIS. 


1025 


is  made,  a  chain  of  these  tuberculous  glands  will  be  found  to  follow  the 
larger  bronchi  for  some  distance  into  the  lung  (Fig.  176).  Sometimes 
one  may  discover  one  of  these  which  has  softened  and  ulcerated  through 
into  a  small  bronchus,  and  in  this  way  has  spread  the  infection  through- 
out that  part  of  the  lung. 

Microscopical  examination  of  these   cheesy  nodules  shows  that  they 
most  frequently  begin  as  tuberculous  deposits  in  the  walls  of  the  small 


Fig.  1V2. 


Fig.  173. 


Fig.  172.— Tuberculous  pneumonia.  A  vertical  section  through  the  middle  of  the  right  lung 
of  a  child  thirteen  months  old.  The  greater  part  of  the  upper  lobe  is  uniformly  caseous— a 
ditt'use  tuberculous  pneumonia;  near  the  centre  the  commencement  of  a  cavity  is  seen  ;  be- 
low it  has  the  appearance  of  a  consolidation  from  simple  pneumonia.  The  part  of  the  lower 
lobe  shown  is  normal. 

Fig.  173. — Cavity  from  breaking  down  of  tuberculous  pneumonia;  another  view  of  the  same 
lung,  the  .section  beinar  made  very  near  the  posterior  border  of  the  lung.  The  cavity  occu- 
pies at  this  point  nearly  the  whole  of  the  upper  lobe.  At  autopsy  this  cavity  contained  nu- 
merous loose  caseous  masses,  the  largest  being  the  size  of  a  marble.  The  lower  lobe  is 
normal.     (For  history  see  Fig.  179.) 


bronchi,  either  in  the  mucous  membrane,  the  fibrous  coat,  or  the  lymphat- 
ics ;  sometimes,  however,  they  begin  in  the  walls  of  a  small  vein  or  artery. 
Cell  proliferation  takes  place,  separating  the  coats  of  the  bronchus  or 
blood-vessel,  and  partly  or  entirely  obstructing  its  lumen.    Softening  may 


1026 


THE   SPECIFIC   INFECTIOUS   DISEASES. 


take  place  and  the  contents  be   discharged  into  the  bronchus  or  blood- 
vessel.    About   this   focus  other  changes   of   an  inflammatory  character 


'^ 


■if 


Fig.  174. — A  small  tuberculous  nodule  siin-Mim.ic.l  l.y  hiiig  tissue  which  shows  only  slight  in- 
flammatory changes.  The  centre  of  the  nodule  is  necrotic ;  at  its  periphery  is  shown  infil- 
tration with  wund  cells  and  several  giant  cells.     (From  Karg  and  Schmorl.) 

occur,  as  a  result  of  which  each  cheesy  nodule  is  surrounded  by  a  zone 
of  simple  broncho-pneumonia  (Fig.  174)  which  tends,  in  a  measure  at 
least,  to  limit  the  tuberculous  process.  The  larger  caseous  areas  are 
formed  by  an  extension  of  this  process  to  the  zone  of  pneumonia 
which  surrounds  it ;  but  in  its  further  growth  it  is  still  preceded  by 
a  simple  pneumonia  (Fig.  175).  The  rapidity  with  which  the  lesions 
advance  differs  much  in  the  different  cases,  and  is  greatly  modified  by 
the  patient's  age  ;  in  infants  the  progress  is  apt  to  be  continuous  until 
the  death  of  the  patient ;  in  older  children  it  is  usually  slower,  and  is 
often  interrupted  by  longer  or  shorter  intervals  of  arrest  and  even  of  par- 
tial retrogression.  Such  periods  are  marked  by  the  absorption  of  the  sim- 
ple inflammatory  products  in  the  zone  of  pneumonia  surrounding  the 
tuberculous  nodule,  accompanied  by  improvement  in  the  symptoms  and 


TUBERCULOSIS. 


1027 


often  by  a  disappearance  of  some  of  the  physical  signs.  During  these  times 
of  quiescence  there  is  an  opportunity  for  the  organization  of  the  cells  in- 
filtrating the  alveolar  walls  and  septa  into  a  more  or  less  resistant  fibrous 
wall  which  acts  as  a  barrier  against  the  advance  of  the  pathological  pro- 
cess. 

Not  infrequently  one  sees  in  the  post-mortem  room  one  or  two  caseous, 
or  less  frequently  calcareous,  nodules  encapsulated  by  firm,  organized  con- 
nective tissue  where  a  most  careful  search  fails  to  showanv  other  tubercu- 


Fio.  175. — Pulmonary  tuberculosis,  showing  areas  of  tuberculous  pneumonia  and  conglomerate 
tubercles.  In  tlie  greater  part  of  the  specimen  the  air  vesicles  are  tilled  with  the  products 
of  simple  pneumonia.  The  larger  darii  areas,  A  A  A,  are  spots  of  tuberculous  pneumonia, 
while  at  B  B  only  single  air  vesicles  or  groups  of  two  or  three  are  affected  by  the  tuber- 
culous process.  The  specimen  shows  a  comparatively  early  stage  of  the  process,  of  which 
the  late  stage  is  represented  by  Fig.  172.  Patient,  a  child  three  months  old ;  the  symptoms, 
those  of  simple  acute  pneumonia.  There  were  conarlomerate  tubercles  scattered  through 
both  lungs,  and  large  areas  of  cheesy  pneumonia  in  the  left  lower  lobe. 


lous   lesion  in  the  lung.     If,  however,  the  nodules  are  widely  scattered 
through  the  lung,  such  an  arrest  of  the  process  is  not  to  be  expected. 
3.  Chronic  pulmonary  tuberculosis,  chronic  phthisis. — With  the  patho- 


;|^028  THE  SPECIFIC   INFECTIOUS   DISEASES. 

logical  process  as  it  is  seen  in  adults,  we  have  nothing  to  do  in  infants 
and  very  young  children.  In  those  who  have  reached  the  age  of  eight 
or  ten  years  the  disease  is  essentially  the  same  as  in  adult  life,  and  need 
not  be  described  here. 

In  little  children  the  nearest  approach  to  this  condition  is  seen  in  the 
cases  of  tuberculous  broncho-pneumonia,  which  run  a  slow,  irregular, 
and  somewhat  chronic  course.  The  essential  features  of  the  process  in 
these  patients  is  a  chronic  interstitial  broncho-pneumonia  with  tubercu- 
lous nodules  which  rarely  undergo  softening,  but  usually  become  encap- 
sulated. 

The  gross  lesions  closely  resemble  those  of  simple  chronic  broncho- 
pneumonia (page  535).  There  are  the  same  generalized  pleuritic  adhe- 
sions and  the  shrunken  cicatricial  condition  of  the  part  of  the  lung  most 
affected,  with  bronchiectasis,  compensatory  emphysema,  etc.  The  tuber- 
culous nodules  are  old  and  for  the  most  part  converted  into  dense  fibrous 
tissue  in  the  centre  of  which,  however,  some  softened,  caseous  areas  are 
often  seen.  Lesions  like  those  described,  which  may  be  regarded  as  a 
form  of  recovery,  are  usually  found  in  patients  who  have  died  of  other 
diseases  ;  sometimes  in  those  who  have  died  of  other  forms  of  tuberculosis 
— of  the  brain,  bones,  or  peritoneum ;  at  other  times  they  are  associated 
with  a  recent  process  in  some  other  part  of  the  lung.  The  bronchial 
glands  may  be  somewhat  enlarged  and  contain  encapsulated  caseous 
masses,  or  they  may  be  calcareous. 

Broncliial  lymph  nodes  {bronchial  glands). — The  prominence  of  the 
lesions  of  the  lymph  nodes  is  one  of  the  most  striking  features  of  tuber- 
culosis in  infancy  and  early  childhood.  Those  which  are  most  frequently 
affected  are  connected  with  the  bronchi.  The  lymph  nodes,  to  which  the 
term  "  bronchial  glands "  is  generally  applied,  consist  of  three  groups : 
the  first  of  which  surround  the  trachea;  the  second  are  situated  at  the 
bifurcation  of  the  trachea  and  surround  the  primary  bronchi ;  while  the 
third  follow  the  course  of  the  bronchi  into  the  lung,  being  found,  accord- 
ing to  anatomists,  as  far  as  the  fourth  division.  The  anatomical  relation 
of  the  different  groups  should  be  borne  in  mind,  since  upon  them  the 
symptoms  principally  depend.  The  first  group,  or  the  peri-tracheal  lymph 
nodes,  are  in  relation  with  the  superior  vena  cava,  the  pulmonary  artery, 
the  pneumogastric  and  recurrent  laryngeal  nerves;  the  second  group,  at 
the  bifurcation  of  the  trachea,  with  the  oesophagus,  pneumogastric  nerve, 
and  aorta;  the  third  group,  Avith  the  bronchi  and  the  branches  of  the 
bronchial  and  pulmonary  arteries  and  veins. 

All  the  groups  are  usually  involved  at  the  same  time,  but  in  varying 
degrees,  and  in  most  cases  those  belonging  to  one  lung  to  a  greater,  extent 
than  the  other ;  in  my  own  cases  those  of  the  right  side  have  more  often 
been  involved  than  those  of  the  left.  There  may  be  simply  two  or  three 
tumours  as  large  as  a  hazelnut,  or  there  may  be  a  mass  two  or  three  inches 


PLATE   XIX. 


Tuberculosis  of  the  Tracheo-Broxchial  Lymph  Nodes. 

From  a  fairly  nourished  child,  four  months  old,  who  was  under  observation  for 
three  weeks,  with  slight  fever  and  a  most  severe,  teasing,  dry  cough,  which  was  almost 
constant,  and  upon  which  no  treatment  seemed  to  have  the  slightest  effect.  At  first 
there  were  no  signs  of  disease  in  the  lungs  ;  later  there  were  a  few  coarse  scattered 
niles. 

There  were  small  tuberculous  deposits  throughout  both  lungs,  with  quite  a  large 
area  of  cheesy  pneumonia  in  the  right  middle  lobe,  and  scattered  miliary  tubercles  in 
other  organs. 


TUBERCULOSIS. 


1029 


in  diameter,  which  is  made  up  of  ten  to  twenty  of  these  nodes  fused 
together  by  inflammatory  products,  completely  surrounding  the  trachea 
and  both  the  large  bronchi.  It  is  rare  that  the  individual  glands  are 
more  than  an  inch  in  diameter,  and  most  of  them  are  smaller  than  this. 


•*'>feu,..: 


Fig.  176.— Tuberculous  bnnieliial  lymph  nixk-s.  Section  of  the  lung  of  an  infant  through 
cheesy  bronchial  lymph  nodes  at  the  root  of  the  lung,  and  adjacent  cheesy  masses,  several 
of  which  have  softened  at  the  centre ;  the  lung  "otherwise  normal ;  life-size.  (After 
Northrup.) 

A  well-marked  but  not  unusual  example  of  this  condition  is  shown  in 
Plate  XIX.  There  is  usually  found  a  chain  of  these  tuberculous  glands 
following  the  course  of  the  large  bronchi  for  some  distance  into  the  lung; 
sometimes  these  are  almost  as  large  as  the  external  group  (Fig.  176) ;  at 
other  times  they  are  not  noticed  unless  a  somewhat  careful  dissection  is 


1030  THE   SPECIFIC   INFECTIOUS   DISEASES. 

made.  The  process  is  not  infrequently  more  advanced  in  these  deeply- 
seated  glands  than  in  those  situated  at  the  root  of  the  lung ;  and  lesions 
here  are  also  more  important,  as  it  is  very  frequently  through  them  that 
the  lung  becomes  infected. 

The  pathological  changes  through  which  these  glands  pass  as  a  result 
of  tuberculous  infection,  are  very  similar  to  those  already  described  with 
reference  to  the  cervical  glands  (page  825).  Suppuration  is  less  frequent 
than  in  the  region  of  the  neck,  while  calcific  degeneration  is  much  more 
so.  This  applies  especially  to  children  over  three  years  old.  In  infancy 
suppuration  is  not  infrequent  in  the  bronchial  glands,  while  at  this  age 
calcification  is  extremely  rare.  Infection  of  these  lymph  glands  is  not 
always  followed  by  general  tuberculosis  or  even  by  infection  of  the  lung. 
Although  the  process  has  gone  on  to  caseation,  these  inflammatory  prod- 
ucts with  bacilli  may  become  encapsulated,  and  may  remain  innocuous  for 
an  indefinite  period.  The  bacilli  may  die  or  may  exist  here,  living,  for 
years.  At  any  time  the  old  process  may  be  lighted  up,  and  a  more  or  less 
rapid  dissemination  of  tubercle  bacilli  take  place  through  the  lungs  or 
through  the  whole  body.  Latent  tuberculosis  more  frequently  exists  in 
the  bronchial  lymph  nodes  than  in  any  other  structure  in  the  body. 

Secondary  lesions  may  be  produced  by  these  lymph  nodes.  The 
pneumogastric  and  recurrent  nerves  may  be  surrounded  by  one  of  these 
cheesy  masses  which  causes  pressure  and  irritation.  The  oesophagus,  the 
trachea,  or  the  bronchi,  may  be  compressed  or  opened  by  ulceration.  The 
superior  vena  cava  usually  suffers  only  compression,  but  this  or  any  of  the 
other  large  vessels  may  be  opened.  Ulceration  may  also  take  place  into 
one  of  the  large  or  small  bronchi  or  the  trachea.  If  the  gland  has  softened 
and  broken  down,  and  if  the  bronchus  is  a  small  one,  the  only  result  of 
this  may  be  a  rapid  spreading  of  tuberculous  infection  throughout  the 
lung.  If  sudden  rupture  occurs,  a  large  caseous  mass  may  escape  into  the 
trachea,  or  a  large  bronchus,  with  a  result  similar  to  that  produced  by  any 
other  foreign  body.  If  suppuration  occurs,  the  abscess  may  rupture  into 
the  surrounding  cellular  tissue,  causing  mediastinal  or  retro-oesophageal 
abscess  (page  276).  This  may  open  externally  at  the  suprasternal  notch, 
or  in  the  first  or  second  intercostal  space,  or  may  ulcerate  into  any  of  the 
large  vessels,  the  oesophagus,  or  the  pericardium,  or  may  burrow  down- 
ward into  the  peritoneal  cavity. 

Plectra. — This  is  rarely  normal  in  any  case  of  tuberculosis.  In  acute 
general  tuberculosis  the  only  lesion  may  be  a  deposit  of  miliary  tubercles 
upon  the  visceral  pleura.  In  most  of  the  other  cases  there  are  found 
fibrous  adhesions  over  the  part  of  the  lung  involved,  binding  it  to  the 
pericardium,  the  diaphragm,  or  the  chest  wall.  The  amount  of  thicken- 
ing of  the  pleura  varies  a  good  deal,  but  is  rarely  great.  In  about  one 
fifth  of  my  own  autopsies  tuberculous  nodules  were  found  in  the  pleura ; 
with  these  lesions  there  is  usually  considerable  thickening.     Pleurisy  with 


TUBERCULOSIS.  1031 

a  haemorrhagic  exudation  is  very  rare  in  the  tuberculosis  of  early  child- 
hood. Empyema  is  also  rare,  being  seen  in  but  five  per  cent  of  my 
cases,  and  then  it  was  small  and  sacculated.  Pneumothorax  and  pyo- 
pneumothorax are  very  rare  in  children  under  three  years  of  age ;  they 
were  not  seen  in  any  of  my  cases. 

Heart. — It  is  excej^tional  for  the  pericardium  to  be  affected  even  in 
the  most  generalized  forms  of  miliary  tuberculosis.  In  such  cases  the 
usual  lesion  is  a  deposit  of  a  few  gray  tubercles  upon  the  visceral  surface. 
In  chronic  cases  other  lesions  analogous  to  those  of  the  pleura  may  be 
seen,  but  all  are  rare  in  childhood.  In  a  single  instance  I  have  seen 
miliary  tubercles  upon  the  endocardium.  They  are  extremely  rare,  and 
the  development  of  cheesy  nodules  in  the  heart  is  almost  unknown  in 
early  life. 

Brain. — Tuberculosis  of  the  brain  is  not  uncommon  during  infancy, 
being  then  associated  in  nearly  all  cases  with  general  tuberculosis,  and 
especially  with  tuberculous  pneumonia ;  but  it  is  relatively  twice  as  fre- 
quent after  the  second  year.  There  may  be  found  miliary  tubercles  alone, 
or  these  may  be  accompanied  by  inflammatory  products — tuberculous 
meningitis — or  there  may  be  caseous  nodules.  Miliary  tubercles  are  fre- 
quently found  in  small  numbers  in  cases  which  have  presented  no  symp- 
toms. The  lesions  of  tuberculous  meningitis  have  already  been  described 
(page  715).  Cheesy  nodules  are  rare  in  infancy,  being  noted  in  but  2'5 
per  cent  of  my  own  autopsies,  which  were  mainly  on  children  under  three 
years  old ;  while  in  the  Pendlebury  Hospital  cases,  including  those  between 
four  and  twelve  years  old,  they  were  noted  in  24-4  per  cent.  These  nod- 
ules vary  in  size  from  a  pea  to  a  child's  fist ;  they  are  usually  associated 
with  tuberculous  meningitis,  but  they  may  exist  alone.  When  they  are 
large  they  rank  as  cerebral  tumours,  being  most  frequently  seen  in  the 
cerebellum.    They  rarely  soften,  but  may  be  the  seat  of  calcareous  deposits. 

Liver. — This  is  frequently  involved  in  general  tuberculosis,  although  it 
is  doubtful  if  it  is  ever  the  seat  of  primary  infection  except  in  the  con- 
genital cases.  Usually  the  only  lesion  is  the  presence  of  miliary  tubercles 
on  its  surface  and  in  its  substance,  and  in  most  cases  these  are  not  numer- 
ous. They  are  found  in  about  two  thirds  of  the  cases.  In  a  smaller 
number  there  are  tuberculous  nodules  of  various  sizes.  In  nearly  every 
protracted  case  the  liver  is  markedly  fatty.  In  very  late  cases  of  tubercu- 
losis of  the  bones,  it  is  frequently  the  seat  of  amyloid  degeneration. 

S2)leen. — This  is  more  frequently  affected  than  the  liver,  but  in  very 
much  the  same  way.  In  most  of  the  cases  of  general  tuberculosis,  miliary 
tubercles  are  present  in  the  spleen,  these  being  usually  numerous,  both 
upon  the  surface  and  throughout  the  organ.  Not  infrequently  small  tuber- 
culous nodules  are  also  seen,  but  there  are  rarely  any  which  are  larger  than 
a  pea.  The  size  of  the  spleen  is  not  altered  if  only  miliary  tubercles  are 
present ;  but  with   the  tuberculous   nodules  it   may   be   much  enlarged. 


1032  THE  SPECIFIC   INFECTIOUS  DISEASES. 

Amyloid  degeneration  is  found  under  the  same  conditions  as  in  the 
liver. 

Stomach. — Tuberculosis  of  the  stomach  is  one  of  the  rare  lesions ;  both 
its  contents  and  its  acid  reaction  seem  to  protect  it  against  direct  infection 
from  the  mouth.  Tuberculous  ulcers  were  seen  in  five  of  my  autopsies, 
which  is  a  larger  proportion  than  is  usually  noted. 

Intestines. — These  are  less  seriously  affected  in  infancy  than  in  older 
children,  which  is  rather  surprising  when  we  consider  how  susceptible  are 
the  intestines  of  infants  to  other  forms  of  infection.  The  explanation  of 
this  difference  seems  to  me  to  be  this  :  Intestinal  infection  is  nearly  always 
secondary  to  disease  of  the  lungs ;  primary  lesions  being  extremely  rare. 
Infants  usually  die  from  the  more  rapid  tuberculous  processes  in  the 
lungs  or  brain  before  there  has  been  time  or  opportunity  for  intestinal 
infection  to  occur.  The  opportunities  for  such  infection  depend  upon  the 
number  of  bacilli  which  are  coughed  into  the  pharynx  and  swallowed.  In 
infancy  this  number  is  small,  because  of  the  many  who  die  of  tuberculous 
pneumonia  or  meningitis  before  extensive  softening  in  the  lungs  has  taken 
place.  In  older  children  the  slower  course  of  the  pulmonary  disease  gives 
ample  time  for  intestinal  infection,  while  the  more  extensive  softening  and 
excavation  are  accompanied  by  the  discharge  of  a  much  larger  number  of 
bacilli.  The  intestinal  lesions  and  those  of  the  mesenteric  lymph  nodes 
with  which  they  are  almost  invariably  associated,  are  described  on  page  361. 

PeritoniBum. — In  infancy  the  peritonaeum  is  not  often  involved  even 
in  general  tuberculosis,  and  at  this  age  it  is  very  rare  for  it  to  be  the  seat 
of  the  principal  tuberculous  process.  This  occurred  but  once  in  my  own 
119  autopsies.  In  older  children  it  is  more  frequent;  of  the  131  Pendle- 
bury  Hospital  cases,  the  peritona3um  was  involved  in  37,  or  twenty-eight 
per  cent.  In  most  cases  of  general  tuberculosis  there  are  only  deposits 
of  miliary  tubercles;  less  frequently  there  are  tuberculous  nodules  with 
other  inflammatory  products.  The  lesions  in  these  cases  are  described  with 
Diseases  of  the  Peritongeum  (page  420). 

Thymus  gland. — In  three  of  my  cases  tuberculous  nodules  were  found 
in  the  thymus  body,  the  size  varying  from  a  small  pea  to  a  hazelnut. 
Some  of  the  largest  nodules  had  undergone  softening  at  the  centre.  All 
these  were  cases  showing  widely  disseminated  tuberculous  lesions. 

Pancreas. — In  three  of  my  cases  this  organ  also  was  the  seat  of  small 
tuberculous  nodules,  all  of  them  being  cases  of  general  tuberculosis. 

Uro-genital  organs. —  Serious  tuberculosis  of  any  part  of  the  urinary 
tract  is  very  rare  in  children.  Miliary  tubercles  were  found  in  the  kid- 
neys in  about  one  third  of  my  autopsies  on  tuberculous  patients.  They 
are  generally  few  in  number.  Tuberculous  nodules  of  the  kidney  I  have 
seen  but  once  in  a  young  child.  They  are  very  rare  before  the  fourteenth 
year  (page  623).  In  two  of  my  autopsies  tuberculous  nodules  were  found 
in  the  suprarenal  capsules.    Tuberculosis  of  the  testicle  has  been  observed 


THE  CLINICAL   FORMS  OP  TUBERCULOSIS.  1033 

in  rare  instances  among  children,  although  not  in  one  of  my  own  series. 
Koplik  (New  York)  has  reported  several  cases. 

Tuberculosis  of  the  bones  and  of  the  external  lymph  nodes  have  al- 
ready been  described  (pages  825  and  837) 

THE  CLINICAL   FORMS   OF   TUBERCULOSIS. 

I.  General  Tuberculosis. — Cases  of  tuberculosis  present  a  wide 
variety  in  their  symptomatology.  Almost  every  case  possesses  some  pecul- 
iar features  which  depend  upon  the  constitution  of  the  patient,  the  source 
of  infection,  the  rapidity  with  which  the  bacilli  are  disseminated  through 
the  body,  or  the  numbers  in  which  they  enter.  The  general  symptoms 
usually  precede  the  local  ones,  but  in  probably  the  majority  of  cases  they 
are  masked  and  unrecognised.  It  is  not  often  possible  to  recognise  tuber- 
culosis until  the  process  is  quite  well  advanced  in  some  one  organ.  The 
early  symptoms  in  most  cases  are  very  indefinite  and  susceptible  of  many 
explanations. 

1.  Cases  Resembling  Infantile  Marasmus. — In  early  infancy,  tubercu- 
losis often  gives  at  first  and  for  a  long  time  only  the  symptoms  of  maras- 
mus. Infants  are  pale  and  thin,  they  do  not  gain  in  weight,  and  finally 
become  emaciated.  There  is  nothing  characteristic  about  these  symp- 
toms, and  it  should  be  remembered  that  they  depend  much  more  fre- 
quently upon  simple  marasmus  than  upon  tuberculosis.  There  may  be  no 
cough  and  no  fever  sufficient  to  attract  attention,  and  the  case  may  even 
go  on  to  a  fatal  termination  without  any  symptoms  except  those  of  in- 
fantile marasmus..  This  I  have  seen  at  least  a  dozen  times  in  cases  that 
came  to  autopsy. 

More  frequently,  however,  there  are  developed  toward  the  end  of  the 
disease  both  the  symptoms  and  signs  of  pulmonary  disease  and  fever. 
These  are  generally  found  together,  as  the  process  in  the  lungs  is  the  cause 
of  the  rise  of  temperature.  The  febrile  symptoms  are  often  not  seen  until 
the  last  two  or  three  weeks  of  life.  The  course  of  the  temperature  is  ir- 
regular. It  is  never  of  the  hectic  tyjoe  and  I'arely  high.  The  usual  range 
is  between  100°  and  102°  F.  The  pulmonary  symptoms  are  generally  few 
and  not  very  well  marked.  There  is  usually  some  cough,  but  it  is  rarely 
severe.  The  breathing  is  more  rapid  than  would  be  explained  by  the 
temperature  alone.  Severe  dyspnoea  and  cyanosis  are  rare,  and  are  seen 
only  at  the  close  of  the  disease.  The  physical  signs  are  those  of  either 
localized  bronchitis  or  of  broncho-pneumonia. 

The  other  symptoms  usually  relate  to  the  digestive  tract.  There  may 
be  indigestion,  with  occasional  vomiting  and  green  undigested  stools,  or 
there  may  be  diarrhoea.  The  intestinal  symptoms  depend  on  the  general 
condition  of  the  child  and  the  constitutional  disease,  rarely  upon  a  tuber- 
culous process  in  the  stomach  or  bowels. 

If  the  case  has  gone  on  to  the  development  of  constant  fever  and  rec- 


1034  THE   SPECIFIC   INFECTIOUS   DISEASES. 

ognisable  physical  sigus  wliich  slowly  spread,  the  infant's  fate  is  sealed. 
The  progress  of  the  case  from  this  time  is  steadily  downward,  and  the 
child  can  live  at  most  but  a  few  weeks.  Death  generally  occurs  from  pro- 
gressive asthenia  without  the  development  of  any  new  symptoms.  Occa- 
sionally toward  the  close,  cerebral  symptoms  rapidly  develop,  and  the 
child  IS  carried  off  in  a  few  days  by  tuberculous  meningitis ;  sometimes 
there  is  a  rapid  spreading  of  the  disease  in  the  lungs,  and  death  occurs 
with  symptoms  of  simple  acute  pneumonia. 

Diagnosis. — The  difficulty  in  diagnosis  is  chiefly  during  the  first  year 
of  life.  Every  circumstance  in  the  patient's  surroundings  and  family 
history  which  bears  upon  the  development  of  tuberculosis  must  be 
weighed  to  establish  the  fact  of  inheritance  or  of  exposure  to  contagion. 
In  simple  wasting,  the  usual  history  is  that  the  infant  was  plump  and  well 
nourished  at  birth.  A  sufficient  cause  for  its  condition  can  in  most 
cases  be  found  in  improper  or  insufficient  nourishment  or  the  want  of 
proper  care.  (See  causes  of  marasmus,  page  204.)  Often  the  wasting 
follows  some  acute  disease  of  infancy,  most  frequently  some  form  of  gas- 
tro-intestinal  disease. 

In  tuberculosis,  the  infant  may  show  all  the  signs  of  malnutrition  at 
birth,  but  in  most  cases  they  are  of  later  development.  They  either  come 
without  adequate  cause,  or  are  associated  with  pulmonary  disease  or  they 
follow  measles  or  pertussis.  No  explanation  of  the  wasting  can  be  dis- 
covered in  the  food,  the  surroundings,  or  in  the  condition  of  the  digestive 
organs.  Diarrhoea  and  vomiting  more  frequently  follow  than  precede  it. 
The  above  facts  are  sufficient  to  warrant  a  suspicion  only  that  tubercu- 
losis is  present  until  some  local  manifestation  occurs,  usually  in  the  lungs. 
The  early  wasting  without  adequate  cause,  followed  by  the  gradual  devel- 
opment of  low  fever,  and  finally  the  appearance  of  signs  of  subacute 
broncho-pneumonia,  form  the  most  characteristic  features  of  general  tu- 
berculosis in  early  infancy.  Yet  all  these  symptoms  are  occasionally  met 
with  in  cases  in  which  the  autopsy  show^s  none  of  the  lesions  of  tubercu- 
losis, for  simple  broncho-pneumonia  frequently  occurs  in  patients  suffer- 
ing from  marasmus;  but  in  such  cases  fever  is  usually  slight  and  it  may 
be  absent. 

The  wasting  and  cachexia  of  hereditary  syphilis  sometimes  resemble 
tuberculosis,  but  the  early  history  in  syphilis  is  usually  so  characteris- 
tic, and  other  symptoms  of  the  disease  are  so  rarely  wanting,  that  the 
mistake  is  not  likely  to  be  made  if  a  patient  is  submitted  to  a  careful  ex- 
amination. In  the  absence  of  definite  syphilitic  symptoms  the  chances 
are  greatly  in  favour  of  tuberculosis. 

2.  Cases  in  Older  Children  with  Symptoms  Resembling  a  Continued 
Fever. — Before  the  development  of  fever  in  these  cases,  there  is  usually 
quite  a  protracted  period  of  very  indefinite  symptoms,  each  one  of  which 
alone  is  unimportant,  but  all  of  which  taken  together  should  excite  sus- 


THE   CLINICAL  FORMS  OP  TUBERCULOSIS.  1035 

picion.  Such  children  are  usually  delicate ;  they  are  persistently  anaemic 
without  sufficient  reason ;  they  often  show  a  loss  in  weight ;  there  is  a 
marked  cachexia,  sometimes  a  capricious  appetite,  and  a  digestion  easily 
disturbed.  In  some  of  them  a  change  in  disposition  is  observed,  and 
they  become  peevish  or  fretful  and  are  disinclined  to  muscular  exertion. 
All  these  symptoms  indicate  a  gradual  decline  in  the  general  health. 

This  clinical  picture  may  be  due  to  many  causes,  but  it  should  always 
arouse  in  the  mind  of  the  physician  a  suspicion  of  incipient  tuberculosis, 
particularly  in  a  child  who  by  surroundings  or  inheritance  is  predisposed 
to  that  disease.  After  these  indefinite  symptoms  have  lasted  a  few  weeks 
fever  is  added.  Sometimes  the  prodromal  symptoms  are  absent  or 
unnoticed  and  fever  is  the  first  evident  symptom.  This  fever  is  peculiar 
in  that  it  comes  without  evident  cause  and  without  any  local  manifesta- 
tions of  disease.  The  temperature  is  not  often  high,  but  it  is  continuous. 
The  tympanites  and  the  rose-coloured  spots  are  not  present,  but  the  gen- 
eral aspect  of  the  patient  is  strikingly  like  that  belonging  to  typhoid 
fever. 

After  the  fever  has  lasted  from  one  to  three  weeks  there  develop  some 
signs  of  localized  tuberculosis,  generally  in  the  lungs,  or  the  fever  may 
decline  gradually,  and  although  the  patient  improves  he  does  not  get 
well.  He  is  still  weak  and  does  not  gain  in  weight,  and  the  thermometer 
shows  the  existence  of  a  very  slight  amount  of  fever.  Before  long  he 
may  grow  rapidly  worse  and  the  course  of  the  temperature  becomes  irreg- 
ular, with  alternate  exacerbations  and  remissions.  Such  an  irregular  and 
inexplicable  fever  sometimes  puzzles  the  physician  for  three  or  four  weeks 
before  the  characteristic  features  which  stamp  the  process  as  tuberculous 
are  present.  One  general  symptom  is  almost  invariably  associated  with 
the  fever,  viz.,  wasting.  This  may  not  be  rapid,  but  is  progressive.  The 
tuberculous  cachexia  is  frequently  unmistakable  ;  but  in  most  of  the  cases 
one  must  wait  for  the  process  to  advance  far  enough  in  some  one  of  the 
organs  to  give  local  signs  or  symptoms  before  he  can  be  sure  of  tuberculo- 
sis. In  four  cases  out  of  five  this  is  in  the  lungs.  Less  frequently  it  is 
in  the  peritoneum,  the  brain,  or  a  general  infection  of  the  lymph  glands 
throughout  the  body.  If  in  the  lungs,  the  process  manifests  itself  as  a 
broncho-pneumonia  whose  tuberculous  character  may  be  suspected  from 
its  localization — the  apex  or  the  middle  of  the  lung  in  front — but  chiefly 
from  the  fact  that  the  general  symptoms,  fever  and  wasting,  have  for  so 
long  a  time  preceded  the  local  signs  of  disease.  From  this  time,  the 
course  of  the  disease  may  be  that  of  a  typical  tuberculous  broncho- 
pneumonia. 

If  the  tuberculous  process  is  localized  in  the  brain,  we  have  dulness, 
vomiting,  headache,  apathy,  irregular  pulse,  irregular  respiration,  and 
finally  convulsions  and  coma — in  short,  the  symptoms  of  tuberculous 
meningitis ;   if  in  the  peritonasum,  we  have  abdominal  distention  from 


1036  THE  SPECIFIC   INFECTIOUS   DISEASES. 

gas  or  fluid,  tenderness,  pain,  diarrhoea,  or  constipation ;  if  in  the  lymph 
glands,  there  is  a  general  enlargement  of  those  situated  in  the  neck,  and 
sometimes  those  of  the  axillary  and  inguinal  regions,  with  symptoms  indi- 
cating similar  changes  in  those  at  the  root  of  the  lung. 

Diagnosis. — In  distinguishing  general  tuberculosis  from  typhoid  fever, 
very  great  stress  is  to  be  laid  on  the  family  and  previous  history  of  the 
patient  and  the  surroundings,  as  favouring  tuberculosis.  On  the  other 
hand,  the  prevalence  of  typhoid  fever  in  the  family,  the  neighbourhood, 
or  the  institution  in  which  the  case  occurs,  is  important.  The  extreme 
infrequency  of  typhoid  in  children  under  two  years  old  should  always 
lead  the  physician  to  scrutinize  very  carefully  every  case  in  which  he  is 
disposed  to  make  such  a  diagnosis  at  that  time  of  life.  In  typhoid,  the 
course  of  the  fever  is  more  regular  than  in  tuberculosis,  but  less  so  than 
in  the  typhoid  of  adults,  and  the  spleen  in  nearly  every  case  is  sufficiently 
enlarged  to  be  easily  felt  below  the  ribs.  The  rose  spots  are  usually  pres- 
ent. But  the  most  conclusive  evidence  is  that  afforded  by  the  blood 
reaction  in  Widal's  serum-test ;  without  this,  by  the  gradual  cessation 
of  the  fever  in  the  third  or  fourth  week  and  complete  recovery  of  the 
patient. 

In  tuberculosis,  on  the  contrary,  the  fever  is  less  regular.  It  common- 
ly shows  wider  fluctuations,  the  spleen  is  not  usually  enlarged,  and  there 
are  no  rose  spots.  Tympanites  and  abdominal  tenderness  are  sometimes 
seen,  but  the  fever  shows  no  disposition  to  stop  after  the  third  week, 
and  the  wastiug  is  continuous.  The  signs  in  the  lungs,  at  first  few,  in- 
crease from  day  to  day.  In  most  cases  one  must  wait  for  ten  days  at 
least,  and  in  many  three  weeks,  before  a  positive  diagnosis  can  be  made. 

II.  Tuberculous  Broncho-Pneumoj^ia.— This  occurs  clinically  un- 
der the  following  conditions  :  (1)  It  may  begin  in  the  lungs  or  extend  to 
the  lungs  from  the  bronchial  glands,  the  symptoms  in  either  case  being 
essentially  pulmonary  from  the  outset.  (3)  It  may  follow  either  form 
of  general  tuberculosis  described — that  resembling  marasmus  in  infants, 
or  that  resembling  a  continued  fever  in  older  children.  In  both  of  these 
the  pulmonary  symptoms  develop  gradually  in  the  course  of  the  general 
symptoms  of  the  disease.  (3)  It  may  occur  in  the  course  of  any  of  the 
forms  of  local  tuberculosis, — of  the  bones,  peritonaeum,  intestines,  external 
lymph  glands,  or  skin.  In  such  cases  the  invasion  of  the  lungs  frequently 
marks  the  last  stage  of  the  process.  (4)  It  may  follow  any  of  the  infec- 
tious diseases,  especially  measles  or  pertussis,  even  though  they  are  not  com- 
plicated by  broncho-pneumonia,  but  more  frequently  when  they  are,  (5) 
It  may  follow  single  or  repeated  attacks  of  simple  bronchitis  or  pneumonia. 

Clinically  the  cases  may  be  divided  into  three  groups :  First,  the  most 
rapid  ones,  lasting  from  one  to  three  weeks ;  secondly,  those  running  a 
more  protracted  course,  with  a  duration  of  from  three  weeks  to  three 
months ;  thirdly,  those  which  are  more  or  less  chronic.     In  the  first  two 


THE  CLINICAL   FORMS   OF   TUBERCULOSIS.  1037 

groups  the  progress  is  nearly  always  steadily  downward,  and  a  fatal  ter- 
mination the  almost  inevitable  result ;  in  the  third  form  the  course  is  more 
irregular,  and  marked  by  a  series  of  exacerbations  and  remissions. 

1.  The  Most  Eapid  Cases. — In  this  form  of  the  disease  there  are  found 
scattered  through  certain  portions  or  nearly  the  whole  of  both  lungs,  mili- 
ary tubercles  and  minute  tuberculous  nodules,  the  intervening  parts  of 
the  lung  being  involved  more  or  less  seriously  in  a  simple  inflammation. 
In  most  of  the  cases  the  clinical  picture  is  that  of  simple  acute  broncho- 
pneumonia, for  it  is  to  the  accompanying  broncho-pneumonia,  and  not  to 
the  scattered  tuberculous  deposits  themselves,  that  the  symptoms  and  the 
physical  signs  are  due.  The  development  of  the  disease,  although  acute, 
is  not  usually  abrupt.  There  are  present,  fever,  cough,  dyspnoea,  acceler- 
ated respiration,  prostration,  and  sometimes  cyanosis.  The  temperature 
in  these  cases  is  never  hectic,  but  its  course  is  a  somewhat  irregular  one 
the  usual  range  being  between  100°  and  104°  F.  In  most  of  the  cases  it 
differs  in  no  respect  from  the  temperature  of  simple  broncho-pneumonia. 
Sometimes  it  is  seen  that  the  general  symptoms  are  severe  and  the  phys- 
ical signs  wide-spread,  and  yet  the  range  of  temperature  is  not  high.  To 
be  sure,  this  is  occasionally  seen  in  a  simple  broncho-pneumonia,  but  it  is 
more  frequent  in  tuberculosis.  The  cough  early  in  the  disease  is  slight, 
but  later  becomes  severe  and  often  distressing.  In  infants  and  young 
children  it  may  be  of  a  paroxysmal  character,  resembling  pertussis.  Ex- 
pectoration is  wanting  in  infancy,  and  is  not  often  seen  in  those  under 
seven  years,  so  that  bacilli  in  the  sputum  is  a  symptom  of  only  a  small 
number  of  cases.     Bloody  expectoration,  likewise,  is  rare  in  children. 

The  conditions  in  the  lungs  which  give  physical  signs  are  bronchitis 
of  the  smaller  tubes,  with  areas  of  complete  or  partial  consolidation.  In 
character,  these  signs  are  identical  with  those  of  simple  broncho-pneu- 
monia (page  499).  They  may  be  scattered  throughout  the  whole  of  both 
lungs;  but  when  localized  they  are  more  frequently  in  the  upper  than  in 
the  lower  lobes,  and  rather  more  frequently  in  front  than  behind.  Al- 
though both  lungs  are  involved,  they  are  usually  not  affected  to  the  same 
degree.  The  patient  may  die  before  signs  of  complete  consolidation  are 
present;  more  often  there  are  during  the  last  few  days  small  areas  of 
partial  consolidation,  as  shown  by  broncho-vesicular  breathing,  exagger- 
ated voice,  and  slight  dulness.  These  signs  may  be  due  to  the  simple 
broncho-pneumonia,  and  are  often  found  in  the  lower  lobes  behind. 
Large  areas  of  complete  consolidation,  with  pure  bronchial  breathing, 
bronchial  voice,  and  marked  dulness  are  infrequent. 

From  the  beginning  of  acute  symptoms  the  progress  of  the  disease  is 
steadily  downward,  death  resulting  from  the  same  causes  as  in  simple 
broncho-pneumonia.  The  end  is  marked  by  cyanosis,  great  dyspnoea, 
weak  pulse,  and  extreme  prostration.  In  a  few  cases  there  develop  shortly 
before  death  cerebral  symptoms,  indicating  tuberculous  disease  of  the 


1038 


THE   SPECIFIC   INFECTIOUS   DISEASES. 


brain.  Such  symptoms  may  be  the  first  to  lead  the  physician  to  suspect 
the  process  to  be  a  tuberculous  one.  In  these  cases  death  may  occur  in 
convulsions  in  two  or  three  days  from  the  first  cerebral  symptoms.  In 
other  cases  the  course  is  slower,  with  tlie  typical  symptoms  of  meningitis. 
2.  The  More  Protracted  Cases. — In  this  form  of  the  disease  there  are 
found  in  the  lungs  caseous  nodules,  with  larger  areas  of  caseous  pneu- 
monia, and  usually  some  spots  of  softening.  The  process  is  not  usually  so 
generalized  as  in  the  cases  just  described,  but  as  in  them  there  is  always 


DAY 

1 

3 

3 

i 

5 

G 

1 

8 

9     10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

29 

30 

106° 

105° 
104° 
103° 
102° 
101° 
100° 
99° 
98° 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

ME 

ME 

M  E 

M  E 

M  E 

M  E 

M  E 

ME 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

ME 

M  E 

M  E 

M  E 

M  E 

M  £ 

A 

A 

\l\ 

A 

f. 

\ 

A 

A 

h 

11 

1 

\f\ 

/ 

A 

\ 

\ 

\/ 

U 

K 

h 

\ 

1 

A 

V 

V 

A 

A 

/ 

s/ 

V 

V 

V 

sl 

4 

\ 

l' 

T 

l\ 

\ 

\ 

A 

\ 

^ 

/ 

\r 

J 

» 

\ 

1 

^, 

1 

1 

\l 

\r 

\ 

\ 

/ 

s; 

\ 

J 

V 

\\ 

V 

V 

V 

} 

DAY 

31 

32 

33 

34 

35 

36 

37 

38 

39 

40 

41 

42 

43 

44 

70 

71 

72 

73 

74 

75 

76 

77 

78 

79 

80 

81 

82 

83 

S4 

100° 

105° 
104° 
103° 
102° 
101° 
100 
99° 
98° 

M  E 

M  E 

M  E 

ME 

M  E 

ME 

M  E 

M  E 

ME 

ME 

ME 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

ME 

M  E 

M  E 

M  E 

ME 

M  E 

M  E 

M  E 

/I 

1 

A 

^ 

h 

A 

/ 

\/ 

1 

\ 

\       1 

/ 

/I 

1 

r 

•\ 

1" 

\ 

'\ 

hi 

»^ 

y 

V 

I 

1 

w 

^ 

r 

J 

\/ 

/ 

v 

1 

A 

» 

1 

1 

/ 

k 

V 

\ 

V 

\ 

I 

u 

V 

V 

y 

V 

^ 

r- 

/ 

\/\ 

\/^ 

1 

J 

\ 

\_ 

J 

V 

V 

^ 

Fig.  177.— Tuberculosis  followinpr  measles.  Child  sixteen  months  old.  inmate  of  an  institu- 
tion. Chart  begins  on  tifth  day  of  a  severe  but  uncomplicated  attack  of  measles,  and  shows 
a  natural  decline  to  normal.  Fever  then  returned  and  continued  till  death,  twelve  weeks 
later.  Record  for  the  period  which  is  omitted  was  much  like  that  which  immediately  pre- 
cedes and  follows.  Early  symptoms  not  acute,  only  .slow  wastinsr.  slitrht  eough  and"  fever, 
with  scattered  rales  throughout  chest.  Signs  of  consolidation  not  distinct  till  eighth  week, 
then  present  in  right  upper  lobe.  Toward  the  end,  rapid  emaciation,  marked  pulmonary 
symptoms,  and  signs  of  cavity  at  right  apex.  Autopsy  showed  a  large  cavity,  extensive 
tuberculous  deposits  throughout  both  lungs  and  in  nearly  all  abdominal  organs.' 

associated  a  certain  amount  of  simple  pneumonia.  This  is  the  most  fre- 
quent and  most  characteristic  form  of  pulmonary  tuberculosis  in  infancy 
and  early  childhood.  Its  usual  duration  is  from  one  to  three  months;  its 
course  is  then  steady  and  uninterrupted.  In  its  slower  or  subacute  form 
it  lasts  from  three  to  six  months,  and  its  course  is  then  more  irregular. 

The  mode  of  onset  will  depend  upon  the  conditions  under  which  the 
disease  develops.  When  the  general  symptoms  of  tuberculosis — fever  and 
wasting, — have  preceded  those  in  the  lungs,  the  evolution  of  the  latter 
is  gradual,  with  cough,  rapid  breathing,  dyspnoea,  increased  prostration, 


THE  CLINICAL  FORMS  OP  TUBERCULOSIS. 


1039 


etc.  When  the  pulmonary  symptoms  are  present  from  the  beginning,  they 
are  the  same  as  in  simple  broncho-pneumonia,  with  the  exception  that  they 
usually  come  on  less  acutely.  The  latter  is  true  of  cases  which  are  second- 
ary to  some  other  form  of  tuberculosis  in  the  bones,  peritonaeum,  etc. 

When  pulmonary  tuberculosis  follows  measles  (Fig.  177)  or  whooping- 
cough  which  has  been  complicated  by  simple  pneumonia,  the  early  symp- 
toms may  present  no  unusual  features.  After  two  or  three  weeks  the  tem- 
perature gradually  falls,  and  the  physical  signs  improve,  but  neither  quite 
disappears.  The  cough  continues,  though  its  severity  somewhat  abates. 
In  the  course  of  a  few  weeks  the  child,  who  has  meanwhile  improved  some- 
what in  his  general  condition,  becomes  distinctly  worse,  often  without  any 
assignable  cause.  The  temperature  rises  to  103°  or  103°  F. ;  the  cough 
increases,  and  an  extension  of  the  disease  in  the  lungs  is  evident  by  the 
physical  signs.  In  other  cases  the  progress  of  the  disease  after  the  pneu- 
monia which  complicated  measles  is  without  an  intervening  period  of 
apparent  improvement.  It  sometimes  happens  that  the  attack  of  measles 
or  whooping-cough  is  not  accompanied  by  any  serious  pulmonary  symp- 
toms, and  the  case  goes  on  to  apparent  recovery,  except  that  there  remain 
anaemia,  a  slight  cough,  and  fever.  The  temperature,  although  not  high, 
persists ;  but  it  may  be  two  or  three  weeks  before  there  are  present  definite 
symptoms  and  signs  of  disease  in  the  lungs. 

Fever  is  a  constant  accompaniment  of  all  active  tuberculous  processes 
in  the  lungs  in  the  child  as  in  the  adult,  it  being  absent  only  during  the 
periods  of  remission  which  occur  in  the  cases  of  slow  and  irregular  prog- 


DAY 

1 

1 

3    4 

5 

G 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

" 

18  19 

20 

21 

22 

23 

24 

25 

26  27 

28 

29  30 

31 

32 

33 

34 

35 

3C 

37 

38139 

40 

41 

42 

43 

44 

45 

46 

47 

106° 
103° 
104° 
103° 
102° 
101° 
100° 
99° 
98 

.1 

" 

"' 

" 

.E 

"' 

•■ 

"' 

" 

" 

"' 

"■ 

.E 

<[ 

"' 

" 

"' 

" 

.1 

"' 

" 

.E 

"' 

"' 

"■ 

.E 

" 

"' 

.E.E 

.e 

"■ 

"' 

"' 

«E 

" 

-E 

•' 

>E 

" 

"■ 

■" 

"' 

"• 

"' 

•' 

.E 

1 

' 

/ 

V 

\ 

\ 

- 

I 

^- 

A- 

^ 

A 

,/\ 

/ 

V 

■\ 

r" 

\ 

/ 

\h 

r 

->v 

\^ 

/ 

\ 

/ 

V 

\ 

/ 

f\ 

y 

^ 

"V 

^ 

J 

/ 

\ 

— / 

V 

\ 

/ 

I 

/^ 

J 

V 

V 

/• 

\ 

\ 

/ 

' 

J 

\ 

\ 

/^ 

^ 

\J 

\ 

1 

1 

Fio.  178. — Tuberculous  pneumonia,  general  tuberculosis.  Patient  eleven  months  old,  and  under 
observation  at  the  time  he  was  taken  sick.  Chart  of  entire  illness  is  gfiven.  Disease  began 
as  an  acute  pneumonia  in  lower  part  of  left  axilla  and  spread  to  entire  lower  lobe.  Early 
signs  of  consolidation;  at  end  of  two  weeks,  tlatness  so  marked  that  a  needle  was  inserted, 
fluid  being  su.speeted.  Vomited  frequently,  and  had  loose  discharges  from  bowels  through- 
out the  illness  ;  abdomen  much  swollen  for  last  two  weeks.  Autopsy  showed  cheesy  pneu- 
monia of  part  of  the  upper  and  the  entire  left  lower  lobe,  where  were  two  small  cavities. 
Recent  tubercles  found  throughout  right  lung,  and  extensive  deposits  in  abdominal  organs 
with  peritonitis,  intestinal  ulcers,  etc. 

ress.  It  is  a  very  important  guide  to  the  progress  of  the  disease.  The 
early  fever  depends  chiefly  upon  the  coexisting  broncho-pneumonia, 
and  its  course  resembles  that  of  simple  pneumonia  of  the  protracted 
variety.  There  is  no  typical  curve.  The  fever  is  not  often  steadily  high, 
and  in  many  cases  it  is  never  high  (Fig.  178).  It  frequently  runs  for 
67 


1040 


THE  SPECIFIC  INFECTIOUS  DISEASES. 


several  days  between  99°  and  102°  F.,  and  then,  without  evident  cause, 
rises  to  104°  F.  or  over ;  again,  it  may  be  scarcely  over  100°  F.  for  days 
together.  In  infants  the  morning  temperature  is  frequently  subnormal, 
although  the  evening  temperature  may  be  102°  or  103°  F.  Even  toward 
the  close  of  the  disease,  when  softening  and  breaking  down  are  actively 
going  on,  the  regular  hectic  temperature  of  adults  is  rarely  seen  in  a 
young  child  (Fig.  179).     While  the  presence  of  fever  is  of  great  signifi- 


w- 

1 

^^ 

s 

4 

o 

0 

7 

8 

•J 

10 

11 

1-.' 

l.i 

H 

15 

lU 

17 

IS 

I'j 

2i> 

:;i 

■2-J 

■2  1 

:;4 

L'5 

■20 

i7 

•JS 

•-"J 

t- 

Ul 

I 
z 

ir 

I 
< 

100 
105 
104 
103 
102 
101 
10(1 
99 
98 
97° 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M   £ 

M  E 

M  E 

M  E 

M  E 

ME 

M  E 

M   E 

M  E 

M  E 

1 

^'       1 

\ 

f. 

A 

sr./\ 

\/\ 

A 

/ 

J\ 

^ 

V 

j 

A 

/ 

, 

V 

V 

\ 

1 

P 

\/'\ 

^ 

A 

A 

V\ 

/ 

/ 

\i^ 

I 

1 

/i 

\ 

1 

i 

V 

l^ 

J 

J 

I 

V 

V 

\l 

^ 

i 

^ 

L 

_ 

Fig.  179. — Tuberculous  pneumonia,  with  extensive  softening  and  excavation.  A  delicate  child, 
thirteen  months  old  ;  weight,  ten  pounds;  came  under  observation  four  weeks  before  death, 
with  consolidation  at  apex  of  right  lung.  Signs  increased  in  intensity,  and  extended  in  area 
until  tiiere  were  heard,  from  clavicle  to  beloV  the  nipple — exaggerated  bronchial  voice  and 
breathing  and  many  moist  rales;  percussion  note  was  flat;  behind,  the  same  signs  at  ex- 
treme apex.  No  distinct  signs  of  a  cavity ;  no  hectic  fever ;  no  sweating.  Autopsy  showed 
large  cavity  (Fig.  173)  at  right  apex  partly  filled  with  caseous  masses  ;  diffuse  caseous  pneu- 
monia (Fig.  172)  of  the  rest  of  right  upper  lobe,  with  scattered  deposits  in  the  other  lobes, 
the  opposite  lung,  and  a  few  in  the  abdominal  organs. 

cance,  its  course  has  almost  no  diagnostic  importance  in  early  life.  Espe- 
cially should  one  beware  of  drawing  the  conclusion  that,  because  the  fever 
is  not  hectic,  therefore  there  is  no  breaking  down  of  the  lung. 

Sweating  belongs  only  to  the  late  stage  of  the  disease,  and  is  usually 
associated  with  the  hectic  type  of  fever ;  both  these  are  regular  symptoms 
in  children  over  seven  years  old,  but  not  in  very  young  children. 

Wasting,  like  fever,  is  characteristic  of  all  active  tuberculous  processes. 
Whenever  they  are  associated,  tuberculosis  should  always  be  suspected, 
no  matter  how  obscure  the  other  symptoms  may  be.  The  wasting  is  not 
always  rapid,  but  it  is  usually  continuous  while  fever  lasts.  During  the 
periods  of  temporary  improvement,  children  may  not  only  cease  to  lose, 
but  may  actually  gain  in  weight.  In  the  early  stage  of  the  disease,  wast- 
ing is  especially  suggestive  when  it  continues  without  apparent  cause 
after  measles  or  pertussis,  or  when  it  persists  under  other  circumstances 
in  spite  of  a  good  appetite  and  apparently  good  digestion.  It  may  at 
first  be  so  slight  as  not  to  be  noticed  unless  the  scales  are  employed.  In 
obscure  cases  this  steady  loss  of  weight  is  a  point  of  much  diagnostic 
value,  and  is  frequently  overlooked.  Toward  the  close  of  the  disease  there 
is  rapid  and  frequently  extreme  emaciation. 

Cough,  although  almost  invariably  present,  shows  no  peculiarities.  It 
may  be  hard,  dry,  or  suppressed ;  it  sometimes  occurs  in  paroxysms  re- 


THE  CLINICAL  FORMS  OF  TUBERCULOSIS.  1041 

sembling  pertussis,  which  may  or  may  not  depend  upon  the  presence  of 
enlarged  bronchial  glands. 

Expectoration  is  absent  in  infants,  the  matters  coughed  up  being 
swallowed.  In  children  over  seven  years  old,  we  often  get  a  profuse  muco- 
purulent expectoration,  but  it  is  very  exceptional  below  this  age. 

Haemoptysis  is  a  rare  symptom,  but  not  unknown  even  in  young  chil- 
dren. Henoch  has  reported  a  case  of  fatal  haemoptysis  in  a  child  ten 
months  old,  where  the  haemorrhage  was  due  to  the  rupture  of  an  aneurism 
in  the  wall  of  a  cavity.  Herz,  in  247  clinical  cases  of  tuberculosis  in  chil- 
dren, records  8  of  haemoptysis — 4  of  them  under  five  years,  and  the  young- 
est only  eighteen  months  old.  The  records  of  131  autopsies  on  tubercu- 
lous children  in  the  Pendlebury  Hospital,  show  that  haemoptysis  was  four 
times  a  cause  of  death ;  two  of  these  patients  were  under  five  years,  and 
one  was  only  twelve  months  old.  I  have  never  met  with  a  case  of  hsemop- 
tysis  under  five  years  old.  As  in  adults,  fatal  haemoptysis  is  usually  due 
to  the  opening  of  a  large  vessel  by  ulceration  in  the  wall  of  a  cavity,  which 
is  sometimes  in  the  lung  and  sometimes  in  one  of  the  bronchial  glands. 

The  respiration  in  all  cases  of  tuberculous  pneumonia  is  accelerated, 
and  usually  out  of  proportion  to  the  rise  in  temperature.  As  the  lung 
becomes  more  and  more  extensively  invaded  there  is  constant  dyspnoea. 
The  pulse  is  rapid  in  the  early  stage,  and  continues  so  throughout  the 
disease;  toward  the  end  it  becomes  weak  and  irregular.  Irregular  respi- 
ration and  a  slow,  irregular  pulse,  may  occur  at  any  time  from  the  develop- 
ment of  cerebral  complications. 

Pleuritic  pains  in  the  chest  are  not  frequent  in  children.  Gastro- in- 
testinal symptoms,  such  as  indigestion,  vomiting,  diarrhoea,  etc.,  are  gen- 
erally present,  but  are  not  peculiar  in  this  disease.  They  usually  depend 
upon  the  patient's  general  condition,  only  exceptionally  upon  tuberculous 
disease  of  the  stomach  or  intestines.  The  characteristic  symptoms  of 
intestinal  tuberculosis — abdominal  pain,  tenderness,  uncontrollable  diar- 
rhoea, and  intestinal  haemorrhage — are  not  often  met  with  in  children 
under  five  years.  With  such  symptoms,  and  sometimes  when  they  are 
doubtful  or  absent,  careful  palpation  of  the  abdomen  may  disclose  the 
presence  of  enlarged  mesenteric  glands.  When  these  are  not  readily  felt 
through  the  abdominal  walls,  they  may  sometimes  be  discovered  by  a  rec- 
tal examination  after  the  method  of  Carpenter  (London). 

The  spleen  is  often  enlarged,  sometimes  very  much  so,  but  this  does 
not  occur  with  sufficient  frequency  to  be  of  much  diagnostic  value.  It 
may  be.  due  to  tuberculous  deposits,  to  causes  connected  with  the  lungs  or 
heart,  or  to  fever.  The  liver  is  never  enlarged  from  tuberculous  deposits, 
but  may  be  so  from  amyloid  or  fatty  degeneration,  or  from  obstructed 
circulation,  as  in  the  case  of  the  spleen. 

Dropsy  is  rare  and  seen  only  toward  the  close  of  the  disease.  It  may 
depend  upon  anaemia,  upon  complicating  nephritis,  especially  amyloid  de- 


1042  THE  SPECIFIC  INFECTIOUS  DISEASES. 

generation,  upon  cardiac  or  pulmonary  conditions  leading  to  interference 
with  the  return  circulation,  or  uj^on  pressure  of  tuberculous  retro-perito- 
neal or  mesenteric  glands  upon  the  inferior  vena  cava.  Clubbing  of  the 
fingers  is  occasionally  seen  in  cases  running  a  very  protracted  course,  and 
is  due  to  obstructed  circulation. 

Ansemia  is  commonly  associated  with  wasting,  and  it  is  of  special  im- 
portance where  the  latter  is  slight  or  absent.  It  is  a  frequent  sequel  of 
acute  disease  in  infancy  when  not  dependent  on  tuberculosis ;  when,  how- 
ever, it  is  associated  with  low  fever,  cough,  and  persistence  of  rales  in  the 
chest,  it  should  always  excite  apprehension. 

3.  Chronic  Tuberculous  Pneumonia. — In  young  children  this  is  a  chronic 
interstitial  pneumonia  associated  with  tuberculous  deposits.  These  cases 
have  usually  had  their  beginning  in  one  of  the  more  acute  forms  just  de- 
scribed. The  primary  attack  runs  a  tedious,  protracted  course ;  there  are 
a  slow  convalescence  and  apparent  recovery,  although  this  is  not  complete. 
Often  a  slight  cough  remains,  or  returns  from  the  slightest  exposure  or 
other  exciting  cause.  The  child  does  not  regain  his  former  weight  or 
vigour,  and  careful  examination  of  the  lungs  shows  that  some  abnormal 
signs  remain.  There  are  frequently  present  feeble  breathing  and  slight 
dulness  over  the  affected  part  of  the  lung,  and  occasionally  friction- 
sounds  may  be  heard. 

After  a  few  months,  possibly,  the  child  has  another  attack  resembling 
the  first  and  running  the  same  tedious  course.  It  is  accompanied  by  fever, 
cough,  and  perhaps  there  is  a  fresh  consolidation  of  some  part  of  the  lung, 
generally  in  the  neighbourhood  of  the  old  disease.  All  active  symptoms 
finally  subside,  and  most  of  the  signs  of  recent  disease  disappear ;  but  it  is 
usually  found  then  that  the  lung  is  not  quite  in  so  good  condition  as  it 
was  before  this  second  illness.  The  acute  attacks  may  be  repeated  several 
times  and  pass  under  the  name  of  bronchitis,  broncho-pneumonia,  or 
pleurisy.  They  may  extend  over  a  period  of  two  or  three  years  or  even 
longer.  The  general  health  in  the  interval  is  not  good,  there  being  present 
in  most  cases  anjemia,  with  the  usual  symptoms  of  malnutrition  ;  the  chil- 
dren are  regarded  as  being  very  delicate. 

The  course  of  this  disease  thus  differs  in  no  essential  particulars  from 
that  of  simj^le  chronic  broncho-pneumonia  (page  535) ;  the  physical  signs 
likewise  are  identical  in  character,  although  they  may  differ  in  their  loca- 
tion. They  are  generally  found  in  the  same  situations  as  are  the  signs  in 
the  more  rapid  forms  of  pulmonary  tuberculosis  in  early  childhood.  A 
fatal  result  in  these  cases  is  usually  brought  about  in  one  of  three  ways : 
(1)  by  the  development  of  acute  tuberculous  pneumonia  or  miliary  tuber- 
culosis of  the  lungs,  occurring  with  the  symptoms  of  one  of  the  previous 
exacerbations  which  has  come  on  without  apparent  cause  or  perhaps  has 
followed  an  attack  of  measles  or  whooping-cough ;  (2)  by  tuberculous 
meningitis ;  (3)  by  a  simple  acute  broncho-pneumonia. 


THE  CLINICAL  FORMS  OP  TUBERCULOSIS.  1043 

Physical  Signs  of  Tuberculous  Pneumonia. — Speaking  generally,  there 
is  no  difference  in  a  young  child  between  the  signs  of  a  tuberculous  and 
those  of  simple  broncho-pneumonia  except  in  their  position ;  for  cavities, 
although  they  are  present  at  autopsy  in  most  of  the  cases,  are  very  rarely 
of  such  size  and  so  situated  as  to  be  recognised  during  life.  In  children 
over  seven  or  eight  years  old,  and  sometimes  in  those  of  five  or  six,  the 
signs  are  essentially  like  those  in  adults. 

By  reference  to  the  description  of  the  lesions  (page  1023)  it  will  be 
noted  that  the  upper  lobes  are  the  seat  of  the  most  advanced  disease  twice 
as  frequently  as  the  lower  lobes,  and  the  right  lung  rather  more  frequently 
than  the  left.  When  the  disease  is  in  the  upper  lobes  it  is  rarely  at  the 
extreme  apex,  and  when  it  is  in  the  lower  lobes  it  is  very  exceptional  to 
find  it  at  the  base,  posteriorly.  The  region  most  often  involved  is  the 
middle  zone  of  the  lung.  If  the  signs  appear  first  behind  they  are,  in  the 
great  majority  of  cases,  in  the  interscapular  space ;  if  in  the  lateral  part 
of  the  chest,  they  are  in  the  middle  or  upper  jmrt  of  the  axilla ;  if  in 
front,  they  are  in  the  mammary  region,  more  frequently  above  than  below 
the  nipple,  but  rarely  extending  quite  to  the  clavicle.  In  other  words,  it 
is  near  the  root  of  the  lung  that  the  disease  most  frequently  begins,  spread- 
ing thence  forward  more  often  than  backward.  The  explanation  of  this 
is  found  in  the  fact  that  the  disease  in  infants  and  young  children  so  often 
extends  from  the  lymph  nodes  at  the  root  of  the  lung  to  the  lung  itself. 
The  physical  signs  themselves  may  be  grouped  under  four  heads,  corre- 
sponding to  the  pathological  conditions  existing  in  the  various  stages 
of  the  disease — viz.,  (1)  localized  bronchitis;  (2)  partial  consolidation; 
(3)  complete  consolidation  ;  (4)  excavation.  The  early  signs  in  the  first 
two  stages  are  identical  with  those  described  in  broncho-pneumonia  (page 
499),  those  of  the  third  stage  being  the  signs  of  the  persistent  form  (page 
502).  As  a  rule,  however,  the  transition  of  the  signs  from  one  stage  to 
another  is  much  slower  in  tuberculous  than  in  simple  broncho-pneumonia. 

As  stated  in  the  description  of  the  lesions,  cavities  are  found  in  the 
lungs  in  the  majority  of  cases  of  infants  dying  from  tuberculosis  of  the  lungs. 
It  is,  however,  rare  that  they  can  be  recognised  in  children  under  three 
years  old.  From  three  to  eight  years  they  give  more  positive  signs,  and 
after  eight  years  practically  the  same  signs  as  in  adults.  The  reason  why 
in  infancy  cavities  are  so  seldom  recognised  during  life  is  because  they 
are  generally  small,  often  centrally  located,  nearly  always  filled  with  thick 
pns  or  cheesy  matter,  and  rarely  communicate  freely  with  the  bronchi. 
On  the  other  hand,  it  is  very  common  to  find  signs  in  young  children 
which,  if  heard  in  adults,  would  be  regarded  as  almost  positive  evidence  of 
a  cavity,  although  none  is  present.  These  signs  are  cracked-pot  reso- 
nance and  cavernous  breathing.  They  are  not  usually  due  to  bronchi- 
ectasis, since  this  condition  belongs  to  chronic  cases,  and  especially  to 
older  children ;  but  most  frequently  to  consolidation  about  a  large  bron- 


1044  THE  SPECIFIC  INFECTIOUS  DISEASES. 

chus  superficially  situated — viz.,  below  the  clavicle,  high  in  the  axilla  and 
in  the  interscapular  region.  The  wide  area  over  which  this  broncho-cav- 
ernous breathing  is  heard,  is  one  of  the  most  striking  points  of  difference 
from  the  signs  of  a  cavity. 

Course,  Duration,  and  Termination. — Whatever  may  be  the  evolution 
of  the  symptoms,  and  the  variations  are  almost  endless,  the  cases  fall  readily 
into  two  groups, — those  in  which  the  progress  is  rapid  and  steady  and  those 
in  which  it  is  slow  and  intermittent.  The  duration  of  the  first  group  is 
from  four  to  eight  weeks.  Fever  is  constant,  wasting  progressive,  and  the 
physical  signs  show  a  steady  advance  of  the  disease  in  the  lungs.  Dyspnoea 
becomes  severe  and  constant ;  the  pulse  grows  more  and  more  rapid  and 
feeble ;  and  death  occurs  from  exhaustion,  pulmonary  oedema,  or  syncope, 
less  frequently  from  meningitis. 

In  the  second  group  the  duration  is  from  two  to  six  months.  The 
course  can  not  better  be  described  than  as  a  succession  of  attacks  of 
broncho-pneumonia,  sometimes  separated  by  an  interval  of  several  weeks, 
at  other  times  one  coming  on  before  the  first  is  fairly  over.  During 
exacerbations  the  symptoms  resemble  those  of  the  first  form,  there  being 
marked  fever,  wasting,  cough,  and  dyspnoea.  The  child  may  seem  hope- 
lessly ill  when,  without  any  special  reason,  a  change  for  the  better  occurs, 
the  acute  symptoms  abating  and  the  signs  of  consolidation  in  great  measure 
disappearing.  Toward  the  end  of  the  disease  the  pulmonary  and  consti- 
tutional symptoms  become  constant,  and  frequently  there  are  added  symp- 
toms due  to  extension  of  the  tuberculous  process  to  other  parts  of  the 
body — the  brain,  peritonaeum,  intestines,  mesenteric  glands,  etc.  These 
cases  die',  as  do  the  more  acute  ones,  from  the  local  disease  in  the  lungs 
or  from  general  infection. 

Diagnosis. — The  evidence  upon  which  a  diagnosis  of  tuberculosis  is 
made,  is  of  two  kinds, — that  which  relates  to  the  patient  and  that  which 
relates  to  the  local  disease.  In  any  case,  a  diagnosis  is  reached  by  weigh- 
ing the  evidence  as  a  whole  rather  than  by  relying  upon  the  presence  of 
particular  symptoms  or  physical  signs.  One  should  investigate  the  family 
history,  surroundings,  and  previous  condition  of  the  patient ;  also  the 
mode  of  onset,  and  course  of  the  disease,  and  consider  the  evidence 
afforded  by  the  examination  of  the  patient. 

A  careful  examination  of  the  family  history  should  be  made  to  deter- 
mine, first  the  existence  of  phthisis  in  the  parents  or  in  other  members  of 
the  family,  near  or  remote.  Children  more  often  inherit  tuberculosis 
from  the  mother  than  from  the  father,  and  are  more  likely  to  contract  it 
from  her,  owing  to  the  closer  contact.  It  is  not  enough  simply  to  inves- 
tigate the  question  of  phthisis.  Inquiry  should  be  made  regarding  menin- 
gitis, disease  of  the  cervical  glands,  spine,  hip,  knee,  or  ankle,  especially  in 
the  other  children  of  the  family.  These  points  are  important  not  only  to 
establish  the  fact  of  heredity  but  also  the  probable  chances  of  exposure. 


THE  CLINICAL  FORMS  OP  TUBERCULOSIS.  1045 

Other  conditions  favourable  for  acquiring  the  disease  should  be  considered, 
such  as  in  a  private  family  exposure  to  nurses  or  other  members  of  the 
household ;  also  whether  the  surroundings  have  been  such  as  would  give 
opportunities  for  infection,  as  in  cases  where  a  child  has  been  reared  in  a 
tenement  house,  or  has  been  long  an  inmate  of  a  hospital  or  other  institu- 
tion. In  the  child's  previous  history,  it  is  important  to  know  whether 
there  have  been  other  manifestations  of  tuberculosis  in  the  cervical  glands, 
spine,  hip,  knee,  or  ankle,  or  the  skin ;  also  whether  he  has  been  liable  to 
attacks  of  severe  or  protracted  bronchitis  or  broncho-pneumonia.  If  he 
has  had  measles  or  pertussis,  it  is  important  to  know  whether  they  were 
severe,  accompanied  by  pulmonary  complications,  or  followed  by  a  pro- 
tracted cough  or  obscure  fever.  The  child's  general  constitution  should 
be  considered,  whether  he  is  delicate,  narrow-chested,  poorly  nourished, 
or  anaemic. 

In  its  symptoms  and  course  it  is  with  simple  broncho-pneumonia  that 
tuberculous  disease  is  likely  to  be  confounded,  hence  the  important  diag- 
nostic points  are  those  which  distinguish  these  two  processes  from  each 
other.  The  onset  of  simple  pneumonia  is  usually  rapid  and  often  abrupt; 
tuberculous  pneumonia,  although  it  sometimes  begins  in  one  of  these  ways, 
usually  develops  gradually  with  constitutional  symptoms  preceding  the  local 
ones  by  several  days  or  even  weeks.  When  tuberculosis  develops  rapidly, 
the  pulmonary  symptoms  and  the  physical  signs  may  be  identical  in  the 
two  conditions.  During  the  period  of  acute  symptoms  there  is  often 
nothing  either  in  the  constitutional  or  local  symptoms  to  awaken  suspi- 
cion. One  may  be  struck  with  the  disproportion  between  the  general 
symptoms — loss  of  flesh,  prostration,  and  temperature — and  the  local  evi- 
dences of  pulmonary  disease.  When  the  patient  dies  in  the  early  acute 
stage  the  disease  is  rarely  recognised,  nor,  indeed,  can  it  be  diagnosticated 
with  certainty.  Usually  it  is  not  nntil  the  time  for  resolution  to  occur 
that  the  course  of  the  disease  suggests  something  different  from  broncho- 
pneumonia. The  question  then  arises  whether  we  have  to  deal  with  a  case 
of  persistent  broncho-pneumonia  or  with  tuberculosis.  It  should  be  remem- 
bered that  it  is  not  infrequent  for  simple  broncho-pneumonia  to  resolve 
slowly  or  to  go  on  to  the  development  of  chronic  interstitial  pneumonia ; 
and  that  local  conditions  as  determined  by  physical  signs,  which  in  adults 
would  be  regarded  as  certainly  tuberculous,  very  often  in  children  are 
simple  processes. 

Often  the  course  of  the  disease,  after  the  first  acute  period  has  passed, 
furnishes  further  evidence  to  clear  up  the  diagnosis ;  but  not  necessarily, 
for  in  tuberculosis  it  may  be  steadily  downward,  or  it  may  be  marked  by 
periods  of  remission  and  exacerbation,  and  the  same  is  true  of  simple  pneu- 
monia. Fever  is  a  more  constant  symptom  in  tuberculosis,  and  it  is  usu- 
ally higher  than  in  persistent  broncho-pneumonia ;  but  the  exceptions  are 
so  many  and  the  variations  so  wide  that  it  is  not  safe  in  young  children 


1046  THE  SPECIFIC  INFECTIOUS  DISEASES. 

to  lay  very  much  stress  upon  the  temperature  curve.  Anaemia  and  wast- 
ing are  more  marked  in  tuberculosis,  and  in  most  cases  progressive.  A 
copious  muco-purulent  expectoration  is  seen  almost  as  frequently  in  pneu- 
monia as  in  tuberculosis ;  but  in  neither  disease  is  it  common  under  five 
years.  The  presence  of  the  bacillus  tuberculosis  in  the  sputum  is,  of 
course,  positive  evidence  of  tuberculosis. 

Simple  broncho-pneumonia  may  affect  any  part  of  the  lungs,  but  by 
preference  the  lower  lobes  posteriorly.  The  signs  of  tuberculosis  may 
likewise  be  found  anywhere,  but  most  frequently  in  the  anterior  part  of 
the  lung,  the  mammary  region,  the  axillary  margin,  or  the  apex ;  if  pos- 
terior, the  signs  are  usually  at  the  apex  or  in  the  interscapular  region. 
From  the  character  of  the  physical  signs,  no  inference  can  be  drawn  unless 
a  cavity  can  be  positively  made  out;  but  when  the  process  has  advanced 
to  that  stage,  the  diagnosis  is  generally  plain  from  the  general  symp- 
toms. 

Meningitis  developing  during  a  pulmonary  disease  of  doubtful  char- 
acter, is  generally  tuberculous,  and  its  occurrence  is  usually  to  be  inter- 
preted as  establishing  the  tuberculous  nature  of  the  process  in  the  lungs ; 
but  this  is  not  invariable,  as  simple  meningitis  may  follow  simple  pneu- 
monia, as  I  have  more  than  once  seen  proven  by  autopsy,  when  both  were 
regarded  during  life  as  tuberculous.  The  development  of  cheesy  lymph 
glands  in  the  neck,  the  groin,  or  axilla,  or  the  presence  of  symptoms  point- 
ing to  enlargement  of  the  bronchial  glands,  or  those  of  chronic  peritonitis 
with  or  without  ascites,  or  intestinal  hasmorrhage, — all  point  strongly  to 
tuberculosis. 

If  the  acute  symptoms  begin  during  measles  and  persist,  they  may  be 
due  either  to  broncho-pneumonia  or  to  tuberculosis.  If,  however,  they  be- 
gin insidiously  during  convalescence  from  measles,  they  are  very  probably 
due  to  tuberculosis.  If  the  symptoms  begin  acutely  during  pertussis, 
they  may  be  due  to  simple  broncho-pneumonia  or  a  tuberculous  process; 
but  if  they  develop  gradually  and  insidiously  after  pertussis,  the  disease  is 
probably  tuberculosis.  It  should  not  be  forgotten,  howevei',  that  it  is  not 
uncommon  for  simple  broncho-pneumonia  occurring  with  pertussis,  to 
persist  until  the  attack  of  pertussis  has  subsided.  I  have  seen  several 
such  cases  in  which  consolidation  has  lasted  two  or  three  months  and 
yet  cleared  up  entirely. 

If  the  child  was  previously  healthy  and  living  in  good  surroundings, 
and  if  the  disease  began  with  acute  symptoms,  the  process  is  simple  pneu- 
monia in  nine  cases  out  of  ten,  no  matter  how  irregular  its  course,  how 
prolonged  its  duration,  or  what  the  physical  signs.  The  physician  will 
more  frequently  be  right  in  his  diagnosis  if  he  bases  it  upon  the  general 
condition  and  previous  history  of  the  patient,  than  upon  the  special  symp- 
toms of  the  disease  or  the  physical  signs.  Still,  after  all  has  been  said, 
the  diagnosis  is  in  all  cases  difficult,  and  in  some,  particularly  the  more 


THE   CLINICAL  FORMS  OF  TUBERCULOSIS.  1047 

chronic  ones,  a  positive  diagnosis  is  impossible,  as  no  one  knows  so  well  as 
he  who  has  an  opportunity  to  follow  his  cases  to  autopsy. 

III.  Chronic  Phthisis. — This  form  of  tuberculosis,  with  its  chronic 
hectic  fever,  slow  cavity  formation,  progressive  emaciation,  night  sweats, 
etc.,  is  very  rarely  seen  before  the  fifth  year,  and  it  is  not  at  all  frequent 
until  the  tenth  or  twelfth  year.  In  its  symptoms,  course,  termination, 
and  physical  signs,  it  resembles  the  same  disease  in  adults,  and  need  not 
be  described  at  length  here. 

IV.  Tuberculosis  of  the  Bronchial  Lymph  Nodes  (Bronchial 
Glands). — This  condition  is  usually  associated  with  some  form  of  pul- 
monary tuberculosis,  but  it  may  exist  as  the  most  important  and  some- 
times as  the  only  tuberculous  lesion. 

Its  symptoms  are  usually  associated  with  those  of  pulmonary  or  gen- 
eral tuberculosis ;  but  they  may  occur  when  the  pulmonary  changes  are 
too  few  to  be  recognised  either  by  symptoms  or  physical  signs.  From  the 
great  frequency  with  which  this  lesion  is  found  in  infants  and  young  chil- 
dren, it  might  be  expected  that  local  symptoms  would  be  common  in  such 
patients.  They  are,  however,  in  my  experience,  quite  exceptional.  Most 
of  the  cases  in  which  well-marked  symptoms  occur  are  in  children  over 
two  years  old,  and  it  is  between  the  third  and  tenth  years  that  they  are 
usually  seen.  In  infancy,  although  these  glands  are  almost  invariably 
affected,  death  in  the  great  majority  of  cases  occurs  from  the  pulmonary 
disease,  before  the  later  changes  in  the  glands  have  had  time  to  develop. 

General  symptoms  indicating  a  tuberculous  cachexia  may  or  may  not 
precede  the  local  ones.  The  latter  are  chiefly  mechanical,  and  depend 
upon  the  size  of  the  glands  and  upon  their  anatomical  relations,  and  very 
little  or  not  at  all  upon  the  nature  of  the  changes  in  them.  The  most 
important  relations,  so  far  as  the  production  of  symptoms  is  concerned, 
are  those  which  they  bear  to  the  pneumogastric  and  recurrent  laryngeal 
nerves,  the  superior  vena  cava,  the  trachea,  and  bronchi ;  those  less  impor- 
tant are  to  the  aorta,  pulmonary  artery,  and  oesophagus. 

Pressure  upon  or  irritation  of  the  pneumogastric  or  recurrent  nerves 
produces  cough,  dyspnoea,  and  sometimes  a  change  in  the  voice.  The  cough 
is  hoarse,  persistent,  and  teasing,  and  frequently  occurs  in  paroxysms  which 
in  many  respects  resemble  those  of  pertussis,  but  it  lacks  the  characteristic 
whoop,  and  is  not  accompanied  by  the  expectoration  of  the  mass  of  tena- 
cious mucus.  These  paroxysms  are  severe  and  often  prolonged,  but  careful 
observation  shows  distinct  differences  from  those  of  pertussis,  though  by 
an  unfamiliar  ear  the  two  are  easily  confounded.  The  dyspnoea,  like  the 
cough,  is  paroxysmal,  and  sometimes  strongly  resembles  ordinary  spas- 
modic croup ;  at  other  times  it  is  like  a  severe  attack  of  asthma.  Such 
symptoms  may  come  and  go,  but  they  are  frequently  prolonged,  and  usu- 
ally in  the  interval  between  the  severe  seizures  the  patient  is  not  wholly 
free  from  dyspnoea.     Although  the  chief  cause  of  dyspnoea  is  no  doubt 


1048  THE  SPECIFIC  INFECTIOUS  DISEASES. 

nerve  irritation,  it  may  be  due  in  part  to  pressure  upon  the  trachea  or  one 
of  the  large  bronchi.  In  dyspnoea  from  pressure  on  the  trachea  the  head 
is  usually  thrown  back,  and  the  obstruction  is  more  frequently  on  expira- 
tion than  on  inspiration. 

After  such  symptoms  as  those  mentioned  have  existed  for  a  few  days 
or  weeks,  and  in  some  cases  without  any  warning,  there  may  occur  a  sud- 
den attack  of  asphyxia  which  may  prove  fatal.  This  is  generally  due  to 
ulceration  of  a  caseous  gland  into  the  trachea  or  a  large  bronchus  and  the 
escape  of  a  large  mass  into  the  air  passages,  where  it  produces  the  same 
effects  as  any  other  foreign  body. 

Loeb  has  collected  fifteen  cases  of  this  description,  a  summary  of 
which  gives  a  good  idea  of  the  circumstances  under  which  this  accident 
usually  occurs :  In  four  cases  death  took  place  in  the  first  attack  of  suffo- 
cation, the  only  previous  symptom  having  been  cough ;  in  three  there 
had  been  a  number  of  milder  attacks  extending,  in  two  of  the  cases,  over 
a  considerable  period  before  the  occurrence  of  the  fatal  one ;  in  three, 
death  occurred  in  the  first  attack,  in  children  who  had  no  previous  cough 
and  who  were  apparently  healthy ;  in  one,  the  fatal  attack  came  on  during 
pertussis.  In  the  majority  of  the  cases,  death  followed  in  from  five  to  ten 
minutes  from  the  first  symptom ;  in  a  few  the  patients  lived  for  an  hour. 
In  rare  cases  after  ulceration  into  the  trachea,  the  patient  has  coughed  up 
a  large  quantity  of  foul  pus,  and  recovered. 

Pressure  upon  the  superior  vena  cava  is  usually  associated  with  spas- 
modic dyspnoea  and  cough,  and  causes  cyanosis  of  the  face  and  blueness 
of  the  lips.  There  is  frequently  a  puflBness  of  the  face,  and  there  may  be 
marked  oedema.  The  coexistence  of  cyanosis  with  such  oedema,  when  the 
urine  is  free  from  signs  of  renal  disease,  should  always  lead  one  to  suspect 
pressure  at  the  root  of  the  lung.  In  some  rare  cases  the  interference  with 
the  return  circulation  has  been  so  marked  that  meningeal  hgemorrhage 
has  resulted.  By  a  process  of  ulceration  set  up  by  these  glands  they  may 
open,  not  only  into  the  air  passages,  but  into  the  pericardium,  the  oesopha- 
gus, or  any  of  the  large  vessels.  The  last  mentioned  is  usually  followed 
by  instant  death.  Aldiberb  reports  two  cases  in  which  the  pulmonary 
artery  was  opened,  death  occurring  from  haemoptysis,  as  tliere  was  also  a 
communication  with  one  of  the  large  bronchi.  In  Vogel's  case  the  sub- 
clavian vein  was  perforated,  and  death  resulted  from  the  entrance  of  air. 
If  ulceration  takes  place  into  the  surrounding  connective  tissue,  a  medias- 
tinal abscess  may  result,  producing  any  of  the  pressure  symptoms  noted 
above,  and,  in  addition,  dysphagia  from  pressure  on  the  oesophagus.  Such 
an  abscess  may  point  in  the  supra-sternal  notch ;  it  may  open  through  the 
chest  anteriorly  between  the  ribs  or  at  the  xiphoid  cartilage ;  or  it  may 
burrow  along  the  oesophagus  to  the  peritoneal  cavity.  As  a  rule,  however, 
patients  die  of  general  tuberculosis  before  the  local  conditions  have  ad- 
vanced so  far. 


THE   CLINICAL   FORxMS  OP   TUBERCULOSIS.  1049 

Physical  Signs. — In  order  to  produce  physical  signs,  the  mass  of  tuber- 
culous lymph  nodes  must  be  large  enough  to  form  a  mediastinal  tumour, 
or  so  situated  as  to  produce  pressure  on  the  trachea  or  bronchi.  As  a  rule, 
the  signs  are  more  characteristic  behind  than  in  front.  Percussion  may 
give  dulness  anteriorly  over  the  first  piece  of  the  sternum  or  posteriorly 
along  one  or  both  sides  of  the  spine  from  the  second  to  the  fifth  dorsal 
vertebra;  the  dulness  is  rarely  complete.  Auscultation  posteriorly  may 
give  in  the  most  marked  cases  amphoric  or  cavernous  breathing,  or  exag- 
gerated bronchial  breathing  with  prolonged  expiration,  in  those  which 
are  less  pronounced.  Large,  moist  rales  are  sometimes  heard.  The  aus- 
cultatory signs  are  so  like  those  of  a  cavity  that  it  is  often  difficult  to 
believe  that  a  cavity  does  not  exist.  The  sounds  heard  appear  to  be  those 
produced  in  the  trachea  and  bronchi  transmitted  to  the  ear  with  great 
exaggeration  by  the  mass  of  lymph  nodes  which  surrounds  them  and 
fills  the  space  between  them  and  the  chest  wall.  When  the  head  is  thrown 
back  a  venous  hum  may  sometimes  be  heard.  If  one  of  the  primary  bron- 
chi or  one  of  its  lobar  divisions  is  compressed,  there  may  be  very  feeble 
respiration  over  one  lung  or  one  lobe ;  if  the  pressure  is  sufficient  to  pre- 
vent the  entrance  of  air,  or  if  one  of  these  large  tubes  has  been  plugged 
by  a  caseous  mass,  there  is  an  absence  of  respiratory  murmur  over  a  single 
lobe  or  an  entire  lung.  This  sign  is  of  great  diagnostic  value,  but  it  is 
not  often  present. 

Diagnosis. — Enlargement  of  the  bronchial  glands  to  a  sufficient  degree 
to  produce  symptoms,  may  occur  in  syphilis,  in  Hodgkin's  disease,  and  in 
various  forms  of  malignant  disease  of  the  mediastinum.  A  certain  amount 
of  swelling  is  seen  in  nearly  all  cases  of  simple  bronchitis  or  pneumonia, 
especially  in  those  running  a  subacute  or  chronic  course.  "Whether  this 
simple  hyperplasia  is  ever  sufficient  to  cause  such  symptoms  as  those  men- 
tioned is  exceedingly  doubtful.  I  have  myself  never  known  it  to  pro- 
duce anything  more  marked  than  a  spasmodic  cough.  The  great  infre- 
quency  of  other  forms  of  enlargement  to  a  sufficient  degree  to  be  of 
clinical  importance,  usually  warrants  us,  from  the  symptoms  mentioned, 
in  making  the  diagnosis  of  tuberculosis.  The  development  in  a  child  of 
a  chronic  abscess  in  the  anterior  mediastinum,  is  almost  always  due  to 
tuberculous  glands ;  and  so  is  one  in  the  posterior  mediastinum,  provided 
Pott's  disease  can  be  excluded. 

The  most  important  points  for  diagnosis  are  the  association  of  a  spas- 
modic cough  Avith  paroxysms  of  dyspnoea  resembling  asthma  or  croup, 
and  oedema  or  congestion  of  the  face.  More  stress  is  to  be  laid  upon 
the  symptoms  than  upon  the  physical  signs ;  the  latter  are  at  most  only 
confirmatory.  The  chief  difficulty  in  diagnosis  is  found  in  those  cases 
which  present  few  or  no  other  signs  of  tuberculosis,  and  which  come  first 
under  observation  with  attacks  of  dyspnoea  or  asphyxia  resembling  laryn- 
geal stenosis.     In  many  such  cases  tracheotomy  has  been  done  without 


1050  THE  SPECIFIC   INFECTIOUS  DISEASES. 

finding  any  cause  for  the  dyspnoea,  the  autopsy  showing  it  to  be  due  to 
ulceration  and  imjDaction  of  a  caseous  gland. 

General  Prognosis  of  Tuberculosis. — The  outlook  for  a  young  child 
with  general  or  pulmonary  tuberculosis  is  always  bad.  So  long  as  the 
disease  remains  confined  to  the  lymph  nodes,  the  child  is  not  usually  in 
danger,  except  from  accidents  connected  with  their  softening  and  ulcer- 
ation, which  after  all  are  rare.  Spontaneous  cure  may  occur  in  these 
glands  in  the  same  way  as  in  others  in  the  body — viz.,  by  encapsula- 
tion, calcification,  etc.  Such  a  result  is  no  doubt  a  very  frequent  one ; 
exactly  how  often  it  occurs  it  is  impossible  to  say.  But  when  once  the 
disease  has  gained  any  headway  in  the  lung  itself,  its  steady  advance  is 
almost  certain  in  a  young  child.  In  those  who  are  older  and  have  more 
resistance  the  chances  of  an  arrest  of  the  process  are  much  greater. 

If  the  bacilli  have  gained  entrance  into  the  body  in  any  considerable 
numbers,  even  though  they  are  shut  up  in  an  encapsulated,  caseous, 
bronchial  gland,  the  patient  is  never  free  from  the  danger  of  general 
infection. 

Prophylaxis. — The  prevention  of  tuberculosis  must  have  constant  ref- 
erence to  its  cause.  The  first  essential  is  the  destruction  of  the  tubercle 
bacilli  wherever  they  exist.  Since  most  of  the  germs  existing  in  the  air 
are  derived  from  the  sputum  of  j^atients  affected  with  pulmonary  tuber- 
culosis, it  should  be  insisted  upon,  everywhere  and  at  all  times,  that  the 
sputum  from  such  cases  should  be  collected  in  special  cups  or  cloths  and 
destroyed  either  by  germicides  or  by  fire.  The  next  point  is  to  avoid 
needless  exposure.  A  tuberculous  mother  should  on  no  account  nurse 
her  child  nor  kiss  it  upon  the  mouth.  A  wet-nurse  likewise  should  be 
free  from  any  tuberculous  taint.  No  nurse  or  other  care-taker  should 
ever  be  employed  about  children  who  has,  or  ever  has  had,  pulmonary 
tuberculosis.  It  is  wise  to  exclude  also  those  who  suffered  when  children 
from  tuberculosis  of  the  bones  or  the  cervical  glands,  although  the  dan- 
ger from  such  persons  is  extremely  slight.  If  active  tuberculosis  exists  in 
any  member  of  the  family,  a  young  child  should  be  kept  away  from  the 
room,  and  if  possible  should  not  reside  in  the  house.  On  no  account 
should  infected  persons  be  allowed  to  kiss  children  or  sleep  in  the  same 
bed  with  them.  The  danger  from  drinking-cups  and  other  dishes  should 
not  be  forgotten.  A  tuberculous  person  should  either  have  his  special 
dishes,  or  the  utmost  care  should  be  taken  to  boil  all  those  which  he  has 
used.  Cows  whose  milk  is  used  for  children  should  be  under  regular  veteri- 
nary inspection  and  should  have  passed  the  tuberculin  test.  In  any  case 
where  the  slightest  doubt  regarding  the  health  of  the  cows  exists,  or  where 
the  source  of  the  milk  is  unknown,  the  milk  should  be  heated  to  a  tem- 
perature of  167°  F.  for  twenty  minutes.  The  danger  of  infection  through 
the  alimentary  canal  is  very  much  less  than  through  the  respiratory  tract, 
and  consequently  the  precautions  first  mentioned  are  much  more  impor- 


THE  CLINICAL  FORMS   OF  TUBERCULOSIS.  1051 

tant  than  those  relating  to  the  food,  although  the  latter  should  on  no 
account  be  neglected. 

In  the  case  of  delicate  children  and  those  of  tuberculous  parents  or 
with  other  tuberculous  relatives,  everything  possible  should  be  done  to 
fortify  them  against  the  disease.  They  should  be  kept  under  more  or 
less  constant  medical  supervision  as  regards  their  clothing,  manner  of  life, 
etc.,  and  should  take  cod-liver  oil  every  winter.  Every  attack  of  bronchi- 
tis or  broncho-pneumonia  should  be  watched  with  the  greatest  solicitude. 
Exposure  to  measles  or  pertussis  should  especially  be  avoided.  The  coun- 
try rather  than  the  city  should  be  chosen  for  residence,  and  the  child 
should  spend  the  winter  and  spring  in  some  warm,  dry  climate,  such 
as  that  of  southern  California,  or  the  interior  of  South  Carolina,  or 
Lakewood,  N.  J.  Parents  should  be  distinctly  taught  that  watchfulness 
and  care  do  not  mean  coddling  or  the  keeping  of  children  in  the  house 
the  greater  part  of  the  time.  Such  children  should  live  as  much  as  pos- 
sible in  the  open  air,  and  every  form  of  sport  encouraged  which  tends  to 
keep  them  there.  Overheated  houses  are  one  of  the  most  prolific  agen- 
cies in  perpetuating  a  delicate  condition  of  health.  Plenty  of  fresh  air 
in  sleeping  apartments  should  always  be  insisted  upon.  All  catarrhal 
troubles  of  the  nose  and  pharynx  should  receive  early  and  prompt  atten- 
tion, especially  should  hypertrophied  tonsils  and  adenoid  growths  of  the 
pharynx  be  removed,  since  these  are  conditions  which  form  a  most 
favourable  nidus  for  the  growth  of  tubercle  bacilli. 

Treatment  of  General  and  Pulmonary  Tuberculosis. — If  fresh  air  and  a 
proper  climate  are  necessary  for  the  cure  of  this  disease  in  adults,  they  are 
tenfold  more  necessary  in  the  case  of  children.  Without  them  there  is 
little  hope  for  a  child  with  active  pulmonary  tuberculosis.  Nowhere  do 
these  cases  do  so  badly  as  in  a  hospital  located  in  a  city,  and  no  class  of 
hospital  cases  do  worse  than  these.  The  same  regions  that  are  beneficial 
for  adult  cases  usually  agree  with  children,  with  the  exception  that  the 
latter,  as  a  rule,  do  better  in  a  warm  than  in  a  cold  climate.  Plenty  of 
fresh  air  and  sunshine  are  essential.  A  child  must  be  where  he  can  be 
kept  in  the  open  air  for  at  least  several  hours  each  day,  in  spite  of 
fever,  cough,  or  other  acute  symptoms. 

For  the  most  acute  cases  where  the  children  are  confined  to  the  bed, 
the  largest,  best-ventilated,  and  sunniest  room  available  should  be  secured, 
and  a  window  should  be  open  the  greater  part  of  the  time.  The  general 
management  of  such  cases  is  the  same  as  for  those  with  acute  pneumonia. 

No  specific  remedy  for  tuberculosis  has  as  yet  stood  the  test  of  expe- 
rience. The  diet  is  a  matter  of  the  utmost  importance.  Tuberculous 
patients  must  be  fed  like  most  other  sick  children,  care  being  taken  not  to 
disturb  the  digestion  by  the  unnecessary  use  of  drugs.  For  a  staple  article 
of  diet,  milk  is  the  best,  and  where  this  is  not  well  borne  some  of  its  sub- 
stitutes— kumyss,  matzoon,  etc. — may  be  tried.     Cream  is  almost  as  use- 


1052  THE   SPECIFIC   INFECTIOUS   DISEASES. 

ful  as  cod-liver  oil,  and  should  be  given  in  one  form  or  another  whenever 
the  child  can  take  it. 

The  two  drugs  which  are  most  useful  are  creosote  and  cod-liver  oil. 
Creosote  may  be  given  both  by  the  stomach  and  by  inhalation,  as  in  cases 
of  pneumonia.  By  the  stomach  there  may  be  used  for  older  children,  the 
shellac-coated  pills  containing  one  or  two  drops  of  creosote ;  for  those 
who  are  younger,  it  may  be  given  in  combination  with  the  liquid  pepto- 
noids  or  in  an  emulsion  with  cod-liver  oil.  It  is  seldom  possible  to  give 
as  a  single  dose  more  than  half  a  drop  to  a  child  of  two  years ;  one  of 
five  years,  two  drops  may  often  be  given.  It  should  be  continued  for  a 
long  period.  Cod-liver  oil  is  usually  best  given  in  a  fresh  emulsion,  al- 
though some  children  bear  the  pure  oil  better  than  any  other  prepara- 
tion. Inunctions  of  this  or  other  oils  are  of  some  value  when  it  is  not  well 
tolerated  by  the  stomach.  Arsenic,  iron,  and  the  compound  syrup  of  the 
hypophosphites  are  all  useful  as  general  tonics,  but  as  specifics  their  ac- 
tion is  very  questionable. 

When  symptoms  pointing  to  tuberculosis  of  the  bronchial  glands  are 
present,  the  syrup  of  the  iodide  of  iron  should  be  used  in  the  same  way  as 
in  disease  of  the  cervical  glands.  When  they  ulcerate  into  the  trachea  or 
larger  bronchi,  they  generally  cause  death,  no  matter  what  is  done.  There 
are  on  record  a  few  cases  in  which  tracheotomy  has  been  of  service  in  this 
condition,  but  in  the  great  majority  it  accomplishes  nothing. 


CHAPTER  XL 

SYPHILIS. 

Syphilis  is  a  communicable  disease  due  to  a  specific  poison.  Although 
a  certain  bacillus,  first  described  by  Lustgarten,  is  quite  generally  found  in 
syphilitic  tissue,  it  is  not  established  that  this  bacillus  is  the  cause  of  the 
disease. 

In  infancy  and  childhood  both  the  acquired  and  the  hereditary  forms 
of  syphilis  are  seen. 

ACQUIRED  SYPHILIS. 

While  acquired  syphilis  is  very  much  less  frequent  than  the  hereditary 
variety,  it  is  by  no  means  a  rare  disease  in  early  life.  It  is  not  improbable 
that  some  of  the  manifestations  of  syphilis  in  later  childhood  which  are 
usually  denominated  "  late  hereditary  syphilis,"  are  really  due  to  the  ac- 
quired form. 

Etiology. — An  infant  may  be  infected  by  its  mother  during  parturi- 
tion ;  but  this  is  extremely  rare  and  can  take  place  only  when  there 
are  lesions   upon   the   mother's  genitals.     Infection   is    more   likely  to 


HEREDITARY   SYPHILIS.  1053 

be  from  a  mother  who  contracts  syphilis  subsequently  to  the  birth  of 
the  child,  and  may  occur  through  nursing  or  accidental  contact  by 
kissing,  etc.  lu  either  of  these  ways  children  may  be  infected  by  wet- 
nurses,  or  from  a  venereal  sore  upon  the  nipple.  Whether  syphilis  can 
be  communicated  through  the  milk  when  the  nipple  is  perfectly  healthy 
and  free  from  fissures,  is  somewhat  doubtful. 

Syphilis  may  be  communicated  directly  from  a  syphilitic  child  to  one 
who  is  healthy  by  kissing,  sexual  contact,  or  indirectly  by  means  of  bot- 
tles, spoons,  cups,  clothing,  etc.  The  latter  mode  of  infection  is  most 
likely  to  occur  in  institutions.  Vaccination  was  formerly  a  not  infre- 
quent mode  of  communicating  syphilis,  but  since  the  general  introduc- 
tion of  bovine  virus  this  is  very  rarely  seen.  Cases  have  been  recorded 
by  Taylor,  Hutchinson,  and  others  where  the  disease  has  been  conveyed 
by  the  rite  of  circumcision,  either  from  the  mouth  or  the  instruments  of 
the  operator. 

The  relative  frequency  of  the  different  sources  of  infection  is  shown 
by  Fournier's  statistics  of  forty  cases :  The  source  of  infection  was  the 
parents  in  nineteen ;  nurses,  in  eight ;  servants,  in  four  ;  sexual  contact, 
in  four ;  vaccination,  in  two ;  other  children,  in  two  ;  a  physician,  in  one. 
The  ages  at  which  the  disease  was  acquired  in  this  series  of  cases  were  as 
follows :  during  the  first  year,  nineteen ;  during  the  second  year,  ten  ; 
during  the  third  and  fourth  years,  seven ;  from  the  fifth  to  the  fourteenth 
years,  six. 

Symptoms. — The  symptoms  of  acquired  syphilis  in  children  are  in  all 
respects  similar  to  the  same  disease  in  the  adult.  A  primary  sore  is  pres- 
ent at  the  site  of  infection,  which  is  most  frequently  the  lips,  the  mouth 
or  some  part  of  the  face ;  very  rarely  is  it  seen  on  the  genitals.  There 
are  very  few  individual  symptoms  belonging  to  hereditary  syphilis  which 
may  not  also  be  present  when  the  disease  is  acquired.  Its  course,  how- 
ever, is  very  much  milder  in  the  latter  and  a  fatal  termination  is  rare. 
Fournier  states  that  of  his  forty-two  cases  only  one  died  of  marasmus. 
This  marked  contrast  to  hereditary  syphilis  is  due  chiefly  to  the  fact  that 
in  the  acquired  variety  the  infant  is  rarely  affected  during  the  early 
months  of  life,  a  time  when  hereditary  syphilis  is  so  very  fatal. 

Tertiary  symptoms  may  appear  at  any  time  from  three  to  twenty  years 
after  the  original  infection. 

The  treatment  is  the  same  as  in  hereditary  syphilis. 

HEREDITARY  SYPHILIS. 

Etiology.— A  child  may  inherit  syphilis  from  both  parents  or  from 
either  separately.  If  both  parents  are  syphilitic,  the  child  is  usually  but 
not  invariably  so.  The  symptoms,  however,  are  not  more  severe  than 
when  the  inheritance  is  from  one  parent  only.  The  likelihood  of  trans- 
mission depends  upon  the  stage  of  the  disease  in  the  parents.     If  both 


1054  THE  SPECIFIC  INFECTIOUS   DISEASES. 

are  suffering  from  secondary  symptoms,  transmission  is  almost  certain. 
If  active  treatment  has  been  employed  for  several  months,  if  the  child  is 
born  at  a  period  when  no  active  symptoms  are  present,  or  if  the  symptoms 
are  of  a  tertiary  character,  the  offspring  will  probably  escape.  First-born 
children  are  more  likely  to  suffer  severely  from  syphilis  than  the  later 
ones,  provided  infection  of  the  parents  has  taken  place  prior  to  the  birth 
of  all  the  children. 

Infection  from  the  father. — Syphilis  may  be  inherited  from  the  father 
alone.  In  this  case  the  disease  is  probably  communicated  directly  from 
the  semen  to  the  ovum.  It  is  more  likely  to  be  transmitted  from  the 
father  than  from  the  mother,  as  the  child  is  frequently  syphilitic  when 
the  mother  has  few  or  no  active  symptoms.  Of  twenty  cases  observed  by 
Meyer  in  which  the  father  alone  was  syphilitic,  the  foetus  was  discharged 
macerated  in  eleven  cases,  and  nine  children  were  born  with  congenital 
syphilis,  all  but  one  dying  soon  after  birth.  It  is  possible,  though  rare, 
for  the  father  to  convey  syphilis  when  he  is  free  from  symptoms,  or  when 
he  is  suffering  from  tertiary  symptoms  only. 

Infection  from  the  mother. — It  is  certain  that  syphilis  may  be  trans- 
mitted when  the  mother  alone  is  diseased,  as  is  shown  by  cases  where 
women  who  have  acquired  syphilis  while  wet-nursing  infected  children, 
have  subsequently  borne  syphilitic  children,  the  father  remaining  healthy. 
If  the  mother  only  is  syphilitic  the  probabilities  of  transmission  to  the 
child  appear  to  be  considerably  less  than  if  the  father  alone  is  affected. 
If  the  mother's  symptoms  are  tertiary  the  child  will  probably  escape. 

Both  parents  healthy  at  the  time  of  conception  and  the  mother  infected 
during  pregnancy. — Under  these  conditions  the  child  may  or  may  not  be 
syphilitic.  Transmission  to  the  child  is  much  less  likely  to  occur  if  the 
mother  is  infected  during  the  last  two  months  of  her  pregnancy  than 
earlier,  although,  as  Hutchinson's  cases  conclusively  show,  there  is  no  cer- 
tainty that  the  child  will  escape.  Diday  states  that  if  the  mother  is  in- 
fected before  the  fourth  week  and  proper  treatment  is  instituted,  the 
child  will  usually  escape  on  account  of  the  relation  of  the  embryo  to  the 
maternal  circulation  during  this  early  period. 

Can  a  healthy  mother  hear  a  syphilitic  child? — In  1837  Colles  enun- 
ciated the  following  proposition,  the  truth  of  which  has  been  abundantly 
verified  since  his  time :  "  A  new-born  child  affected  with  inherited  syphi- 
lis, even  although  it  may  have  symptoms  in  the  mouth,  never  causes 
ulceration  of  the  breasts  which  it  sucks  if  it  be  the  mother  who  suckles  it, 
although  continuing  capable  of  infecting  a  strange  nurse." 

Caspary  inoculated  with  syphilis  a  woman,  apparently  healthy,  who 
had  aborted  with  a  syphilitic  child ;  the  result  was  negative.  A  similar 
experiment  was  made  by  Neumann,  with  a  like  result.  Vidal  reports  a 
case  of  an  apparently  healthy  woman  who  had  a  syphilitic  child  by  an 
infected  husband ;  later,  by  a  second  husband  who  was  free  from  syphilis. 


HEREDITARY   SYPHILIS.  1055 

she  had  a  syphilitic  child.  The  conclusion  seems  irresistible  that  the  car- 
rying of  a  syphilitic  child  gives  immunity  to  the  mother  against  the 
disease,  and  that  this  immunity  is  due  to  the  fact  that  she  herself  suffers 
from  syphilis,  or  a  modification  of  that  disease.  According  to  Hutchinson, 
the  modified  syphilis  acquired  by  a  woman  under  the  circumstances  men- 
tioned, bears  to  syphilis  acquired  from  a  chancre  a  somewhat  similar  rela- 
tion to  that  which  vaccinia  bears  to  smallpox.  The  mother  under  these 
circumstances  can  not  be  inoculated,  either  by  her  syphilitic  nursing-in- 
fant or  artificially. 

Lesions. — Death  may  be  due  to  syphilis,  and  yet  the  autopsy  may  re- 
veal no  characteristic  anatomical  changes,  and  in  fact  there  may  be  no 
demonstrable  changes  in  any  of  the  organs.  This  is  sometimes  the  case 
in  children  dying  from  syphilis  soon  after  birth,  but  it  is  especially  likely 
to  be  the  case  with  infants  who  die  from  syphilitic  marasmus  during  the 
first  few  months.  Syphilis  in  these  cases  acts  more  as  an  indirect  than  as 
a  direct  cause  of  death.  The  most  important  lesions  of  hereditary  syphilis 
are  found  in  the  bones,  liver,  spleen,  and  mucous  membranes. 

Bones. — In  the  case  of  a  syphilitic  foetus,  a  stillborn  child,  or  one 
dying  soon  after  birth,  the  changes  in  the  bones  are  more  uniformly  pres- 
ent than  are  any  other  lesions.  They  are  in  fact  rarely  wanting,  and  it  is 
by  them  usually  that  syphilis  is  recognised  post  mortem.  These  early 
changes  were  first  fully  described  by  Wegner,  and  since  then  have  been 
studied  by  Kassowitz,  Taylor,  and  others.  The  long  bones  are  principally 
affected,  the  most  important  changes  being  found  at  the  junction  of  the 
shaft  with  the  epiphyseal  cartilage.  The  lesion  is  termed  an  epiphyseal 
osteo-chondritis  or  acute  epiphysitis.  There  are  in  the  early  stage  con- 
gestion, swelling,  and  cell  proliferation,  which  may  be  followed  by  separa- 
tion of  the  epiphysis,  suppuration  in  the  neighbouring  joint,  osteom3^elitis, 
and  necrosis.  These  changes,  as  well  as  those  belonging  to  late  syphilis, 
are  more  fully  considered  under  Diseases  of  the  Bones  (page  851). 

Liver. — This  is  probably  more  frequently  involved  in  the  foetus  and 
newly-born  infant  than  any  other  organ.  The  syphilitic  lesions  of  the 
liver  have  been  studied  very  fully  by  Hudelo.*  He  describes  as  present 
in  the  youngest  infants  an  interstitial  hepatitis,  a  gummatous  hepatitis, 
and  a  combination  of  the  two  varieties. 

In  the  interstitial  form,  which  is  most  frequent  in  infancy,  there  are 
first  a  congestion  and  swelling  of  the  organ,  with  the  exudation  of  leuco- 
cytes in  groups.  The  liver  is  enlarged,  frequently  very  much  so,  but  pre- 
sents few  other  gross  changes.  Later  there  is  increased  exudation 
between  the  liver  cells,  new  connective  tissue  forms,  and  atrophy  of  the 
liver  cells  takes  place,  with  obliteration  of  some  of  the  portal  and  hepatic 
vessels.     This  process  may  be  diffuse,  but  it  is  usually  in  patches.    Groups 

*  Monograph,  Paris,  1890. 
68 


1056  THE  SPECIFIC   INFECTIOUS  DISEASES. 

of  miliary  syphilomata  may  also  be  found.  If  the  process  is  diffuse,  the 
liver  is  large,  firm,  and  of  a  grayish-yellow  colour.  If  it  is  localized,  the 
affected  areas  are  yellow  or  gray  and  the  other  parts  are  normal. 

The  gummatous  form  is  not  frequent  in  early  infancy,  but  belongs  to 
a  little  later  period.  In  this  there  may  be  miliary  syphilomata  with  in- 
terstitial changes,  and  in  addition  the  formation  of  small  or  large  gum- 
matous tumours,  which  may  be  softened  at  the  centre.  They  are  sur- 
rounded by  zones  of  new  connective  tissue  and  the  liver  cells  are  atro- 
phied.    Amyloid  changes  may  be  present. 

In  the  late  form  of  hereditary  syphilis,  usually  seen  in  children  over 
four  or  five  years  old,  the  liver  is  rarely  affected.  Hudelo  was  able  to 
collect  but  forty-seven  such  cases.  The  lesions  resemble  those  of  the 
congenital  variety.  There  are  found  cirrhotic  changes,  which  may  be 
diffuse  or  circumscribed,  and  gummatous  deposits,  which  vary  from  a 
minute  size  to  that  of  a  cherry ;  there  may  be  amyloid  degeneration. 

Spleen. — This  is  almost  invariably  enlarged  in  newly-born  children 
with  syphilis  and  in  syphilitic  foetuses,  but  nothing  characteristic  is  found 
under  the  microscope  (Birch-Hirschfeld).  In  older  children  the  enlarge- 
ment of  the  spleen  is  apt  to  be  greater  than  at  birth ;  the  organ  may  be 
the  seat  of  interstitial  changes,  and  sometimes  there  may  be  gummatous 
deposits.     These  changes  are  rare  in  children  under  two  years  of  age. 

Resjnratory  system. — In  syphilitic  infants  which  are  stillborn  and  in 
those  which  die  soon  after  birth,  there  is  frequently  found  in  the  lungs 
what  is  known  as  "  white  pneumonia."  This  process  consists,  according 
to  Hillier,  in  fatty  changes  in  the  epithelium  of  the  air  vesicles ;  with  this 
thei'c  is  associated  a  certain  amount  of  interstitial  pneumonia,  which  is 
chiefly  peri-bronchial.  In  older  cases  the  interstitial  j^neumonia  is  ex- 
tensive, and  the  lungs  may  be  the  seat  of  gummatous  deposits,  which 
soften  and  form  small  cavities.  Accompanying  these  changes  there 
may  be  bronchiectasis,  emphysema,  and  the  usual  secondary  lesions 
which  follow  chronic  interstitial  pneumonia.  In  syphilitic  infants  there 
is  a  strong  tendency  for  all  inflammations  of  the  lungs  to  become  chronic. 

The  trachea  and  bronchi  are  in  rare  cases  the  seat  of  stenosis,  which 
results  from  cicatrization  following  the  softening  of  gummatous  deposits 
in  their  walls.  Lesions  of  the  larynx  (page  457)  are  also  infrequent. 
There  is  usually  perichondritis,  which  more  often  involves  the  epiglottis 
than  any  other  part,  and  sometimes  there  is  the  formation  of  papilloma- 
tous masses ;  but  ulceration  and  stenosis  are  both  rare. 

The  nasal  mucous  membrane  in  the  early  stage  of  the  disease  is  very 
constantly  the  seat  of  a  chronic  catarrhal  inflammation,  which  may  be 
accompanied  by  superficial  ulceration.  In  the  late  cases  there  is  deeper 
ulceration,  from  the  breaking  down  of  gummata,  with  extension  to  the 
periosteum,  cartilages,  and  bones,  causing  perforation  of' the  septum,  ne- 
crosis of  the  bones,  etc. 


HEREDITARY  SYPHILIS.  1057 

Nervous  system. — Syphilitic  lesions  of  the  brain  and  cord  are  rare  in 
children  as  compared  with  adults,  and  they  are  especially  so  in  infancy. 
The  most  characteristic  cerebral  lesion  of  the  newly-born  child  is  hydro- 
cephalus, which  may  depend  upon  ependymitis,  as  in  two  cases  reported 
by  D'Astros,  the  disease  proving  fatal  in  the  second  month.  Syphilitic 
meningitis  is  exceedingly  rare  under  two  years.  There  is  occasionally  seen 
in  young  infants  a  chronic  basilar  meningitis  (page  721)  of  syphilitic 
origin.  Chronic  pachymeningitis  associated  with  gummata  has  been 
observed  as  early  as  the  fourth  year.  Money  (London)  has  reported  a  case 
with  symptoms  beginning  at  eleven  months,  in  which  there  was  chronic 
meningitis  with  great  thickening  of  the  dura  mater  and  cerebral  sclerosis. 
A  few  other  cases  of  a  similar  nature  have  been  recorded. 

Syphilitic  endarteritis  of  the  brain  has  been  observed  by  Chiari  in  a 
child  only  fifteen  months  old.  In  this  case  there  was  chronic  meningitis, 
with  endarteritis,  thrombosis,  and  minute  spots  of  yellow  softening.  Gum- 
mata are  very  rare  before  the  fourth  year,  although  Barlow's  patient  with 
multiple  gummata  at  the  base,  was  only  fifteen  months  old.  Nearly  all 
the  syphilitic  lesions  of  the  nervous  system  which  are  seen  in  adult  life 
have  been  observed  in  childhood,  although  they  are  infrequent,  and  in 
young  children  they  are  extremely  rare. 

Digestive  system. — Chronic  catarrhal  pharyngitis  is  almost  a  constant 
symptom  of  the  early  cases.  Later  there  is  seen  superficial  or  deep 
ulceration  of  the  pharynx,  tonsils,  or  fauces,  which  may  lead  to  perfora- 
tion of  the  soft  palate  or  to  the  formation  of  condylomata. 

There  are  no  important  lesions  of  the  stomach  or  intestines  either 
with  early  or  late  syphilis.  The  rectum  is  occasionally  the  seat  of  ulcera- 
tion, and  condylomata  may  form  even  in  young  children. 

Organs  of  special  sense. — Otitis  is  a  frequent  accompaniment  of  the 
early  syphilitic  pharyngitis.  It  is  very  likely  to  become  chronic,  and  in 
many  cases  results  in  a  permanent  impairment  of  hearing.  Iritis  is  rela- 
tively rare  in  children,  but  it  may  occur  even  in  intra-uterine  life,  as 
shown  by  the  presence  of  adhesions  in  newly-born  children.  It  is  usually 
seen  in  infants  four  or  five  months  old,  and  is  always  serious.  Interstitial 
keratitis  occurs  frequently  as  a  late  manifestation  of  syphilis.  Choroid- 
itis and  optic  neuritis  are  both  occasionally  seen,  but  they  are  rare. 

Genito-urinary  organs. — Nearly  all  these  may  be  affected,  but  gener- 
ally in  the  late  period  of  the  disease.  There  may  be  chronic  intersti- 
tial nephritis  and  more  rarely  gummatous  deposits  in  the  kidney,  intersti- 
tial changes  in  the  suprarenal  bodies,  and  orchitis,  which  usually  affects 
the  body  of  the  organ,  rarely  the  epididymis ;  it  is  generally  an  inter- 
stitial inflammation,  with  or  without  gummatous  deposits. 

Among  the  less  frequent  visceral  lesions  may  be  mentioned,  abscesses 
of  the  thymus,  which  are  usually  small  and  multiple ;  enlargement  of  the 
pancreas,  with  an  increase  of  connective  tissue  and  glandular  atrophy  ;  and 


1Q58  THE   SPECIFIC  INFECTIOUS  DISEASES. 

chronic  peritonitis.  The  lesions  of  the  mucous  membranes  will  be  con- 
sidered under  Symptoms. 

Symptoms. — As  the  result  of  syphilis,  abortion  may  take  place  at  any 
period  of  pregnancy,  with  the  discharge  of  a  dead  or  macerated  foetus,  or 
the  child  may  be  stillborn  at  term,  or  it  may  be  born  alive  prematurely, 
but  with  so  feeble  a  vitality  that  it  survives  but  a  few  hours.  Under 
these  circumstances  it  is  often  difficult  and  sometimes  impossible  to  decide 
positively  with  reference  to  the  existence  of  syphilis.  Maceration  of  the 
foetus  or  peeling  of  the  skin  is  no  proof,  and  even  the  examination  of  the 
internal  organs  may  not  be  conclusive.  Lomer  examined  43  foetuses,  all 
dying  before  the  thirtieth  week  of  pregnancy ;  he  found  the  spleen  and 
liver  enlarged  in  all,  and  marked  bone  changes  in  31.  Birch- Hirschf eld 
examined  108  newly-born  syphilitic  infants;  he  found  the  spleen  invaria- 
bly enlarged ;  typical  bone  changes  were  present  in  35,  but  in  many  cases 
the  bones  were  normal.  Mervis,  from  an  examination  of  92  syphilitic 
foetuses,  states  that  no  eruption  upon  the  skin  was  found  earlier  than  the 
eighth  month. 

Symptoms  are  present  at  birth  in  only  a  small  number  of  cases.  In 
such  there  is  usually  a  very  severe  degree  of  infection,  and  the  infants 
do  not  often  live  more  than  a  few  days.  Upon  the  skin  there  may  be 
seen  an  eruption  of  pustules,  papules,  or  buUas.  The  bullae  are  usually 
upon  the  soles  and  palms,  but  may  be  found  upon  other  parts  of  the  body. 
The  name  "  syphilitic  pemphigus  "  is  often  given  to  this  condition.  Pem- 
phigus in  the  newly  born,  however,  is  not  invariably  due  to  syphilis,  but 
may  be  present  in  other  conditions  of  low  vitality.  The  bullae  are  at  first 
small,  and  then  coalesce  and  form  larger  ones  two  inches  or  more  in 
diameter.  They  contain  a  turbid  serum  which  is  sometimes  tinged 
with  blood,  and  sometimes  3'ellow  from  pus.  Pustules,  when  present,  are 
usually  seen  upon  the  face  or  scalp.  The  general  appearance  of  these  in- 
fants is  wretched  in  the  extreme.  The  body  is  wasted,  the  skin  wrinkled, 
and  temperature  subnormal.  The  spleen  is  usually  enlarged  and  often 
the  liver  also.  They  suck  feebly  or  not  at  all,  and  usually  die  from  inani- 
tion within  two  weeks. 

In  the  great  majority  of  cases  the  infant  appears  healthy  at  birth,  and 
continues  so  for  a  variable  time  before  the  manifestation  of  the  character- 
istic symptoms  of  syphilis.  As  a  rule,  the  more  intense  the  infection,  the 
earlier  the  symptoms  make  their  appearance.  The  earliest  symptoms  are 
generally  seen  between  the  second  and  the  sixth  weeks.  If  three  months 
pass  without  evidence  of  syphilis,  the  child  may  be  considered  safe, 
the  exceptions  to  this  rule  being  very  few.  Miller  *  (Moscow)  gives  the 
following  statistics  of  the  time  of  beginning  of  symptoms,  in  1,000 
cases : 

*  Jahrbuch  fiir  Kinderheilkunde,  Bd.  xxvii,  S.  359. 


HEREDITARY   SYPHILIS.  1059 

Symptoms  appeared  during  the  first  week 85  cases. 

*'  *'  •'         "    second  week 138  " 

"  "  "        "    third  week 240  " 

"  "  "         "    fourth  week 177  " 

"  "  "        "    fifth  week 80  " 

"  "  "        "    sixth  week 54  " 

"  "  "        "   seventh  week 50  " 

"  "  "         "    eighth  week 30  " 

After  the  eighth  week 140  " 


Sometimes  the  constitutional  symptoms — wasting,  cachexia,  etc. — are 
noticed  before  the  local  ones,  but  usually  this  is  not  the  case.  Generally 
the  first  symptom  is  the  coryza  or  "  snuffles,"  which  resembles  an  ordinary 
cold  in  the  head,  except  that  it  persists.  It  is  accompanied  by  a  hoarse 
cry,  indicating  that  the  larynx  participates  in  the  catarrhal  inflamma- 
tion. Soon  the  eruption  makes  its  appearance,  being  generally  first  seen 
upon  the  hands  and  face.  Fissures  and  mucous  patches  may  be  seen  upon 
the  lips,  about  the  anus,  etc.  With  these  symptoms  tliere  is  often  slight 
fever,  the  temperature  usually  ranging  from  99°  to  101°  F.  There  may 
also  be  observed  excessive  tenderness  about  the  shoulders,  elbows,  wrists, 
or  ankles,  due  to  acute  epiphysitis,  which  may  cause  the  child  to  cry  from 
the  slightest  amount  of  handling,  and  the  limbs  may  be  moved  so  little 
that  paralysis  is  suspected.  There  may  be  swelling  near  any  of  the  joints 
mentioned. 

In  a  severe  case,  as  these  local  symptoms  develop,  the  infant's  general 
nutrition  suffers  in  a  very  marked  way.  It  loses  steadily  in  weight ;  it 
becomes  extremely  anaemic ;  it  whines  and  frets  almost  continually,  but 
especially  at  night.  The  facies  is  so  characteristic  as  to  be  almost  diag- 
nostic;  the  features  have  a  pitiful,  drawn  expression;  and  the  face  is 
wrinkled,  giving  the  infant  the  look  of  being  very  old.  The  skin  has  a 
peculiar  sallow  colour,  which  has  been  well  described  as  cafe  au  lait.  The 
symptoms  may  continue  until  a  condition  of  extreme  marasmus  is  reached, 
and  death  occurs  from  inanition,  exhaustion,  or  from  some  intercurrent 
affection  of  the  lungs  or  digestive  organs. 

In  the  milder  forms  of  infection  the  severe  constitutional  symptoms 
described  are  not  seen,  although  the  local  evidences  of  disease  are  almost 
as  marked  as  in  the  cases  just  described.  The  severity  of  the  symptoms 
is  also  much  modified  by  treatment,  especially  when  this  is  begun  at  an 
early  period. 

The  most  important  local  symptoms  are  the  coryza,  eruption,  fissures 
about  the  mouth  and  anus,  mucous  patches,  painful  swellings  at  the  ex- 
tremities of  the  long  bones,  pseudo-paralysis,  and  onychia. 

Coryza. — In  most  of  the  cases  this  is  the  first  symptom.  Beginning 
like  an  ordinary  catarrh,  it  is  distinguished  by  its  severity  and  its  persist- 
ence.    There  is  a  copious  discharge  of  mucus  and  serum,  sometimes  of 


IQQQ  THE  SPECIFIC  INFECTIOUS  DISEASES. 

muco-pus,  and  often  it  is  tinged  with  blood.  Thick  crusts  form,  which 
produce  the  usual  symptoms  of  nasal  obstruction ;  there  is  great  difficulty 
in  nursing ;  the  infant  breathes  through  the  mouth,  and  the  mucous 
membrane  of  the  mouth  is  dry,  causing  great  discomfort.  If  untreated, 
the  process,  which  at  first  involves  the  mucous  membrane  only,  may  extend 
to  the  submucous  tissue,  causing  ulceration ;  but  the  cartilages  and  the 
bones  of  the  nasal  fossae  are  not  involved  till  a  later  period  in  the  disease. 

The  nasal  catarrh  is  associated  with  more  or  less  laryngitis.  This 
causes  hoarseness,  which  at  times  may  amount  almost  to  complete  aphonia. 
There  are  very  rarely  symptoms  of  laryngeal  stenosis.  Dillon  Brown  has, 
however,  reported  one  case  in  an  infant  six  weeks  old,  which  recovered 
after  intubation. 

Eruption. — This  usually  occurs  after  the  coryza  has  lasted  about  a 
week ;  but  the  two  may  come  at  the  same  time ;  or  the  coryza  may  be  ab- 
sent or  so  slight  that  the  rash  appears  to  be  the  first  symptom. 

Occasionally  there  is  seen  a  diffuse  blush  or  roseola,  but  more  frequent- 
ly the  eruption  is  macular,  occurring  in  small,  dark-red  spots  about  the 
size  of  the  infant's  finger  nails,  usually  circular  and  often  slightly  elevated  ; 
there  is  no  surrounding  inflammation,  and  rarely  any  itching.  It  is  usu- 
ally most  abundant  upon  the  face,  the  neck,  and  the  anterior  surface 
of  the  upper  and  lower  extremities,  especially  the  hands  and  feet,  not  in- 
frequently extending  over  the  entire  body,  although  it  is  generally  scanty 
over  the  shoulders  and  back.  When  it  first  appears  the  colour. is  bright, 
but  gradually  becomes  of  a  dusky-red  or  coppery  hue.  After  a  little  time 
very  fine  scales  may  be  seen  upon  the  surface  of  the  red  patches.  The 
rash  comes  out  slowly,  usually  requiring  from  one  to  three  weeks  for  its 
full  development.  It  fades  gradually,  leaving  a  coppery  discoloration  of 
the  skin,  which  continues  for  a  long  time.  The  duration  of  the  eruption  is 
from  three  to  eight  weeks.     It  is  shorter  if  active  treatment  is  employed. 

A  papular  eruption  is  rarely  seen  alone,  but  is  usually  associated  with 
the  macular  variety.  The  papules  are  of  a  brownish  colour  and  are  hard. 
They  are  seen  most  frequently  upon  the  palms  and  soles,  and  occurring 
alone  they  are  not  characteristic. 

A  squamous  eruption  is  frequently  seen  upon  the  palms  and  soles,  but 
very  rarely  elsewhere.  In  a  few  cases  this  scaliness  forms  the  most  dis- 
tinctive feature  of  the  cutaneous  lesion. 

Fissures  and  mucous  jiatches. — These  are  among  the  most  diagnostic 
features  of  early  hereditary  syphilis.  Fissures  are  most  frequently  seen 
on  the  lips  and  about  the  anus,  but  they  may  occur  about  the  nostrils  and 
occasionally  elsewhere.  The  fissures  of  the  lips  are  really  linear  ulcers, 
and  are  distinguished  by  their  persistence  in  spite  of  local  treatment. 
They  are  multiple,  deep,  painful,  and  bleed  easily.  Those  at  the  angle  of 
the  mouth  are  especially  troublesome. 

Mucous  patches  may  develop  from  fissures,  but  more  frequently  from 


HEREDITARY   SYPHILIS.  1061 

papules  v/hich  are  situated  in  regions  where  they  are  exposed  to  constant 
moisture  and  friction.  They  are  very  common  upon  the  muco-cutaneous 
surfaces  and  wherever  the  skin  is  especially  thin.  Tlie  situations  where 
they  are  most  apt  to  be  seen  are  about  the  lips,  anus,  scrotum,  and  vulva, 
but  they  may  also  be  found  behind  the  ears,  between  the  toes,  in  the  folds 
of  the  groin,  axillae,  or  buttocks.  In  size  they  vary  from  an  eighth  to  half 
an  inch  in  diameter ;  they  are  whitish  in  colour,  have  rounded  borders, 
and  are  raised  rather  than  excavated ;  they  never  extend  deeply. 

With  these  lesions  there  may  be  associated  ulcers  upon  any  of  the 
mucous  membranes,  but  they  are  most  frequently  seen  in  the  mouth  or  on 
the  genitals.  The  usual  seat  in  the  mouth  is  on  the  inner  surface  of  the 
lips,  the  tongue,  palate,  or  fauces ;  they  are  seldom  symmetrical,  and  while 
they  extend  superficially  they  are  never  deep. 

Hcemorrhages. — They  are  generally  associated  with  the  lesions  of 
the  mucous  membranes,  but  sometimes  occur  without  them.  Slight 
bleeding  from  the  nose  and  lips  is  not  uncommon  in  ordinary  cases  of 
syphilis,  and  all  haemorrhages  of  the  newly  born  are  more  frequent  in 
syphilitic  than  in  other  children.  Fischl  has  reported  seven  cases  of 
multiple  haemorrhages  in  the  newly  born,  associated  with  other  symptoms 
of  congenital  syphilis.  Mracek  noted  haemorrhages  in  thirty-three  per 
cent  of  160  autopsies  on  syphilitic  stillborn  infants  or  those  dying  soon 
after  birth.  Examination  of  the  blood-vessels  in  some  of  these  cases  showed 
infiltration  of  their  walls  and  narrowing  of  their  lumen.  The  vascular 
changes  were  thought  to  be  the  cause  of  the  bleeding. 

JVails. — The  nails  present  several  peculiarities  in  syphilitic  infants. 
There  may  be  a  disease  of  the  matrix  resulting  in  suppuration  and  exfo- 
liation of  the  nail — a  true  onychia.  Sometimes  the  nails  are  repeatedly 
exfoliated  ;  at  other  times  they  are  deeply  wrinkled  or  furrowed ;  or  the 
dorsum  is  very  much  arched,  and  the  nail  appears  as  if  it  had  been 
pinched  near  the  matrix  by  a  pair  of  forceps.  Such  nails  are  often  ex- 
panded toward  the  extremity,  and  may  be  decidedly  claw-shaped ;  they 
are  frequently  opaque,  sometimes  having  a  purplish  discoloration ;  they 
may  be  short  and  split  into  layers.  The  most  characteristic  appear- 
ance is  the  narrow,  pinched,  claw-shaped  nail ;  this  is  an  early  symptom 
of  some  diagnostic  importance.  The  hair  and  eyebrows  frequently  fall 
out  completely.  This  symptom  is  not  usually  present  in  very  early 
infancy. 

Fseudo-jjarali/sis. — This  is  due  to  acute  epiphysitis,  and  it  may  be 
the  first  symptom  of  hereditary  syphilis  to  attract  attention.  It  is  usu- 
ally noticed  when  the  infant  is  a  few  weeks  old  that  one  or  sometimes 
both  arms  are  not  moved,  and  that  the  parts  are  tender  and  painful 
when  handled.  The  condition  is  easily  confounded  with  peripheral  birth 
palsies.  The  arm  is  very  frequently  held  in  marked  inward  rotation 
with  the  palm  looking  outward,  resembling  the  position  in  Erb's  palsy ; 


1052  THE   SPECIFIC  INFECTIOUS  DISEASES. 

but  careful  examination  makes  it  evident  that  the  loss  of  power  is  only- 
apparent,  and  that  it  is  due  either  to  the  pain  which  motion  produces  or 
to  epiphyseal  separation.  A  history  will  usually  be  obtained  that  loss  of 
power  did  not  exist  at  birth,  but  developed  subsequently.  The  electrical 
reactions  in  these  cases  are  normal,  and  the  rapid  improvement  under 
mercurial  treatment  is  always  diagnostic.  The  lesions  of  the  viscera  in 
early  syphilis  rarely  give  rise  to  any  marked  signs  or  symptoms,  with  the 
exception  of  the  spleen,  which  is  almost  invariably  found  enlarged. 

Late  Hereditary  Syphilis. — These  symptoms  may  come  on  at  any  period 
during  childhood  or  about  the  time  of  puberty,  but  very  rarely  at  a  later 
time  than  this.  They  are  seen  both  in  those  who  have  had  the  usual 
symptoms  of  hereditary  syphilis  in  early  infancy,  and  in  others  where  the 
most  careful  examination  into  the  history  fails  to  disclose  any  symptoms 
whatever  of  early  syphilis.  It  is  fair  to  assume  in  such  cases  either  that 
early  symptoms  were  absent  or  that  they  were  of  trivial  importance.  It 
is  still  a  matter  of  dispute  whether  these  late  symptoms  should  be  re- 
garded as  hereditary,  tertiary  syphilis,  which  has  not  previously  given 
signs,  or  as  the  late  stage  of  ordinary  syphilis  in  which  the  early  symp- 
toms have  been  overlooked.  It  is  certain  that  the  symptoms  are  quite  as 
apt  to  be  severe  when  there  is  no  history  of  early  syphilis  as  when  this  has 
been  typical.  •  It  is  quite  possible  that  some  of  these  may  be  the 
late  manifestations  of  the  acquired  syphilis  not  recognised  in  the  early 
stage. 

Late  hereditary  syphilis  shows  itself  by  symptoms  which  in  acquired 
disease  would  be  classed  as  tertiary.  The  most  characteristic  are  the  affec- 
tions of  the  teeth,  the  bones,  gummatous  deposits  in  the  solid  viscera, 
the  skin,  or  mucous  membranes,  the  breaking  down  of  which  may  lead  to 
ulceration. 

Teeth. — There  are  no  peculiarities  in  the  first  teeth  of  syphilitic  chil- 
dren except  their  proneness  to  early  decay.  They  are  rather  more  likely 
to  appear  early  than  late.  Hutchinson  states  that 
there  occasionally  occur  abscesses  of  the  gum  in 
young  infants,  on  opening  which  the  crown  of 
the  milk-tooth,  usually  an  upper  central  incisor, 

FiG.isoT-Typieai  "Hutch-      may  be  removed. 

mson's  teeth."    (After  The  characteristic  teeth  of  svphilis  are  those 

lournier.)  -  ^ 

of  the  second  set.     In  estimating  the  diagnostic 

value  of  these  changes,  only  the  upper  central  incisors  are  to  be  relied 

upon ;  these  are  the  test  teeth.     Although  changes  are  frequently  seen  in 

other  teeth,  they  are  not  always   diagnostic.      Typical   syphilitic   teeth, 

according  to  Hutchinson,  have  each  a  single  notch  in  the  centre  of  the 

edge  (Fig.  180).     The  notch  is  usually  shallow  and  more  or  less  crescentic 

in  shape.     The  enamel  is  generally  deficient  in  the  centre  of  the  notch, 

and  the  tooth  here   is  apt  to  be  discoloured.     The  teeth  are  dwarfed, 


HEREDITARY  SYPHILIS. 


1063 


both  as  regards  their  length  and  width.     They  often  taper  regularly  from 

the  base  to  the  edge,  giving  rise  to  the  term  "screw-driver  teeth"  (Fig. 

181).     The  teeth  are  not  so  flat  as  the  normal  incisors,  but  somewhat 

rounded  and  peg-like.    They  are  not 

properly  placed,  but  incline  either 

toward   or  away  from  each   other. 

They  are  seldom  large   enough  to 

touch  the   adjacent  teeth  on  both 

sides. 

Although  Hutchinson's  teeth 
may  generally  be  taken  as  conclu- 
sive evidence  of  syphilis,  they  are 
not  invariably  so,  as  Keyes  and 
others  have  shown.  It  is  to  be 
remembered  in  this  connection  that 
the  absence  of  changes  in  the  teeth 
is  of  no  importance  whatever  as 
evidence  that  syphilis  is  not  present. 
Hutchinson  states  that  they  ar« 
wanting  in  more  than  half  the 
cases. 

Bones.  —  The   form  of   disease 
which  is  usually  seen  at  this  period 
is  an  osteo-periostitis,  affecting  prin- 
cipally the  shaft  of  the  long  bones  and  the  cranium 
described  (page  853). 

Lymj^h  nodes. — They  are  much  less  frequently  affected  than  in  adults, 
and  in  early  infancy  they  are  seldom  involved.  In  most  cases  after  the 
first  year  there  may  be  found  a  moderate  degree  of  enlargement  of  the 
post-cervical  and  epitrochlear  glands,  swelling  of  the  latter  having  con- 
siderable diagnostic  value.  They  are  situated  just  above  the  internal 
condyle  of  the  humerus,  and  under  normal  conditions  can  scarcely  be  felt. 
In  syphilitic  children  they  may  be  as  large  as  a  pea  or  a  small  bean  ;  some- 
times two  or  three  of  them  can  be  distinguished.  They  are  so  rarely  en- 
larged from  other  constitutional  conditions  that,  provided  no  local  cause 
for  the  swelling  exists,  they  should  always  create  a  suspicion  of  syphilis. 
The  post-cervical  glands  are  frequently  alTected,  but  are  not  so  diagnostic. 
The  degree  of  enlargement  is  rarely  great.  Occasionally  there  are  seen 
in  the  neck  large  masses  of  swollen  lymph  glands  which  resemble  tuber- 
culous swellings.     Tiiey  are,  however,  very  rare. 

Special  .'tenses. — The  most  frequent  affection  of  the  eye  in  late  syphilis 
is  interstitial  keratitis,  the  close  connection  of  which  with  hereditary  syphi- 
lis was  first  pointed  out  by  Hutchinson.  It  is  usually  found  associated 
with  the  typical  notched  teeth.    The  diagnostic  value  of  keratitis  in  syphi- 


FiG.  181. — Sypliilitio ".bcrew-ariver  teeth."    Boy 
nine  years  old.     (Same  patient  as  Fij,'.  148.) 


It  has  already  been 


1064  THE  SPECIFIC  INFECTIOUS  DISEASES. 

lis  is  denied  by  Fournier,  who  states  that,  while  often  syphilitic,  it  is  not 
infrequently  due  simply  to  malnutrition.  Both  eyes  are  usually  affected, 
and  in  all  degrees  of  severity,  from  a  slight  haziness  of  the  cornea  to  com- 
plete opacity.  However,  with  an  early  diagnosis  and  prompt  treatment, 
recovery  may  be  expected  in  most  cases. 

Chronic  otitis  may  be  a  result  of  the  acute  process  seen  in  early 
infancy.  There  is  nothing  peculiar  about  the  inflammation  in  these 
cases.  A  form  of  deafness  occurs  in  older  children,  which  Hutchinson 
states  is  almost  invariably  due  to  syphilis.  Its  onset  is  quite  sudden, 
without  pain  and  frequently  without  discharge.  The  loss  of  hearing  is 
apt  to  be  permanent,  and  if  it  occurs  early  in  childhood  it  is  a  cause  of 
deaf-mutism. 

Skill. — The  most  important  of  the  later  manifestations  of  syphilis  con- 
sist in  the  formation  of  subcutaneous  gummata.  In  the  early  stage  they 
are  indurated,  elastic,  of  a  grayish  colour,  with  red  borders.  Under  treat- 
ment they  disappear  quite  rapidly  by  absorption  ;  but  when  neglected  they 
break  down,  leaving  large  deep  ulcers.  These  ulcers  are  quite  charac- 
teristic in  appearance,  but  may  be  confounded  with  those  due  to  tubercu- 
losis. The  syphilitic  ulcer  has  rounded,  thickened,  indurated  borders, 
and  a  base  which  is  depressed  and  has  the  appearance  of  being  scooped 
out.  It  is  sometimes  covered  by  hard  crusts  and  is  surrounded  by  a  red 
areola.  It  leaves  a  smooth  white  scar.  The  most  frequent  situation  is 
upon  the  face  and  upper  part  of  the  legs  or  thighs.  Tuberculous  ulcers 
have  usually  soft,  flat  edges,  and  do  not  extend  so  deeply ;  they  are  more 
irregular  in  outline ;  the  cicatrix  left  is  of  a  purplish  colour,  which  be- 
comes red  and  slowly  fades.  Tubercle  bacilli  may  be  found.  Sometimes 
it  is  only  by  the  effect  of  treatment  that  the  diagnosis  can  be  made  be- 
tween these  two  lesions. 

Nose  and  palate. — Disease  of  these  parts  generally  begins  as  the  break- 
ing down  of  gummatous  deposits  in  the  mucous  membrane.  The  nose 
may  in  consequence  be  the  seat  of  a  protracted  fetid  discharge  (ozaena). 
The  disease  may  take  on  a  destructive  form  of  ulceration  which  is  at  times 
phagedenic,  and  may  cause  rapid  destruction  of  the  nasal  cartilages  and 
bones,  perforation  of  the  septum,  and  occasionally  of  the  floor  of  the  nasal 
fossae.  There  may  be  necrosis  of  the  turbinated  bones,  the  vomer,  or  the 
ethmoid.  In  the  most  severe  forms  the  nose  may  be  almost  destroyed  in 
the  course  of  a  few  weeks.  There  may  be  at  the  same  time  deep  ulcera- 
tion of  the  soft  palate,  leading  to  perforation.  In  a  young  person  this  is 
almost  invariably  due  to  syphilis.  In  many  particulars  these  ulcerations 
of  the  nose  and  palate  resemble  lupus;  they  are  distinguished  by  the 
rapidity  of  their  progress,  syphilis  often  doing  as  much  damage  in  weeks 
as  is  done  by  lupus  in  years  (Hutchinson). 

Other  symptoms. — Syphilitic  disease  of  the  larynx  and  bronchi  is  rare 
in  childhood.      The  former  (page  457)   may  give  rise  to  hoarseness  or 


HEREDITARY  SYPHILIS.  '  1065 

aphonia  and  occasionally  to  stenosis  ;  the  latter  *  to  a  chronic  cough  and 
asthmatic  attacks.  There  are  no  characteristic  symptoms  belonging  to 
syjjhilis  of  the  lungs.  The  different  lesions  of  the  central  nervous  system 
which  may  be  due  to  syphilis  are  all  quite  rare.  The  forms  have  already 
been  mentioned,  and  their  symptomatology  is  discussed  in  Diseases  of  the 
Nervous  System. 

The  only  visceral  changes  which  aid  much  in  diagnosis  are  those  of 
the  liver  and  spleen.  The  liver  is  often  enlarged,  sometimes  to  a  marked 
degree,  and  occasionally  there  is  ascites,  but  very  seldom  jaundice. 

Enlargement  of  the  spleen  is  a  very  frequent  symptom — in  fact,  it  is 
almost  constant  during  active  syphilitic  disease.  I  have  several  times 
seen  it  so  swollen  as  to  form  an  abdominal  tumour  of  considerable  size. 
In  one  case,  in  a  boy  three  years  old,  the  spleen  extended  five  inches  below 
the  free  border  of  the  ribs,  quite  to  the  crest  of  the  ileum.  It  was  asso- 
ciated with  moderate  enlargement  of  the  liver,  as  is  usually  the  case. 

In  addition  to  the  local  symptoms  of  late  hereditary  syphilis  enumer- 
ated, there  are  others  of  a  general  character  which  are  quite  as  important. 
The  body  is  usually  undersized  ;  the  constitution  is  delicate,  and  shows 
but  little  resistance  to  all  forms  of  disease  ;  puberty  is  frequently  delayed, 
and  the  development  of  the  breasts  and  the  genital  organs  often  imper- 
fect ;  ansemia  is  usually  present,  and  the  skin  has  a  sallow  appearance. 
Mentally,  many  of  these  children  are  somewhat  deficient,  and  in  a  few 
instances  they  become  idiotic,  epileptic,  or  the  subjects  of  dementia. 

Diagnosis. — The  diagnosis  of  early  syphilis  in  most  cases  is  not  diffi- 
cult. The  coryza,  eruption,  labial  fissures,  mucous  patches  about  the 
anus  and  genitals,  and  general  cachexia, — all  form  a  picture  which  it  is 
difficult  to  mistake.  In  irregular  cases  the  diagnosis  is  easy  just  in  pro- 
portion to  the  number  of  the  foregoing  symptoms  which  are  present. 
Special  care  should  be  taken  not  to  confound  the  moist  papules  of  simple 
intertrigo  upon  the  buttocks  or  thighs  with  those  of  syphilis. 

In  late  syphilis  the  following  symptoms  are  the  most  reliable  for  diag- 
nosis :  notching  of  the  teeth,  falling  in  of  the  bridge  of  the  nose,  intersti- 
tial keratitis,  deafness  not  traceable  to  ordinary  otitis,  enlargement  of  the 
spleen  and  epitrochlear  glands,  ulceration  of  the  palate  or  nose,  the 
sabre-like  deformity  of  the  tibia,  and  nodes  upon  the  tibia  or  cranium. 

Prognosis. — Generally  speaking,  the  prognosis  is  much  worse  in  infan- 
tile syphilis  than  in  that  of  adults.  In  infancy  it  is  much  worse  when 
hereditary  than  when  acquired,  for  the  reason  that  often  the  child  who 
is  the  subject  of  hereditary  syphilis  has  been  affected  by  the  poison  from 
the  very  beginning  of  its  existence,  and  this  has  modified  its  entire  devel- 
opment. 


*  See  A.  Seihert.  M.  D..  in  Archives  of  Pediatrics,  vol.  ix,  for  a  report  of  four  cases 
and  others  collcctcil  from  literature. 


1066  THE  SPECIFIC  INFECTIOUS  DISEASES. 

The  results  of  206  syphilitic  pregnancies  observed  by  Jullien  (Paris) 
were  as  follows :  abortion  occurred  in  3G,  stillbirths  in  8,  and  09  children 
died  soon  after  birth,  making  a  total  mortality  of  55  per  cent;  50  were 
living  and  syphilitic  ;  only  43  living  and  in  good  health.  Still  worse  were 
the  results  in  cases  observed  by  Le  Pileur :  of  154  pregnancies  in  syphi- 
litic women,  there  were  120  abortions  or  stillbirths,  26  children  died  soon 
after  birth,  and  only  8  survived.  The  statistics  of  the  Foundling  Asylum 
in  Moscow  for  ten  years  showed  that  of  2,038  syphilitic  infants  the  mor- 
tality was  over  70  per  cent. 

Such  a  mortality  as  that  indicated  in  the  above  statistics  is  seen  only 
in  institutions  where  little  or  no  previous  treatment  has  been  emp)loyed. 
In  private  practice  certainly  nothing  approaching  it  occurs. 

In  addition  to  those  who  die  early  as  the  result  of  syphilitic  infection, 
there  must  be  added  many  whose  constitutions  are  so  impaired  by  syphilis 
that  they  fall  an  easy  prey  in  infancy  to  pneumonia,  diarrhoea  or  other 
forms  of  acute  disease.  The  remote  effects  of  syphilis  in  infancy  it  is 
hard  to  estimate ;  it  exerts  a  modifying  influence  ii])on  the  constitution  in 
childhood  and  even  throughout  the  life  of  the  individual. 

The  prognosis  in  an  individual  case  depends  upon  the  age  at  which 
the  symptoms  develop,  the  time  when  treatment  is  begun,  upon  its  thor- 
oughness, and  upon  the  surroundings  and  mode  of  nourishment  of  the 
child.  The  outlook  is  better  the  longer  after  birth  the  -first  symptoms 
appear ;  it  is  also  better  in  infants  who  are  nursed  than  in  those  who 
are  artificially  fed. 

As  compared  with  syphilis  of  the  adult,  relapses  are  rare,  and  when 
they  occur  early  they  are  nearly  always  the  result  of  insufficient  treatment. 
If  proper  early  treatment  is  carried  out,  the  severe  late  symptoms  are  rare; 
patients  are  usually  free  from  all  symptoms  until  six  or  seven  years  old,  or 
until  near  the  time  of  puberty — two  periods  when  they  are  likely  to  develop. 

The  prognosis  is  better  in  the  later  children  of  syphilitic  parents  than 
in  the  earlier  ones,  provided  infection  has  preceded  the  birth  of  all  the 
children.  This  fact  illustrates  the  general  tendency  of  the  syphilitic 
poison  to  diminish  in  virulence  as  time  passes,  even  without  treatment. 
The  following  instance  cited  by  Bertin  well  illustrates  this  point : 

In  the  first  pregnancy,  the  child  died  at  the  sixth  month  ;  in  the 
second,  at  the  seventh  month ;  in  the  third,  at  seven  and  a  half  months ; 
in  the  fourth  the  child  was  born  at  term,  and  lived  eighteen  days;  in  the 
fifth  it  lived  six  weeks ;  in  the  sixth  the  child  lived  four  months,  without 
treatment. 

Prophylaxis. — Xo  infected  person  should  be  allowed  to  marry  until  at 
least  two  years  have  passed  after  the  initial  sore,  steady  treatment  being 
continued  meanwhile ;  nor  if  there  are  any  active  symptoms,  no  matter 
how  long  a  time  has  elapsed  since  infection.  There  is  no  certainty  in 
either  case  that  the  child  will  escape. 


HEREDITARY   SYPHILIS.  1067 

The  mother  should  be  treated  during  her  pregnancy :  (1)  if  she  is 
syphilitic,  whether  the  disease  was  acquired  at  the  time  of  concep- 
tion or  subsequently ;  (2)  if  the  father  is  known  to  be  suffering  from 
syphilis,  whether  the  mother  has  symptoms  or  not ;  (3)  if  the  mother  has 
previously  shown  signs  of  syphilis,  but  has  had  no  active  symptoms  for 
a  considerable  period.  In  all  these  conditions  if  efficient  treatment  is 
carried  on  throughout  pregnancy  there  is  a  strong  probability,  but  in  no 
case  a  certainty,  that  the  child  will  escape.  The  third  condition  mentioned 
is  the  one  in  which  treatment  is  most  likely  to  be  neglected,  especially  if 
the  mother  has  previously  borne  a  child  who  was  not  syphilitic.  Syphilis, 
however,  shows  a  strong  tendency  to  reappear  and  become  active  during 
pregnancy,  even  though  it  has  been  long  quiescent,  as  the  following  case 
cited  by  Diday  shows: 

A  woman  who  had  lost  seven  children  from  syphilis  was  put  under 
treatment  during  the  eighth  pregnancy  ;. result — child  born  healthy,  and 
continued  so.  In  the  ninth  pregnancy  treatment  was  continued  with  a 
like  result ;  in  the  tenth  pregnancy,  no  treatment,  child  syphilitic,  dying 
when  six  months  old  ;  in  the  eleventh  pregnancy,  treatment  repeated, 
child  healthy. 

The  danger  of  infection  during  labour  is  slight.  If  there  are  upon 
the  genitals  of  the  mother  either  a  chancre  or  syjohilitic  ulcers,  they 
should  be  thoroughly  cauterized  before  labour. 

As  the  greatest  danger  of  infecting  a  child  afterbirth  is  from  its  parents 
or  a  wet-nurse,  syphilitic  parents  should  be  duly  warned  of  the  danger  to 
their  children,  and  especially  should  be  cautioned  against  kissing  them 
or  sleeping  in  the  same  bed  with  them.  The  utmost  care  should  be  ex- 
ercised to  prevent  a  healthy  child  from  being  infected  by  a  syphilitic 
nurse.  A  nurse  should  never  be  accepted  without  a  thorough  examina- 
tion, no  matter  how  clear  a  history  may  be  given.  As  a  syphilitic  child 
in  the  household  may  be  the  means  of  infecting  other  children,  the 
same  precautions  should  be  taken  as  in  the  case  of  other  contagious 
diseases.  The  chief  danger  to  other  children  comes  from  kissing  or 
from  using  bottles,  spoons,  or  cups  which  have  been  infected ;  as  the 
syphilitic  infant  is  chiefly  dangerous  on  account  of  the  lesions  in  the 
mouth.  Trouble  most  frequently  occurs  because  of  ignorance  regard- 
ing the  nature  of  the  disease.  It  is  possible  for  a  syphilitic  child  to  nurse 
a  healthy  womaii  without  communicating  syphilis,  if  the  child's  mouth 
is  treated  and  the  nipple  not  allowed  to  become  fissured  ;  but  it  is  an  ex- 
periment which  should  never  be  tried. 

Treatment. — This  should  always  be  begun  as  soon  as  the  first  positive 
symptoms  of  syphilis  appear.  Under  certain  circumstances  it  may  be 
advisable  not  to  wait  for  symptoms ;  as,  for  example,  where  both  parents 
have  recently  sufi'ered  from  active  symptoms,  where  previous  children 
have  died  soon  after  birth,  or  where,  with  marked  symptoms  in  the  par- 


1068  'fllK   SPECIFIC   INFECTIOUS   DISEASES. 

ents,  the  child  exhibits  the  cachexia  of  syphilis,  but  no  definite  local 
symptoms.  Such  anticipatory  treatment  need  not  be  continued  longer 
than  six  weeks  unless  symptoms  appear. 

The  indirect  treatment,  designed  to  reach  the  child  through  the 
mother's  milk,  has  fallen  into  deserved  disuse,  as  it  is  very  uncertain  and 
altogether  unsatisfactory. 

Mercury  is  as  much  a  specific  for  hereditary  as  for  acquired  syphilis. 
There  are  many  ways  of  introducing  it  into  the  system  :  it  may  be  given 
by  inunctions,  by  the  mouth,  by  fumigations,  by  baths,  or  hypodermically. 
In  most  cases  inunction  is  the  manner  to  be  preferred  in  young  infants. 
Gr.x  of  mercurial  ointment,  diluted  with  the  same  amount  of  vaseline,  may 
be  rubbed  daily  into  the  palms,  soles,  axilljB,  or  the  inner  surface  of  the 
thighs.  It  is  advisable  to  change  the  place  of  inunction  from  day  to  day; 
and  if  this  is  done,  it  is  extremely  rare  that  erythema  is  produced.  If  for 
any  reason  inunctions  are  objectionable,  as  they  may  be  where  the  family 
are  to  be  kept  in  ignorance  of  the  treatment,  either  the  gray  powder  or  the 
bichloride  may  be  given  by  the  mouth.  The  usual  dose  of  the  gray  powder 
should  be  gr.j  four  times  a  day;  that  of  the  bichloride  gr.  gL  four  times  a 
day,  always  well  diluted.  It  is  rare  that  larger  doses  are  advisable.  When 
the  symptoms  are  urgent,  it  is  often  best  to  substitute  calomel  for  a  few 
weeks,  as  the  system  can  usually  be  brought  more  rapidly  under  the  influ- 
ence of  mercury  by  this  than  by  the  other  preparations  mentioned  ;  gr.  -^^ 
four  times  a  day  is  the  usual  dose  required.  Other  methods  of  administra- 
tion and  other  preparations  offer  no  advantages,  and  have  some  very  ob- 
vious disadvantages. 

The  iodide  of  potassium  is  to  be  used,  either  alone  or  in  combination 
with  mercury,  whenever  such  lesions  exist  as  are  classed  among  adults  as 
tertiary.  This  includes  all  the  late  manifestations,  and  the  earlier  ones 
whenever  the  bones  or  viscera  are  affected.  The  iodide  is  usually  well 
borne  by  children,  and  may  be  given  in  almost  any  desired  dosage.  In 
infancy  it  is  rare  that  more  than  twenty  grains  daily  are  required,  but 
in  older  children  the  necessary  amount  may  be  from  one  to  two  drachms 
daily.     It  should  always  be  given  largely  diluted. 

The  duration  of  mercurial  treatment  should  be  at  least  one  year.  The 
doses  during  the  last  six  months  may  be  reduced  to  one  half  or  one  third 
those  employed  while  active  symptoms  are  present.  Treatment  should  be 
longer  than  a  year  if  symptoms  exist.  It  is  often  better  not  to  give  the 
mercury  continuously,  but  with  short  periods  of  intermission. 

The  tonic  treatment  of  syphilis  is  important  and  should  not  be  neg- 
lected. After  specific  treatment  has  been  carried  on  for  a  time,  particu- 
larly if  rapidly  pushed,  the  child  often  becomes  anaemic,  and  suffers  greatly 
from  general  malnutrition.  Under  such  circumstances  also  it  is  often 
wise  to  discontinue  mercury  altogether  for  a  time,  or  at  least  to  reduce 
the  dose  very  mucli,  and   administer  cod-liver  oil,  iron,  wine,  and  other 


INFLUENZA.  1069 

tonics.  Such  a  change  is  frequently  found  to  act  most  beneficially,  even 
when  lesions  are  present,  which  perhaps  have  been  very  little  or  not  at  all 
affected  by  the  specific  remedies  employed.  A  judicious  combination  of 
specific  and  tonic  treatment  is  required  in  every  case,  whether  the  reme- 
dies are  given  simultaneously  or  alternately. 

Local  treatment. — Ulcerative  lesions  of  the  skin  require  cleanliness, 
dusting  with  calomel  or  iodoform,  or  bathing  with  the  black  wash.  Mu- 
cous patches  should  be  dusted  with  equal  parts  of  calomel  and  bismuth. 
Fissures  and  ulcers  of  the  mucous  membranes  should  be  treated  by  nitrate 
of  silver.  Phagedenic  ulcers  of  the  palate  or  nose  should  be  cauter- 
ized with  nitric  acid  or  the  acid  nitrate  of  mercury.  The  late  syphilitic 
ulcers  of  tlie  skin,  due  to  the  breaking  down  of  gummata,  should  be 
treated  with  iodoform. 


CHAPTER  XII. 

IJSFLUENZA. 
Synonym :  La  grippe. 

Influenza  is  an  infectious,  communicable  disease,  which  is  now  gen- 
erally admitted  to  be  due  to  the  bacillus  described  by  Pfeiffer  in  1892. 
It  is  a  serious  disease  in  children  chiefly  from  its  tendency  to  complica- 
tions of  the  upper  and  lower  resjiiratory  tracts,  in  which  respect  it  closely 
resembles  measles. 

Etiology. — Besides  the  bacillus  of  Pfeiffer,  there  are  frequently  found, 
either  associated  or  separately,  in  the  organs  of  patients  dying  from  in- 
fluenza, the  streptococcus  and  the  diplococcus  pneumonias,  for  the  develop- 
ment of  which  influenza  creates  conditions  in  the  highest  degree  favour- 
able. 

Influenza  prevails  epidemically,  and  after  epidemics  it  may  be  endemic 
for  a  number  of  years.  In  New  York  the  disease  has  been  present,  ac- 
cording to  Loomis,  for  at  least  twenty-five  years,  although  it  attracted 
little  attention  under  the  name  of  influenza  until  the  great  epidemic 
of  1891.  Epidemics  prevail  chiefly  in  winter  and  spring.  All  ages 
are  liable  to  the  disease,  infants  under  one  year  least  so,  and  in  some 
epidemics  they  may  escape  altogether.  The  disease  has,  however,  been 
observed  in  infants  only  a  few  days  old,  where  the  mother  was  suffering 
from  it  at  the  time  of  delivery.  The  children  most  frequently  affected 
are  those  from  two  to  ten  years  of  age. 

The  period  of  incubation  is  uncertain.  It  is  usually  short,  being  gen- 
erally believed  to  be  from  one  to  seven  days.  No  immunity  is  afforded 
by  one  attack ;  recurrences  and  second  attacks  are  not  uncommon  in  the 


1070  THE  SPECIFIC   INFECTIOUS  DISEASES. 

same  epidemic,  and  a  patient  who  has  once  had  influenza  seems  to  be  more 
susceptible  to  the  disease  in  consequence. 

Lesions. — There  are  no  characteristic  lesions  of  influenza;  those  which 
are  most  frequently  found  are  due  to  catarrhal  inflammation  of  the  re- 
spiratory or  the  digestive  tract.  In  some  cases  only  the  upper  respiratory 
tract  is  involved,  in  which  case  the  disease  often  spreads  to  the  middle 
ear ;  in  otliers,  only  the  lower  respiratory  tract,  this  in  infancy  usually 
spreading  rapidly  to  the  lungs,  and  resulting  in  broncho-pneumonia. 
Inflammation  of  the  stomach  and  intestines  is  much  less  frequent  and, 
as  a  rule,  less  severe.  This  will  be  considered  more  fully  under  Complica- 
tions. 

Symptoms. — The  symptoms  of  influenza  are  due  to  the  systemic  effects 
of  a  general  poison,  and  to  certain  local  congestions  and  inflammations 
which  are  regarded  as  complications.  The  two  classes  of  symptoms — the 
general  and  the  local  ones — are  found  in  all  possible  combinations. 

1.  The  mild,  u7icomplicated  variety. — This  lasts  from  two  to  five  days, 
occasionally  a  week.  The  onset  is  usually  abrupt,  with  chilliness,  mus- 
cular pains,  and  sometimes  vomiting.  The  temperature  ranges  from  101° 
to  103°  F.  Even  though  the  fever  is  not  high,  the  prostration  is  consider- 
able, and  children  are  often  ill  enough  to  remain  in  bed  for  several  days. 
The  usual  general  symptoms  which  accompany  fever  are  present.  After 
the  fever  has  subsided,  the  child  is  left  weak  and  anaemic ;  convalescence 
is  frequently  protracted,  and  it  may  be  three  or  four  weeks  before  the 
general  health  is  regained.  This  is  the  most  common  variety  seen,  the 
essential  symptoms  being  fever  and  prostration  without  evidences  of  local 
inflammation.  Often  there  is  in  addition  a  mild  coryza  at  the  outset  and 
a  slight  but  persistent  cough. 

2.  Uncomplicated  cases  of  the  severe  type. — These  are  not  frequent  in 
children.  They  are  characterized  by  high  temperature,  severe  toxic  symp- 
toms, and  great  prostration.  They  closely  resemble  cases  of  pneumonia, 
with  the  exception  that  the  local  symptoms  and  physical  signs  in  the 
chest  are  wanting.  The  onset  is  usually  abrupt  with  vomiting  and  head- 
ache, sometimes  even  with  convulsions.  The  temperature  ranges  from 
102°  to  10G-o°  P.  It  more  often  remains  steadily  high  than  fluctuates 
widely.  In  three  cases  recently  observed  I  have  seen  a  temperature  over 
106°  F.  in  uncomplicated  influenza.  Marked  nervous  symptoms  are 
usually  present ;  there  may  be  headache,  photophobia,  delirium,  stupor, 
opisthotonus,  and  convulsions, — strongly  suggesting  meningitis,  but  all 
usually  lasting  but  a  day  or  two.  In  other  cases  the  tongue  has  a  brown 
coating,  the  lips  are  dry  and  parched,  the  pulse  is  weak  and  rapid,  and 
other  symptoms  of  the  typhoid  condition  are  present.  The  duration  of 
these  severe  attacks  is  from  two  to  five  days,  where  no  complication  de- 
velops; a  slight  fever  may,  however,  continue  for  a  week,  or  even  two 
weeks,  gradually  subsiding  until  it  reaches  the  normal.     Although  the 


INFLUENZA.  1071 

symptoms  are  very  alarming,  the  attacks  are  seldom  fatal  unless  pneu- 
znonia  develops ;  but  it  is  a  long  time  before  the  full  effects  of  such  an 
illness  have  entirely  disappeared. 

3.  Cases  complicated  hy  catarrhal  injlamination  of  the  ujjper  respira- 
tory tract. — In  this  group  there  are  added  to  the  general  symptoms  of  the 
mild  uncomplicated  variety,  a  severe  coryza,  with  pharyngitis  and  often 
stomatitis.  The  catarrhal  symptoms  differ  from  ordinary  catarrh  of  these 
mucous  membranes  chiefly  in  severity.  They  are  also  likely  to  be  more 
prolonged,  and  there  is  a  greater  tendency  to  involve  the  ears  and  the 
cervical  lymph  nodes.  The  usual  symptoms  of  acute  rhino-pharyngitis 
are  present  with  its  serous,  sero-mucous,  or  muco-purulent  discharge. 
The  whole  pharynx  may  be  the  seat  of  an  acute,  erythematous  blush,  or 
the  mucous  membrane  may  present  a  granular  or  spongy  appearance. 
The  tonsils  are  red;  occasionally  there  is  follicular  tonsillitis;  rarely 
membranous  patches.  The  nostrils  and  upper  lip  are  often  excoriated 
from  the  nasal  discharge.  The  mouth  may  be  the  seat  of  a  simple 
or  a  herpetic  stomatitis  with  superficial  ulceration.  These  catarrhal  symp- 
toms are  usually  severe  for  three  or  four  days,  and  gradually  subside.  In 
infants  the  temperature  may  be  104°  or  105°  F.  at  the  outset,  but  con- 
tinues high  only  for  a  day  or  two.  In  older  children  the  temperature 
ranges  from  100°  to  103°  F. 

There  are  two  complications  which  in  infancy  are  very  frequent, — 
otitis  and  cervical  adenitis.  Otitis  may  be  either  catarrhal  or  purulent. 
It  runs  the  usual  course  of  otitis  following  simple  catarrhal  processes  of 
the  pharynx,  and  usually  terminates  in  comi^lete  recovery.  Exceptionally 
these  cases  may  go  on  to  the  development  of  chronic  otitis,  or  the  disease 
may  extend  to  the  mastoid  cells.  In  addition  to  the  severe  cases,  there 
are  frequently  seen  attacks  of  catarrhal  deafness  from  inflammation  of  the 
Eustachian  tube.  Pain  in  this  form  is  less  severe,  and  may  be  absent ; 
there  is  no  increased  fever.  Deafness  is  the  chief  symptom,  and  in  most 
cases  it  disappears  spontaneously. 

The  adenitis  usually  involves  either  the  lymph  nodes  situated  below 
the  ear  and  behind  the  angle  of  the  jaw,  or  those  of  the  retro-pharyngeal 
region.  The  inflammation  runs  the  usual  course  of  such  inflammations 
when  associated  with  other  diseases. 

4.  Cases  luith  bro)icho-pulmo7iary  complications. — A  moderate  amount 
of  inflammation  of  the  mucous  membrane  of  the  larynx,  trachea,  and  large 
bronchi  occurs  in  most  of  the  cases  of  influenza.  In  the  more  severe 
forms,  broncho-pneumonia  or  lobar  pneumonia  often  develops.  Some- 
times the  pulmonary  symptoms  do  not  appear  for  two  or  three  days, 
or  even  a  week ;  at  other  times  they  are  coincident  with  the  development 
of  the  fever  and  other  constitutional  symptoms,  and,  except  for  the  prev- 
alence of  influenza,  this  would  not  be  considered  a  factor  in  these  cases. 
A  striking  feature  in  these  attacks  is  that  the  temperature,  prostration, 

69 


1072 


THE  SPECIFIC  INFECTIOUS  DISEASES. 


DAY 

106" 
105° 
104° 
103° 
102° 
101° 
1C0° 
99° 
98° 

1 

a 

3       1 

4 

5 

6       1 

- 

- 

- 

- 

- 

p- 

1 

1 

/ 

' 

\ 

~ 

__ 



_ 

_ 

^ 

-- 

_  _ 

and  cerebral  symptoms  are  out  of  all  proportion  to  the  pulmonary  signs 
and  symptoms. 

The  broncho-pneumonia  complicating  influenza  may  not  differ  essen- 
tially from  the  ordinary  types,  except  that  the  proportion  of  cases  which 

do  not  go  on  to  the  development  of 
areas  of  consolidation,  is  larger  than 
is  seen  under  most  other  conditions. 
If  lobar  jDneumonia  develops,  it 
frequently  runs  its  regular  course. 
But  besides  these  two  varieties  of 
pneumonia,  quite  a  large  number  of 
cases  of  an  irregular  type  are  seen 
with  influenza.  These  are  often  of 
short  duration,  but  accompanied  by 
extremely  high  temperature  (Fig. 
182).  In  many  cases  there  is  an 
excessive  amount  of  pleurisy,  so  that 
the  process  is  really  a  pleuro-pneu- 
monia.  In  an  epidemic  occurring 
in  the  New  York  Infant  Asylum  in 
the  winter  of  1891  and  1892  nearly 
every  pneumonia  was  of  this  type, 
and  in  a  few  weeks  there  were  about 
twenty  cases,  all  of  a  very  severe  form. 
This  is  often  followed  by  empyema. 

5.  Cases  loWi  g astro-enteric  complications. — Vomiting  and  diarrhcea 
are  frequent  at  the  beginning  of  influenza,  and  in  some  cases,  especially  in 
infants,  they  may  be  the  predominant  symptoms  of  the  attack.  The  stools 
may  be  large  and  fluid,  or  they  may  contain  mucus  and  even  blood,  and 
be  passed  with  pain  and  tenesmus, — the  symptoms  being  those  of  an 
acute  gastritis  or  of  ileo-colitis  of  moderate  severity.  The  duration  of 
these  attacks  is  usually  three  or  four  days,  and  except  in  very  young  or 
delicate  children  they  are  rarely  fatal.  In  older  children  there  may  be 
initial  vomiting,  abdominal  pain,  tympanites,  protracted  diarrhoea,  and 
other  symptoms  strongly  suggestive  of  typhoid  fever. 

6.  Influenza  in  very  young  infants. — The  severe  cases  in  infants  un- 
der six  months  old  often  present  peculiar  features.  Even  though  the  tem- 
perature is  frequently  but  little  above  the  normal,  the  prostration  is  ex- 
treme. The  eyes  are  sunken,  the  face  is  pale,  there  is  marked  apathy,  and 
food  is  often  refused  altogether.  In  other  cases  there  are  cyanosis  and  very 
rapid  respiration,  indicating  acute  congestion  of  the  lungs,  although  no 
abnormal  signs  are  present,  except  very  feeble  breathing  sounds.  Nearly 
always  there  is  a  disturbance  of  digestion,  with  vomiting  and  undigested 
stools.     Death  may  occur  in  two  or  three  days  ;  sometimes  it  is  postponed 


Fig.  182. — Acute  broncho-pneumonia,  abor- 
tive type,  complicating  influenza,  in  an 
infant  six  months  old.  The  entire  left 
lung  posteriorly,  was  involved. 


INFLUENZA.  1073 

for  a  week,  tlie  chief  symptoms  being  gradually  increasing  prostration, 
and  finally  collapse,  without  the  development  of  any  marked  local  evi- 
dences of  disease.  The  system  seems  in  these  cases  to  be  overpowered 
by  the  intensity  of  the  poison.  In  other  cases  pneumonia  develops,  and 
from  this  death  occurs. 

Complications  and  Sequelae. — The  most  frequent  ones — pneumonia,  oti- 
tis, acute  adenitis,  and  gastro-enteritis — have  already  been  considered. 
Cutaneous  eruptions  are  not  infrequent,  and  are  often  very  puzzling. 
There  may  be  a  general  eruption  resembling  urticaria,  or  an  erythema 
which  sometimes  simulates  measles,  but  more  frequently  scarlet  fever. 
These  eruptions  are  irregular  in  their  course  and  often  in  their  distribu- 
tion, and  are  not  followed  by  desquamation.  In  most  of  the  cases  with 
high  temperature  the  urine  contains  albumin  ;  although  nephritis  is  rare, 
one  should  be  on  the  watch  for  it  even  in  young  children.  I  have  once 
seen  acute  pyelitis  as  a  complication.  The  nervous  sequelae  of  adults — 
mental  disturbances,  multiple  neuritis,  etc. — are  extremely  rare  in  child- 
hood, although  they  have  been  observed.  One  of  the  most  frequent  sequelae 
is  marked  ansemia;  this  is  well-nigh  constant  after  a  severe  form  of  the 
disease.  Following  the  disease  of  the  mucous  membranes,  there  may  be 
enlarged  tonsils,  adenoid  growths  of  the  pharynx,  or  chronic  enlargement 
of  the  cervical  lymph  glands.  Attacks  of  influenza  bear  the  same  relation 
to  the  development  of  tuberculosis  as  do  those  of  measles. 

Convalescence  after  influenza  is  usually  very  slow,  and  it  is  often  many 
months  before  the  full  effects  of  a  severe  attack  have  disappeared.  A  re- 
currence of  the  symptoms  before  complete  recovery  is  not  uncommon,  and 
often  second  attacks  during  the  same  season  are  seen.  For  a  long  time 
the  mucous  membranes  are  in  an  extremely  sensitive  condition.  Relapses 
are  often  brought  about  by  slight  exposure  before  the  symptoms  have 
quite  disappeared,  and  I  have  often  seen  them  occur  simply  from  airing 
an  infant  in  the  room. 

Diagnosis. — This  is  usually  easy  when  the  disease  is  epidemic.  The 
sporadic  cases  often  present  great  diflEiculties,  particularly  in  the  early 
part  of  the  disease.  It  is  often  impossible  to  tell  for  two  or  three  days 
whether  the  case  is  one  of  pneumonia,  malaria,  or  influenza.  In  most  of 
the  severe  cases  I  have  seen,  pneumonia  has  been  the  diagnosis  first 
made;  it  is  only  by  the  course  of  the  disease  and  the  absence  of  any 
physical  signs  that  influenza  can  be  distinguished  from  pneumonia. 
From  malaria,  influenza  is  differentiated  by  the  course  of  the  tempera- 
ture, the  absence  of  enlargement  of  the  spleen  and  of  the  plasmodium  in 
the  blood.  The  cerebral  symptoms  may  lead  to  the  diagnosis  of  menin- 
gitis ;  the  catarrhal  symptoms,  to  a  suspicion  of  measles ;  and  the  vomit- 
ing, high  temperature,  and  erythema  to  a  diagnosis  of  scarlet  fever.  In 
all  these  cases  it  is  only  the  course  of  the  disease  which  clears  up  the 
diagnosis.     Influenza  is  characterized  most  of  all  by  severe  constitutional 


1074  THE  SPECIFIC  INFECTIOUS  DISEASES. 

symptoms,  without  the  development  of  any  signs  of  local  disease,  while 
it  lacks  the  characteristic  symptoms  of  the  other  fevers  mentioned. 

From  ordinary  catarrh,  influenza  differs  only  in  its  high  communica- 
bility,  its  severity,  and  the  frequency  with  which  it  is  complicated  by  oti- 
tis, adenitis,  and  pneumonia.  Mild  cases  when  not  epidemic  can  not  be 
diagnosticated  from  simple  catarrh  of  the  respiratory  tract. 

Prognosis, — As  a  rule,  the  type  of  influenza  seen  in  children  is  milder 
than  that  which  occurs  in  adults.  In  the  case  of  children  previously 
healthy,  few  die  except  from  pulmonary  com];)lications,  while  the  great 
majority  of  attacks  are  mild  and  recover  promptly.  In  infants  the  tend- 
ency to  pulmonary  complications  is  much  greater  than  in  older  children. 
Uncomplicated  cases  are  seldom  fatal,  except  in  infants  under  six  months 
old ;  and  even  though  the  temperature  is  very  high  and  the  symptoms 
severe,  recovery  may  usually  be  predicted  so  long  as  there  is  no  evi- 
dence of  serious  comjilications.  The  prognosis  of  the  pneumonia  of  in- 
fluenza is  rather  worse  than  that  of  sim^^le  broncho-pneumonia,  and  de- 
pends chiefly  upon  the  age  of  the  patients  affected.  In  a  word,  influenza 
is  particularly  serious  in  the  very  young,  or  when  there  are  pulmonary 
complications,  but  rarely  otherwise.  In  infants  the  constitutional  de- 
pression which  results  may  be  the  beginning  of  a  condition  of  malnu- 
trition which  goes  on  to  the  development  of  marasmus ;  or  a  child  falls 
an  easy  victim  to  some  other  form  of  acute  disease.  The  remote  effects 
of  influenza  may  therefore  be  serious,  even  though  the  attack  itself  is  not 
especially  severe. 

Treatment. — The  communicability  of  the  disease  makes  it  desirable 
that  cases  of  influenza  should  be  isolated  whenever  this  is  practicable,  and 
particularly  that  delicate  children,  or  those  prone  to  pulmonary  disease, 
should  not  be  exposed  to  it. 

The  disease  appears  to  be  self-limited,  running  its  course,  when  un- 
complicated, in  from  three  to  seven  days.  As  there  is  no  specific  for  it, 
the  indications  are  to  sustain  the  patient,  to  make  him  comfortable  dur- 
ing the  attack,  and  to  prevent  so  far  as  possible  the  occurrence  of  compli- 
cations. Every  child  with  influenza  should  be  put  to  bed  and  kept  there 
so  long  as  any  elevation  of  the  temperature  continues.  At  the  outset  the 
bowels  should  be  opened  by  castor  oil  or  calomel,  and  means  used  to 
induce  free  perspiration,  such  as  the  use  of  hot  drinks,  the  hot  pack,  or 
small  doses  of  Dover's  powder  in  combination  with  phenacetiue.  A  very 
high  temperature  should  be  relieved  by  cold  sponging  or  the  cold  pack, 
precisely  as  in  pneumonia,  liut  large  doses  of  antipyretic  drugs  are  to  be 
avoided.  The  nervous  symptoms — restlessness,  pain,  headache,  and  other 
disturbances — are  best  controlled  by  phenacetine  in  combination  with  co- 
deine— e.  g.,  to  a  child  of  one  year,  phenacetine  gr.  j,  codeine  gr.  ^,  every 
three  or  four  hours.  Double  the  dose  may  be  given  to  a  child  of  four 
years.     Alcoholic  stimulants  are  required  whenever  the  pulse  shows  signs 


MALARIA.  1075 

of  weakness,  as  it  does  in  most  of  the  severe  cases,  and  in  most  young 
infants.  They  should  be  given  according  to  the  same  rules  as  in 
pneumonia.  Next  to  alcohol,  strychnine  is  the  most  valuable  heart  stim- 
ulant. 

In  older  children  there  is  a  decided  advantage  in  the  use  of  moderately 
large  doses  of  quinine — e.  g.,  gr.  ij,  four  or  five  times  a  day,  to  a  child  five 
years  old;  but  in  infants  this  had  best  be  omitted,  on  account  of  its  tend- 
ency to  upset  the  stomach.  The  cough  which  so  often  persists  after  in- 
fluenza is  best  controlled  by  cod-liver  oil  and  creosote,  used  as  after  acute 
bronchitis.  With  persistent  bronchitis  which  resists  ordinary  remedies,  a 
patient  should  be  sent  to  a  warm,  dry  climate.  The  complications  of  in- 
fluenza are  to  be  treated  as  they  arise,  in  the  same  manner  as  when  they 
occur  under  other  conditions.  In  all  cases  careful  feeding  in  accordance 
with  the  general  rules  laid  down  for  feeding  in  acute  diseases,  good  nurs- 
ing, and  care  to  avoid  exposure  during  convalescence,  are  essentials  in 
treatment.  One  should  be  particularly  anxious  about  patients  who  have  a 
strong  tendency  to  tuberculosis,  and  such  cases  should  be  watched  with 
the  greatest  solicitude. 

In  prolonged  or  constantly  recurring  attacks  nothing  is  of  much  avail 
except  a  change  of  air.  If  this  is  impossible,  a  child  should  be  frequently 
removed  from  one  apartment  to  another,  as  re-infection  often  appears  to 
take  place  from  the  sick-room. 


CHAPTER  XIII. 

MALARIA. 

Malaria  is  a  general  infectious  disease  due  to  the  presence  in  the 
blood  of  a  specific  organism  known  as  the  jilasmodiiwi,  or  hemtitozoon 
malaricB.  It  manifests  itself  in  children  by  the  ordinary  acute  febrile  at- 
tacks which  are  seen  in  adults  and  by  chronic  malarial  poisoning.  Both 
of  these  forms  may  present  certain  peculiar  symptoms  dependent  upon 
the  age  of  the  patient. 

Etiology. — The  hematozoon  malarias  was  discovered  by  Lavaran  in 
1881.  It  is  a  parasite  of  the  blood  and  belongs  to  the  group  of  the  proto- 
zoa.* The  anemia  of  malaria  results  from  the  extensive  destruction  of 
the  red  corpuscles  caused  by  the  growth  of  the  parasite.  How  it  enters 
the  blood  is  as  yet  undetermined. 

Malaria  affects  all  ages,  even  the  newly-born  infant.     "We  must  accept 

*  For  a  description  of  the  plasmodium,  methods  of  staining,  etc.,  see  James,  Xew 
York  Medical  Record,  1888';  Councilman,  The  Medical  News,  January  15,  1887;  or 
Thayer  and  Hewetson,  Johns  Hopkins  Hospital  Reports,  vol.  v,  1895. 


1076  THE   SPECIFIC   INFECTIOUS  DISEASES. 

with  some  allowance  the  statements  made  by  the  older  writers  upon  the  sub- 
ject of  intra-uterine  infection,  but  in  the  following  case  occurring  in  the 
practice  of  my  associate,  Dr.  Crandall,  there  seems  little  doubt  that  the 
disease  was  contracted  in  utero  :  For  ten  days  before  delivery  the  mother 
had  suffered  from  a  tertian  intermittent  of  moderate  severity.  Eighteen 
hours  after  birth  the  child  was  noticed  to  have  cold  hands  and  feet,  blue 
lips  and  nails,  and  a  pinched  face.  These  symptoms  lasted  about  half  an 
hour  and  were  followed  by  a  distinct  fever.  Upon  the  following  day  the 
paroxysm  was  repeated.  Examination  of  the  blood  of  both  mother  and 
child  was  made  by  Dr.  Walter  James,  who  found  the  malarial  organisms 
in  both  cases. 

Malaria  is  more  frequently  overlooked  in  young  children  than  in  later 
life,  from  the  fact  that  its  forms  are  more  irregular,  and  this  has  led  to 
the  belief  that  young  children  are  less  liable  than  adults  to  the  disease.  I 
believe,  however,  the  opposite  to  be  the  case.  In  a  large  number  of  in- 
stances where  families  have  been  exposed  to  malarial  poisoning  I  have 
noted  that  the  young  children  were  frequently  the  first  to  show  the 
symptoms  of  the  disease. 

Malaria  is  an  endemic  disease  prevailing  in  certain  localities.  In 
New  York  it  rarely  develops  except  in  patients  who  live  along  the  river 
fronts  or  in  the  districts  contiguous  to  Central  Park.  In  many  of  the 
suburbs  malaria  is  exceedingly  prevalent,  and  in  them  originate  most 
of  the  cases  coming  under  observation  in  New  York.  Malarial  attacks 
may  be  seen  at  any  season,  but  are  more  frequent  in  the  fall  and  spring. 
They  are  particularly  liable  to  occur  when  the  general  health  of  the 
patient  is  reduced  by  some  other  influence,  especially  by  derangement  of 
the  digestive  organs,  and  they  often  follow  in  the  wake  of  other  acute  in- 
fectious diseases.  The  poison  of  malaria  may  remain  latent  in  the  system 
for  an  indefinite  time,  producing  symptoms  when  the  conditions  favour- 
able for  its  development  are  present. 

Lesions. — Opportunities  for  a  study  of  the  peculiarities  of  the  lesions  of 
malaria  in  children  are  infrequent,  especially  in  New  York,  as  fatal  cases 
are  extremely  rare.  I  have  myself  seen  but  two.  As  observed  by  others,  the 
lesions  do  not  differ  in  any  marked  way  from  the  adult  form  of  the  disease. 
The  most  important  changes  are  the  destruction  of  the  red  corpuscles  of 
the  blood,  enlargement,  and  in  chronic  cases  hyperplasia  with  pigmenta- 
tion of  the  spleen ;  less  frequently  i^igmentation  of  the  liver,  kidneys, 
and  brain.     Pneumonia  and  gastro-enteritis  are  occasional  complications. 

Symptoms. — The  clinical  forms  of  malarial  fever  in  children  from  six 
to  ten  years  old,  do  not  differ  essentially  from  the  same  disease  in  adults. 
Both  intermittent  and  remittent  forms  occur,  the  former  being  the  type 
usually  seen.  Of  the  different  varieties  of  intermittent  fever,  the  quotidian 
(Fig.  183)  is  the  most  common,  although  the  tertian  (Fig.  184)  is  fairly 
frequent,  but  the  quartan  is  extremely  rare.     The  stages  of  the  paroxysm 


MALARIA. 


1077 


are  generally  well  marked.  The  cold  stage  begins  with  a  chill  or  vomiting, 
with  headache,  lassitude,  and  general  pains.  The  hot  stage  is  usually  char- 
acterized by  a  higher  temperature  than  in  adults,  and  this  is  followed  by 
the  sweating  stage,  which  is  generally  marked.     The  paroxysm  may  be 


DAY 

1 

2 

3 

1 

■^                      1 

«                        1 

7 

HOUR 

A.M.       1       P.M. 

J       S     1o|  2      5     10 

/■r,o 

P.M.       1 

A.M. 

2       6     1o| 

A.M. 

2      6     10 

2      6     10.| 

2       6     10 

A.M. 

2      E     10 

2      S    'lo| 

jTioI 

P.M. 
2      G     10| 

106° 

105° 

IM 

103 

102 

101 

100° 

99° 

98 

97° 

1 

1 

>^ 

1 

1 

1 

1 

1 

1 

n 

1 

11 

1 

1 

1 

1 

1 

1 

■ 

1 

1 

1 

■ 

1 

1 

, 

1 

1 

1 

! 

1 

1 

- 

1 

\ 

1 

1 

\ 

1 

I 

\ 

11 

V 

1 

\ 

1 

\ 

1 

\ 

* 

'- 

s 

1 

Ui 

1 

1 

!-• 

■■" 

1v 

\ 

1 

1 

, 

^ 

Z' 

" 

V 

■  1 

\ 

>  L--! 

y 

^ 

" 

,/ 

/ 

1 

/ 

1 

/ 

1 

V 

^ 

1 

1 

_ 

_ 

_ 





V 







.!_ 



: 

Fig.  183.— Typical  malarial  temperature,  quotidian  type,  in  a  boy  six  years  old.  Each  paroxysm 
preceded  by  a  chill.  It  will  be  noticed  that  the  temperature  rose  higher  with  each  succeed- 
ing paroxysm;  x  marks  the  time  when  quinine  was  begun. 

repeated  every  day  or  every  other  day  until  controlled  by  quinine,  or  the 
stages  may  become  less  and  less  distinct  as  the  disease  progresses  until  a 
more  or  less  remittent  type  of  fever  develops.  Less  frequently  the  fever 
is  remittent  from  the  beginning  and  the  constitutional  symptoms  are  of 
greater  severity.  In  this  form  there  is  marked  prostration,  the  tongue 
is  thickly  coated,  there  are  often  tenderness  and  pain  in  the  region  of  the 
liver,  and  occasionally  there  is  slight  Jaundice. 

In  infants  and  very  young  children  the  peculiar  types  of  malaria  are 
seen.  A  well-marked  intermittent  fever  with  distinct  stages  is  quite  ex- 
ceptional, most  of  the  cases  assuming  more  of  a  remittent  type  or  an  irregu- 


1078 


THE  SPECIFIC  INFECTIOUS  DISEASES. 


lar  form  of  intermittent  (Fig,  185).  The  onset  is  usually  abrupt  with 
vomiting,  a  well-marked  chill  being  rare.  I  have  seldom  seen  a  malarial 
chill  in  a  child  under  five  years  old.  This  is  replaced  in  infants  by  cold 
hands  and  feet,  blue  lips  and  nails,  sometimes  slight  general  cyanosis, 
pallor,  drowsiness,  and  prostration.  Vomiting  was  present  in  two  thirds 
of  my  own  cases.*  Four  times  have  I  seen  a  malarial  attack  ushered  in 
by  convulsions. 

The  fever  is  relatively  higher  than  in  adults,  rising  rapidly  to  104°  or 
105°  F.,  occasionally  to  106°  or  106-5°  F.  This  continues  from  four  to 
twelve  hours  and  gradually  falls,  usually  to  normal.     The  other  constitu- 


DAY 

1 

2 

3 

i 

5 

6 

-^       1 

HOUR 

/e%| 

P.M. 

e    10 

2*'rio 

P.M. 
2      6     10 

A.M. 

2       G     10 

P.M. 

2       6     10 

2      6     10 

2      ?     10 

2     e    10 

2       6     10 

P.M. 

2      G     10 

2T-1o| 

105 
104 
103° 
102 
101 
100° 
99° 

98 
97 

1 

/ 

/ 

1 

\ 

1 

1 

1 

1 

' 

\ 

\ 

t 

\ 

1 

I 

1 

\ 

1 

\ 

1 

1 

1 

I 

1 

1 

1 

1 

1 

1 

• 

■ 

, 

1 

s 

/ 

s 

1 

V 

s, 

/ 

s. 

1 

\ 

.^ 

/ 

4 

K 

I 

J 

\ 

/ 

' 

"^ 

■^ 

'^ 

/ 

/ 

S 

1 

V 

' 

/ 

'\ 

/ 

S, 

' 

, 
^ 

.,  J 

Fig.  184. — Tj'pical  malarial  temperature,  tertian  type,  in  a  boy  five  years  old.  Onset  with  vom- 
iting and  drowsiness,  but  no  chill.  Tliis  was  an  antieipatin?  "intermittent,  the  first  parox- 
ysm occurring  at  3  p.  m.,  the  second  at  12  m.,  the  third  at  10  a.  m.  ;  x  murks  the  time  when 
quinine  was  begun. 

tional  symptoms  of  the  febrile  stage  are  much  less  severe  than  in  most  dis- 
eases with  the  same  elevation  of  temperature.     The  sweating  stage  is  only 


*  The  Symptoms  and  Diagnosis  of  Malaria  in  Children.     The  American  Journal  of 
Obstetrics  and  Diseases  of  Women  and  Children,  Nos.  I  to  IV,  1883. 


MALARIA.  10Y9 

slightly  marked  and  is  often  absent  altogether.  With  the  fall  in  the  tem- 
perature there  is  a  gradual  subsidence  of  all  the  other  symptoms  of  the 
febrile  stage. 

After  the  first  paroxysm  the  patient  may  be  quite  well  for  several 
hours  or  even  for  a  day,  when  the  second  paroxysm  occurs.  This  is  gen- 
erally not  so  well  marked  as  the  first  one,  the  third  may  be  even  less  so, 
and  the  case  may  resemble  more  and  more  one  of  continuous  fever  with 
wide  oscillations  in  the  temperature.  In  some  cases  it  is  remittent  at  first 
and  later  becomes  intermittent,  but  it  is  very  rare  under  either  circum- 
stances that  the  temperature  does  not  touch  the  normal  point  at  some 
time  in  the  twenty-four  hours.  In  infants  the  quotidian  has  been  in  my 
experience  very  much  more  frequent  than  any  other  type,  the  tertian  being 
rare  and  the  quartan  almost  unknown. 

Enlargement  of  the  spleen  is  present  in  the  great  majority  of  cases,  and 
usually  to  a  sufficient  degree  to  be  readily  appreciated  by  examination. 
The  most  satisfactory  method  of  examination  is  by  palpation  (page  832). 
A  spleen  which  can  be  easily  felt  below  the  ribs  (except  in  the  rare  cases 
in  which  the  organ  is  displaced  downward  by  some  condition  in  the  thorax) 
is  enlarged.  When  it  is  not  sufficiently  enlarged  to  be  readily  felt  by  a 
practised  observer  under  favourable  conditions  for  examination,  it  is  not 
large  enough  to  be  of  any  diagnostic  importance.  None  of  the  other 
symptoms  occurring  in  malarial  fever  are  characteristic  ;  they  are  quite 
similar  to  those  which  are  seen  in  almost  all  febrile  attacks.  There  are 
anorexia,  coated  tongue,  constipation,  and  restlessness. 

Masked  or  Irregular  Forms  of  Malaria. — These  are  quite  frequent  in 
young  children,  and  are  due  to  the  presence  of  certain  special  or  uncom- 
mon symptoms  which  may  readily  lead  to  a  mistake  in  diagnosis.  They 
are  more  often  seen  than  cases  of  true  malarial  cachexia. 

Among  the  most  frequent  of  the  irregular  forms  are  those  relating  to 
the  nervous  system.  Headache  is  exceedingly  common  and  is  usually 
frontal.  When  severe  and  associated  with  continuous  drowsiness,  vomit- 
ing, and  constipation,  it  may  lead  to  a  strong  susj^icion  of  tuberculous 
meningitis.  Vertigo  is  not  a  frequent  symptom,  but  it  is  sometimes  very 
prominent.  Pains  in  various  parts  of  the  body  are  very  common.  A  sharp 
severe  pain  at  the  epigastrium  is  frequent  at  the  beginning  of  a  paroxysm. 
It  is  often  associated  Avith  tenderness,  but  has  no  relation  to  vomiting. 
Less  frequently,  pain  is  localized  in  the  region  of  the  spleen  or  liver.  Tri- 
facial neuralgia  of  malarial  origin  is  rare  in  childhood.  Aching  or  drag- 
ging pains  in  the  muscles  of  the  lower  extremities  are  frequent  symptoms 
during  acute  attacks,  but  they  are  of  short  duration,  disappearing  with 
the  fever.  They  are  to  be  distinguished  from  the  acute  lancinating  pains 
of  multiple  neuritis,  which  is  occasionally  seen  as  a  result  of  malarial  poi- 
soning. I  have  seen  the  latter  in  young  children  in  three  cases,  and  it  has 
been  observed  by  others.      The  pain  is  accompanied  by  tenderness  of 


1080 


THE  SPECIFIC   INFECTIOUS  DISEASES. 


the  muscles  and  uerve  trunks,  and  by  loss  of  power,  which  is  usually 
partial. 

Spasmodic  torticollis  (page  683)  I  have  seen  in  eight  cases,  in  which 
the  condition  seemed  very  clearly  to  depend  upon  malaria.      This  was 


"i-                  1                               2                              3                              4                               5                              C                               7 

"""-^     2  *6"-10     2  "f'yo     2   *g"-10     2    "'"'^O     2    \"\o     ,  "s^'lo     5    ^"lO      2   T,0      2  'c^'lO     2  "f'lO     2  \"\o      2  's^'lo      2   Wo     2   "e^'lO 

r 

' 

-j 

-          N^                                         2.                        T 

-                   ^                                           r-         V                                          5 

-                    nt     J 

it   r 

103                        --            -                              tX-^                                        -h- 

T4^                           t 

t4?                    V 

t   t                    t 

ft 

-              ^      t           t 

?      t           t 

t^ 

V 

-                4^ 

^i            : 

-  J      4 

_  J      vf 

^•^           --        -4                      1       . 

1                     It-   - 

r                      ^t   -- 

t                       4   t     -  ^ 

99                           -                       C                                                  '4       J            -^-V                                         ^-^       ^=1 

90                                                                                  y     /            I    1                              ^-,      ^-. 

f^                         ^         i^v     t^     t            /^ 

6          ^r-/^  7  4^   ^   n   ^ 

I             t'^\_Z:   ^^      W       ^'^ 

98                        --                                                                                                                        V       V                 V            ^            ^ 

1 1    1    1    1    1    1    1    1    1    1    1    M 1 _     _]_ 

Fig.  185. — An  irreiifular  malarial  temperature  in  a  child  nine  months  old.  The  paroxysm  on  the 
fourth  day  was  accompanied  by  an  attack  of  acute  pulmonary  congestion  which  came  near 
being  fatal ;  x  marks  the  time  when  quinine  was  begun.  Althoush  the  course  of  the  tem- 
perature is  irregular,  it  touched  the  normal  line  both  on  the  second  and  fourth  days. 

shown  by  the  fact  that  the  spasm  was  intermittent,  coming  on  every  after- 
noon, but  being  absent  in  the  morning;  that  it  was  accompanied  by  a 
slight  rise  in  temperature,  and  usually  by  enlargement  of  the  spleen ;  and 
that  it  was  immediately  controlled  by  quinine.  This  combination  of  symp- 
toms seemed  to  be  conclusive  evidence  of  the  malarial  origin  of  the  affec- 
tion, although  these  cases  were  observed  before  the  time  when  blood' ex- 
aminations were  made. 

Accompanying  the  paroxysm  of  malaria  there  is  occasionally  seen, 
more  often  in  infants  than  in  older  children,  acute  pulmonary  conges- 
tion (Fig.  185),  which  may  give  rise  to  obscure  and  often  very  alarming 
symptoms.  There  is  an  acute  onset  with  vomiting  and  prostration,  high 
temperature,  cough,  rapid  respiration,  and  often  slight  cyanosis.  On  ex- 
amination of  the  chest  there  is  found  feeble  or  rude  respiration  over  one 
lung,  or  over  both  lungs  behind,  and  sometimes  coarse  moist  rales  ;  these 
signs  and  symptoms  may  disappear  in  the  course  of  a  few  hours  with  the 


MALARIA.  1081 

fall  in  temperature,  to  return  with  the  next  paroxysm,  or  if  quinine  is  given 
they  may  disappear  entirely.*  This  group  of  symptoms  has  often  led  to 
the  mistaken  opinion  that  the  disease  was  pneumonia,  which  had  been 
aborted  by  the  administration  of  quinine. 

Subacute  or  Chronic  Forms  of  Malaria, — The  most  constant  symptoms 
are  anaemia,  enlargement  of  the  spleen,  and  slight  fever.  The  anaemia  is 
usually  marked,  often  being  extreme.  The  enlargement  of  the  spleen  is 
distinct,  and  easily  made  out  by  palpation,  and  sometimes  is  very  great. 
The  fever  is  often  so  slight  as  to  be  discovered  only  when  the  temperature 
is  taken  five  or  six  times  in  the  twenty-four  hours.  The  other  symptoms 
are  of  a  very  indefinite  character ;  there  may  be  slight  oedema  of  the  lower 
extremities,  general  muscular  weakness,  so  that  the  child  is  easily  fatigued, 
loss  of  appetite,  coated  tongue,  constipation,  headache,  muscular  pains,  and 
often  cough  from  a  slight  bronchitis.  These  symptoms  may  depend  upon 
many  conditions  other  than  malaria,  even  when  they  are  seen  in  a  malarial 
district.  The  only  positive  evidence  of  malaria  in  such  cases  is  the  pres- 
ence of  the  malarial  organisms  in  the  blood.  Even  the  swollen  spleen, 
anaemia,  and  slight  fever,  which  are  often  looked  upon  as  diagnostic,  may 
be  present  in  cases  of  anaemia  with  which  malaria  has  nothing  whatever 
to  do. 

Diagnosis. — The  positive  diagnosis  of  malaria  rests  upon  the  demon- 
stration of  the  malarial  organisms  in  the  blood.  They  will  be  found  in 
nearly  all  the  cases  when  examined  under  favourable  conditions,  which  are : 
(1)  that  the  examination  be  made  by  one  with  considerable  experience  in 
searching  for  malarial  organisms  ;  (3)  that  the  examination  be  thorough  ; 


*  The  following  case  is  a  good  example  of  this  condition  in  its  more  severe  form, 
and  illustrates  the  difficulties  in  the  diagnosis  of  malaria  in  infancy  :  A  fairly  nourished 
child,  nine  months  old,  who  had  been  under  observation  in  an  institution  for  two  weeks, 
was  suddenly  taken  with  vomiting  and  fever  (Fig.  185).  A  cathartic  was  followed  by 
a  large  undigested  stool,  and  as  the  temperature  then  fell  to  normal,  the  attack  was 
regarded  as  one  of  indigestion.  On  the  third  day  the  temperature  was  again  high  and 
accompanied  by  cough ;  coarse  rales  were  found  throughout  the  chest,  and  fine  rales 
at  the  right  base :  it  was  then  thought  that  pneumonia  was  developing.  On  the  fourth 
day  all  the  symptoms  were  so  much  improved  that  the  infant  was  regarded  as  conva- 
lescent. At  6  P.  M.  the  temperature  was  normal  and  the  infant  went  to  sleep  quietly. 
At  9.30  p.  M.  he  awoke  with  a  temperature  of  104°,  extreme  restlessness,  and  marked 
dyspnoea.  In  half  an  hour  his  symptoms  had  increased  to  a  point  where  he  seemed 
likely  to  die.  He  became  cyanotic,  the  respirations  were  of  a  panting  character  and 
rose  nearly  to  100  a  minute,  and  he  coughed  with  almost  every  breath  ;  the  pulse  was 
scarcely  perceptible.  The  severe  symptoms  continued  for  about  an  hour,  then  passed 
away  gradually,  and  at  the  end  of  two  and  a  half  hours  they  had  completely  disap- 
peared, and  the  child  was  in  a  quiet  sleep  which  continued  until  morning.  Malaria 
was  now  suspected,  and  the  diagnosis  established  by  the  discovery  of  the  plasmodium 
in  the  blood.  The  spleen  was  at  this  time  much  enlarged  ;  the  signs  in  the  chest  were 
those  only  of  bronchitis  of  the  large  tubes.  Quinine  was  now  begun  in  full  doses,  and 
immediately  controlled  the  temperature  and  the  pulmonary  symptoms. 


1082  THE  SPECIFIC  INFECTIOUS  DISEASES. 

(3)  that  it  be  made  during  the  paroxysm ;  and  (4)  that  no  quinine  shall 
have  been  -previously  given.  Blood  from  the  spleen  is  more  certain  to 
show  the  organisms  than  that  from  the  finger ;  and  if  possible  the  exami- 
nation should  be  of  fresh  blood  as  well  as  of  dried  specimens.  While  a 
positive  result  is  conclusive,  a  negative  one  is  not  always  so  because  of  the 
impossibility  of  fulfilling  all  the  above  conditions.  The  technique  of  blood 
examinations  is  somewhat  difficult,  and  for  the  great  majority  of  the  pro- 
fession a  diagnosis  must  for  the  present  rest  upon  the  other  symptoms. 
These,  in  order  of  their  importance,  I  place  as  follows  :  enlargement  of  the 
spleen ;  prompt  curability  (especially  in  cases  of  fever)  by  quinine ;  dis- 
tinct periodicity  in  the  symptoms ;  and  a  history  of  an  exposure  in  a  dis- 
trict known  to  be  malarial.  Particular  importance  is  to  be  attached  to  the 
therapeutic  test.  Recent  experience  emphasizes  more  and  more  strongly 
the  fact  that  quinine  has  very  little  influence  upon  fevers  which  are  not 
malarial,  and,  conversely,  that  a  fever  immediately  and  permanently  con- 
trolled by  quinine  is  pretty  certain  to  be  malarial.  The  combination  of 
all  the  above  symptoms,  even  in  the  absence  of  an  examination  of  the 
blood,  may  be  regarded  as  sufficient  to  establish  the  diagnosis  of  malaria. 

The  cachexia  and  course  of  the  temperature  in  septicsemia,  pyaemia, 
broncho-pneumonia,  tuberculosis,  and  empyema,  may  easily  cause  them  to 
be  mistaken  for  malaria.  The  fever  and  recurring  chills  of  pyelitis  are 
often  attributed  to  malaria;  as  are  also  the  heaviness,  lethargy,  headache, 
coated  tongue,  and  slight  fever  of  chronic  intestinal  indigestion.  Many 
conditions  accompanied  by  an  enlarged  spleen  may  be  confounded  with 
malaria,  especially  simple  anaemia,  leuc^mia,  rickets,  and  syphilis.  While 
malaria  may  be  multiform  in  its  manifestations,  the  physician  can  fall 
into  no  more  serious  error  than  to  regard  all  ailments  with  indefinite 
symptoms  as  malarial,  neglecting  careful  physical  examinations,  by  which 
means  alone  accurate  diagnosis  is  reached. 

Prognosis. — xllthough  it  is  seldom  fatal  in  itself,  an  attack  of  malaria 
in  an  infant  may  so  undermine  the  constitution  that  the  child  may  suc- 
cumb to  some  other  acute  disease,  usually  of  the  lungs  or  intestines.  Cases 
are  often  difficult  to  cure  while  the  patient  remains  in  the  malarial  dis- 
tricts, and  while  a  constant  absorption  of  the  poison  continues.  Under 
other  circumstances  the  prognosis  of  malaria  is  good. 

Treatment. — The  general  treatment  is  symptomatic,  and  is  to  be 
conducted  as  in  all  acute  febrile  diseases.  In  the  cold  stage,  stimulants 
or  a  hot  bath  may  be  required  ;  in  the  hot  stage,  ice  to  the  head  and  fre- 
quent sj)ongiug.  The  bowels  in  all  cases  should  be  freely  opened,  prefer- 
ably by  calomel. 

Metliods  of  administration  of  quinine. — For  infants  my  own  prefer- 
ence is  to  give  the  bisulphate  in  an  aqueous  solution,  one  grain  to  the 
teaspoonful,  according  to  the  age  of  the  patient.  Most  infants  take 
such  a  solution  with  less  difficulty  and  vomit  it  less  frequently  than  the 


MALARIA.  1083 

combinations  with  the  various  vehicles  supposed  to  cover  its  taste.  In  the 
event  of  failure  by  this  method,  the  same  solution  may  be  given  joer  rectum 
through  a  catheter.  It  should  then  be  more  largely  diluted  with  some 
bland  fluid  such  as  gruel,  and  in  double  the  dose.  This  is  necessary,  not 
only  because  absorption  is  less  certain  and  complete,  but  also  because  a 
rectal  dose  can  seldom  be  repeated  of  tener  than  every  five  or  six  hours. 
There  is  sometimes  an  advantage  in  giving  part  of  the  quinine  by  the 
mouth  and  part  of  it  by  the  rectum  ;  should  both  fail  it  should  be  given 
hypodermically.  For  this  purpose  the  bimuriate  of  quinine  and  urea,  the 
hydrobromate,  or  the  bisulphate  may  be  used.  The  salt  first  mentioned 
is  to  be  preferred  on  account  of  its  greater  solubility.  The  bisulphate  is 
the  most  irritating  of  these  preparations  and  there  usually  follows  some 
induration  at  the  site  of  its  injection,  which  may  last  a  long  time.  This 
method  of  administration  will  not  often  be  required,  but  in  certain  cases 
it  is  invaluable.  Injections  should  be  made  deeply  in  the  buttock  or 
thigh ;  if  the  needle  is  clean  no  abscess  will  result. 

For  children  from  two  to  seven  years  old  the  taste  of  quinine  must  be 
concealed.  An  aqueous  solution  may  be  mixed  with  the  syrup  of  sarsa- 
parilla,  orange,  or  yerba  santa ;  or  the  powdered  salt  may  be  given  in  sus- 
pension in  the  same  vehicle,  the  mixture  being  made  in  both  instances  just 
before  the  dose  is  taken ;  otherwise  the  partial  solution  of  the  drug  will 
render  the  whole  dose  exceedingly  bitter.  When  the  dose  required  is  not 
large,  as  in  the  milder  cases,  the  lozenges  of  the  tannate  of  quinine  com- 
bined with  chocolate  answer  the  i)urpose  admirably,  for  these  are  so 
nearly  tasteless  that  children  will  take  them  without  difficulty.  Each 
lozenge  usually  contains  one  grain  of  the  tannate,  which  is  equivalent  to 
about  one  third  of  a  grain  of  the  sulphate  of  quinine.  A  similar  lozenge 
containing  one  grain  of  the  sulj^hate  may  be  made,  which  is  often  taken 
by  children  without  the  slightest  objection.  The  bisulphate  may  be  given 
in  solution  by  the  rectum,  or,  better,  at  this  age,  in  the  form  of  supposi- 
tories; but,  as  in  infancy,  with  urgent  symptoms,  it  is  better  to  resort  at 
once  to  the  hypodermic  method  in  case  of  failure  by  the  stomach. 

For  children  over  seven  years  old,  the  same  methods  of  administration 
may  usually  be  employed  as  in  adults.  It  is  always  preferable  to  give 
quinine  in  solution,  or  if  not  so,  in  capsule,  but  never  in  pill  form. 

In  a  case  with  well-marked  paroxysms  the  quinine  should  be  given  in 
the  interval,  with  the  largest  dose  about  four  hours  before  the  expected 
paroxysm.  In  infancy  this  plan  is  sometimes  impracticable,  as  frequent 
small  doses  are  usually  better  borne  by  the  stomach  than  a  few  large  ones. 
If  other  methods  of  administration  are  employed,  however,  this  should 
always  be  done.  I  have  never  succeeded  in  getting  the  physiological  effects 
of  quinine  by  inunction,  though  there  are  good  observers  who  claim  this 
result.  It  is  certainly  a  very  uncertain  way  of  introducing  quinine  into 
the  system. 


1084  THE  SPECIFIC   INFECTIOUS  DISEASES. 

Dosage. — Relatively  mucli  larger  closes  of  quinine  are  required  for  young 
children  than  for  adults.  Except  for  its  tendency  to  disturb  the  stomach, 
quinine  is  borne  remarkably  well  by  little  patients.  Generally  too  small 
doses  are  given.  An  infant  of  a  year  with  a  sharp  attack  of  malarial 
fever  will  usually  require  from  eight  to  twelve  grains  of  the  sulphate 
(ten  to  fourteen  grains  of  the  bisulphate)  daily.  Occasionally  I  have 
found  it  necessary  to  give  double  the  quantity  referred  to,  and  I  have  seen 
no  unpleasant  cerebral  symptoms.  It  is  useless  to  expect  to  control  an 
acute  attack  of  malaria  by  such  doses  as  one  grain  three  or  four  times  a 
day.  Children  from  five  to  ten  years  old  require  almost  as  large  doses  as 
do  adults.  None  of  the  substitutes  for  quinine  are  to  be  relied  upon  in 
acute  cases. 

In  chronic  cases,  arsenic  and  iron  are  usually  required  in  combination 
with  smaller  doses  of  the  quinine  than  those  mentioned.  For  children 
over  seven  years  old,  Warburg's  tincture  may  be  employed.  In  most 
chronic  cases  a  cure  can  be  effected  only  by  a  change  of  climate. 

The  marked  and  irregular  manifestations  of  malaria  are  to  be  treated 
in  the  same  manner  as  cases  of  malarial  fever. 


SECTION   X. 
OTHER  GENERAL  DISEASES. 

CHAPTER   I. 

RHEUMATISM. 

The  rheumatic  diatliesis  manifests  itself  in  children  by  quite  a  differ- 
ent group  of  symptoms  from  those  seen  in  adults ;  for  this  reason  the 
disease  was  formerly  supposed  to  be  a  rare  one  in  early  life.  It  is  only 
within  recent  years  that  its  frequency  and  its  peculiarities  have  come  to 
be  appreciated.  For  our  present  understanding  of  the  subject  we  are  in- 
debted largely  to  the  Avork  of  English  physicians,  especially  Cheadle,* 
who  has  brought  out  more  fully  than  anyone  else  the  close  connection  ex- 
isting between  many  conditions  formerly  not  regarded  as  rheumatic.  One 
who  has  in  mind  only  the  adult  types  of  articular  rheumatism,  and  regards 
arthritis  as  a  necessary  symptom  for  a  diagnosis,  will  overlook  in  early  life 
many  manifestations  which  are  clearly  the  result  of  the  rheumatic  poi- 
son. There  is  seen  at  this  period  a  group  of  clinical  phenomena,  which 
often  occur  in  combination  or  in  succession,  whose  association  was  not 
understood  until  they  were  all  discovered  to  be  related  to  rheumatism. 
Sometimes  one  member  of  the  group  and  sometimes  another  is  first  seen, 
but  when  one  has  appeared  others  are  likely  soon  to  follow. 

Rheumatism  in  childhood,  then,  is  manifested  not  alone  by  arthritis 
with  acute  or  subacute  symptoms,  but  by  a  large  number  of  other  condi- 
tions which  are  not  to  be  regarded  in  the  light  of  complications,  but  rather 
as  forms  of  the  disease. 

Etiology. — It  is  not  in  the  province  of  this  work  to  discuss  the  various 
theories  regarding  the  nature  of  rheumatism  and  its  exciting  cause.  The 
drift  of  medical  opinion  to-day  is  strongly  toward  the  view  that  acute 
rheumatism  is  an  infectious  disease,  probably  of  microbic  origin,  although 
the  character  of  the  micro-organism  is  as  yet  unknown.  The  excessive 
formation  of  acids  in  the  system  may  be  regarded  as  a  result  of  the  infec- 
tion, or  possibly  as  a  condition  necessary  for  the  activity  of  the  specific 
poison.  Under  five  years  of  age  articular  rheumatism  is  rare,  and  in  in- 
fancy it  is  extremely  rare.     I  have,  however,  once  seen  in  a  nursing  infant, 

*  See  the  Harveian  Lectures,  1889. 
1085 


1086  OTHER  GENERAL  DISEASES. 

a  little  more  than  a  year  old,  a  tyjiical  attack  of  rheumatic  fever  with 
multiple  joint  lesions,  and  undoubted  cases  have  been  reported  at  as  early 
an  age  as  six  months.  Still,  all  these  are  very  exceptional,  and  one  should 
be  wary  of  diagnosticating  rheumatism  during  the  first  two  years  of  life. 

After  the  fifth  year  both  the  articular  and  the  other  manifestations  of 
rheumatism  become  more  common,  and  occur  with  increasing  frequency 
•  up  to  the  time  of  puberty. 

Heredity  is  a  very  important  etiological  factor,  and  in  fully  two  thirds 
of  the  cases  that  have  come  under  my  care,  a  rheumatic  family  history 
was  obtained.  Of  the  other  important  causes,  the  most  frequent  are  living 
in  damp  dwellings,  direct  exposure  to  cold  and  wet,  poor  hygienic  sur- 
roundings, and  insufficient  food.  While  seen  among  all  classes,  rheuma- 
tism is  more  common  among  those  who  are  badly  housed. 

Attacks  of  rheumatism  are  seen  at  all  seasons,  but  are  much  more 
frequent  in  the  spring  months.  One  attack  strongly  predisposes  to  a 
second,  and  in  most  cases  there  is  a  history  of  a  large  number  of  attacks 
of  greater  or  less  severity.  Among  my  own  patients,  girls  have  been 
affected  with  greater  frequency  than  boys. 

Symptoms. —  The  general  and  articular  manifestations. — The  clinical 
types  of  rheumatism  in  children  present  very  notable  contrasts  to  those 
seen  in  adults.  A  typical  attack  of  acute  articular  rheumatism  such  as  is 
seen  in  adult  life,  with  a  sudden  onset,  high  temperature,  severe  inflam- 
mation of  several  joints,  profuse  acid  perspiration,  and  occasional  delir- 
ium, is  rarely  seen  in  a  child  under  eight  or  ten  years  old.  In  most  of 
the  attacks  in  childhood  the  onset  is  not  very  acute,  the  temperature  is 
but  slightly  elevated — only  100°  or  101-5°  F. — the  swelling  and  pain  are 
moderate,  and  the  redness  is  often  absent.  The  number  of  joints  involved 
is  generally  small,  those  most  frequently  affected  being  the  ankles,  the 
knees,  the  small  joints  of  the  foot,  the  wrists,  or  the  elbows.  These  symp- 
toms are  often  not  severe  enough  to  keep  the  patient  in  bed,  and  only  the 
pain  in  the  joints  of  the  lower  extremities  prevents  him  from  walking. 
The  duration  of  these  attacks  is  from  one  to  three  wrecks,  and  in  the 
course  of  a  month  most  of  them  recover  even  without  treatment. 

Not  infrequently  the  symptoms  are  limited  to  a  single  joint,  usually  the 
hip,  knee,  or  ankle.  Possibly  the  joints  of  the  upper  extremity  are  affected 
oftener  than  would  appear,  but  disease  here  is  much  more  likely  to  be 
overlooked  than  when  lameness  is  present.  The  swelling  is  moderate  and 
may  not  be  evident  except  on  a  close  examination  ;  in  some  cases  there  is 
none.  There  is  stiffness  of  the  joint,  as  shown  by  lameness,  and  there  may 
be  so  much  pain  and  soreness  that  the  child  refuses  to  walk  altogether. 
Muscular  spasm  about  the  affected  joint  is  often  marked,  and  may  be  the 
most  striking  objective  symptom.  The  tenderness  is  sometimes  local- 
ized, but  it  may  affect  the  ligaments,  tendons,  and  even  the  muscles. 
These    symptoms    may  persist  for    two  or  three  weeks    and  lead  to  the 


RHEUMATISM.  1087 

suspicion  of  incipient  tuberculous  disease  of  the  joint.  Rheumatism  is 
distinguished  by  its  more  acute  onset  and  usually  by  the  presence  of 
slight  fever ;  some  elevation  of  temperature  being  the  rule,  though  it  is 
not  often  much  over  100°  F.  A  family  history  of  rheumatism,  or  a  his- 
tory of  previous  similar  attacks  in  the  patient  affecting  the  same  or  other 
joints,  or  other  manifestations  of  rheumatism,  are  also  of  assistance  in  the 
diagnosis.  Occasionally  all  doubt  is  removed  by  the  disease  extending  to 
other  joints,  or  by  the  development  of  endocarditis.  In  some  cases  the 
symptoms  are  less  in  the  articulation  than  in  the  muscles,  and  they  are 
dismissed  as  simply  "  growing  pains,"  having  nothing  characteristic  about 
them  except  their  occurrence  in  damp  weather. 

Cardiac  manifestations. — These  may  occur  where  the  articular  symp- 
toms are  very  mild,  and  in  some  cases  where  they  are  entirely  absent. 
The  most  frequent  is  endocarditis.  This  is  much  more  often  seen  in  the 
acute  rheumatism  of  children  than  of  adults,  and  probably  occurs  in  the 
majority  of  all  severe  cases;  if  it  does  not  come  in  the  first  attack,  it  is 
likely  to  be  seen  in  the  later  ones.  It  frequently  occurs  with  a  mild  rheu- 
matic arthritis,  often  being  unnoticed  until  valvular  disease  of  considerable 
severity  has  developed.  Sometimes  there  is  only  high  fever  with  severe 
constitutional  symptoms  of  an  indefinite  character,  but  no  arthritis,  and 
no  suspicion  that  the  attack  is  rheumatic  until  endocarditis  is  discovered. 
Such  cases  are  not  infrequent.  If  the  patients  are  kept  under  observation, 
articular  symptoms  are  almost  certain  to  develop  later,  and  often  there  are 
other  manifestations  of  rheumatism,  especially  chorea. 

Pericarditis  is  less  frequent  than  endocarditis,  and  usually  occurs  in 
children  over  seven  years  old.  It  is  often  associated  with  endocarditis. 
The  most  characteristic  form  of  inflammation  in  early  life  is  a  subacute, 
dry,  fibrous  form,  often  resulting  in  great  thickening  with  extensive  adhe- 
sions, and  frequently  in  obliteration  of  the  pericardial  sac.  When  once 
started  it  shows  a  strong  tendency  to  recurrence  and  persistence. 

The  heart  is  so  frequently  affected  in  the  rheumatism  of  childhood 
that  it  should  be  closely  watched  whenever  articular  symptoms  are  present, 
no  matter  how  mild  they  may  be ;  and  not  only  in  these  cases,  but  in  all 
the  conditions  hereafter  enumerated  with  which  rheumatism  is  likely  to  be 
associated. 

Inffammafions  of  other  serous  memhranes — the  pleura,  peritonaeum, 
and  pia  mater — were  much  more  frequently  ascribed  to  rheumatism  in  the 
past  than  now.  There  is  little  doubt  that  on  rare  occasions  any  one  of 
these  may  be  due  to  rheumatism.  The  pleura  is  most  often  involved,  but 
even  this  is  rare  in  young  children. 

Torticollis  when  it  occurs  acutely  is  frequently  rheumatic.  This  form 
is  characterized  by  its  sudden  development,  continuous  spasm,  the  great 
amount  of  muscular  soreness,  the  moderate  pain,  and  the  fact  that  it  usu- 
ally disappears  spontaneously  after  a  few  days.  It  is  often  seen  in  con- 
70 


1088  OTHER  GENERAL   DISEASES. 

nection  with  a  rheumatic  sore  throat.  Other  manifestations  of  muscular 
rheumatism  are  less  characteristic  and  usually  affect  the  muscles  of  the 
extremities. 

Ancemia  is  almost  invariably  seen  in  rheumatic  patients,  both  during 
and  between  the  attacks.  The  effect  of  the  rheumatic  poison  upon  the 
blood  resembles  that  of  malaria.  The  presence  of  anaemia  is  so  evident 
and  its  degree  often  so  marked,  that  one  may  have  great  difficulty  in  dis- 
tinguishing cardiac  murmurs  which  are  hsemic  from  those  due  to  endo- 
carditis. 

Chorea. — In  the  article  upon  Chorea  (page  674)  I  have  already  dis- 
cussed the  association  of  that  disease  with  rheumatism  and  expressed  my 
own  belief  in  a  very  close  relationship  existing  between  them.  Not  very 
infrequently  chorea  is  the  first  manifestation  of  the  rheumatic  diathesis, 
to  be  followed  soon  by  articular  symptoms  or  by  endocarditis  without  such 
symptoms.  In  other  cases  chorea  and  acute  endocarditis  occur  together 
without  articular  symptoms,  or  all  three  may  be  associated.  Whichever  of 
the  three  conditions  is  first  seen,  the  physician  should  always  be  on  the 
lookout  for  the  others.  The  frequency  of  rheumatism  in  choreic  patients 
has  been  variously  estimated  by  different  observers ;  in  my  own  cases  over 
fifty-six  per  cent  gave  unmistakable  evidences  of  the  rheumatic  diathesis. 

Tonsillitis. — Children  who  are  the  subjects  of  freqiteut  attacks  of 
acute  tonsillitis  and  pharyngitis  should  be  regarded  as  possibly  rheumatic, 
and  should  be  closely  watched  for  other  signs  of  that  disease.  A  careful 
examination  of  the  family  history  usually  reveals  other  evidences  of  rheu- 
matism. Acute  tonsillitis  often  ushers  in  an  attack  of  rheumatic  endo- 
carditis or  arthritis,  and  in  one  of  my  own  cases  a  cardiac  murmur  was 
discovered  after  an  ordinary  attack  of  tonsillitis  in  a  patient  whose  heart 
previously  was  normal  and  who  had  exhibited  no  articular  symptoms.  Of 
the  different  forms  of  tonsillitis,  quinsy  is  most  closely  associated  with 
rheumatism. 

Subcutaneous  tendinous  nodules. — General  attention  was  first  drawn 
to  these  as  a  manifestation  of  rheumatism  by  Barlow  and  Warner,  in  1881, 
who  described  them  as  "  oval,  semi-transparent,  fibrous  bodies  like  boiled 
sago  grains."  They  are  most  frequently  found  at  the  back  of  the  elbow, 
over  the  malleoli,  at  the  margin  of  the  patella ;  occasionally  on  the  exten- 
sor tendons  of  the  hands,  fingers,  or  toes,  or  over  the  spinous  processes  of 
the  vertebrae  or  the  scapulae.  They  are  composed  of  fibrous  tissue,  and 
vary  in  size  from  a  large  pin's  head  to  a  small  bean,  sometimes  being  as 
large  as  an  almond.  The  nodules  may  come  in  crops,  lasting  for  a  few 
weeks  and  then  disappearing,  or  they  may  last  for  months.  An  erup- 
tion of  nodules  is  usually  coincident  with  other  rheumatic  manifestations. 
These  nodules  are  better  felt  than  seen,  although,  as  Cheadle  observes, 
they  are  visible  if  the  skin  is  tightly  drawn.  They  are  certainly  not  com- 
mon in  this  country ;  notwithstanding  that  I  have  made  it  a  rule  to  exam- 


RHEUMATISM.  1089 

ine  rheumatic  patients  for  them,  I  have  seen  them  but  seldom,  and  they 
have  been  marked  in  only  two  or  three  cases.  This,  I  think,  has  also 
been  the  experience  of  most  observers  in  New  York.  From  published 
reports,  however,  they  appear  to  be  much  more  frequent  in  England. 
There  can  be  no  doubt  regarding  the  connection  of  these  nodules  with 
rheumatism. 

Erythema. — The  connection  between  rheumatism  and  the  various 
forms  of  erythema — marginatum,  papulatum,  and  nodosum — has  been 
very  clearly  shown  by  Cheadle.  None  of  these  are  frequent  conditions  in 
childhood,  but  when  seen  they  should  always  suggest  rheumatism. 

Purpura. — The  association  of  purpura  with  rheumatism  is  so  often 
seen  that  there  can  be  little  doubt  of  the  close  connection  between  the 
two  conditions.  Eheumatic  purpura,  however,  is  quite  distinct  from  the 
other  forms  of  purpura,  and  is  a  much  less  frequent  disease. 

Diagnosis. — In  order  to  recognise  rheumatism  in  a  child,  one  must 
free  his  mind  from  preconceived  notions  of  the  disease  drawn  from  its 
manifestations  in  adults,  as  very  few  cases  correspond  to  the  adult  type  of 
acute  rheumatism.  In  early  life  the  disease  is  recognised  not  by  any  one 
or  two  special  symptoms,  but  by  the  association  or  combination  of  a  num- 
ber of  conditions  which  may  appear  unrelated.  In  determining  whether 
or  not  any  given  set  of  symptoms  is  due  to  rheumatism,  one  should  con- 
sider: (1)  The  family  history,  since  in  early  life  heredity  is  so  important 
an  etiological  factor ;  (3)  the  previous  history  of  the  patient,  not  only  as 
regards  articular  pains  and  swelling,  the  slight  joint-stiffness  without 
swelling,  the  indefinite  wandering  pains  of  damp  weather,  and  the  so-called 
growing  pains,  but  also  the  previous  existence  of  chorea,  frequent  attacks 
of  tonsillitis,  torticollis,  or  erythema ;  (3)  the  examination  of  the  patient, 
which  should  include  a  careful  search  for  tendinous  nodules,  as  well  as  a 
thorough  examination  of  the  heart  for  signs  of  endocarditis  or  pericar- 
ditis, and,  in  cases  which  are  at  all  acute,  the  temperature.  In  doubtful 
cases  with  mon-articular  symptoms  much  importance  is  to  be  attached 
to  the  presence  of  slight  fever,  the  abrupt  onset,  and  tenderness  of  the 
neighbouring  muscles  and  tendons, — all  occurring  without  a  history  of 
traumatism.  Eheumatism  is  more  often  overlooked  than  confounded 
with  other  diseases ;  although  in  childhood  multiple  neuritis  and  tubercu- 
lous and  syphilitic  bone  disease  are  often  mistaken  for  it,  and  in  infancy 
the  same  is  true  of  scurvy.  The  extreme  infrequency  of  rheumatism 
during  the  first  two  years  of  life  should  always  make  one  skeptical  regard- 
ing it.  In  an  infant,  when  the  symptoms  are  confined  to  the  legs  and 
are  not  accompanied  by  fever,  they  are  almost  certain  to  be  due  to  scurvy 
even  though  the  gums  are  normal  and  ecchymoses  have  not  yet  appeared 
(page  213). 

Prognosis. — Rheumatism  in  a  child  is  in  itself  seldom  if  ever  danger- 
ous to  life.     In  the  great  majority  of  cases  the  articular  symptoms  soon 


IQ20  OTHER   GENERAL  DISEASES. 

disappear,  even  without  special  treatment.  The  danger  from  the  disease 
consists  in  its  cardiac  complications.  One  attack  of  rheumatism  is  almost 
certain  to  be  followed  by  others,  and  when  once  the  heart  has  been  af- 
fected its  lesions  are  likely  to  increase  with  each  recurrence  of  the  disease. 

Treatment. — Rheumatism  in  children  derives  its  chief  importance  from 
its  relation  to  cardiac  disease.  Cardiac  complications  are  so  frequent  and 
so  serious  that  everything  possible  should  be  done  to  avert  rheumatism 
from  those  who  by  inheritance  are  especially  predisposed  to  it,  to  prevent 
its  recurrence  in  a  child  who  has  once  had  the  disease,  and  during  an  attack 
to  prevent  the  heart  from  being  involved.  The  relation  of  diet  to  rheuma- 
tism is  very  imperfectly  understood ;  but  it  is  certainly  a  fact  that  rheu- 
matic children  do  much  better  upon  a  diet  composed  largely  of  nitroge- 
nous food,  where  starches  are  restricted  in  amount,  than  the  reverse.  Milk 
should  be  freely  given  in  all  cases.  The  underclothing  should  be  of  flan- 
nel during  the  entire  year,  in  summer  the  lightest  weight  being  worn. 
The  feet  should  be  carefully  protected,  and  exposure  in  damp  weather 
avoided.     In-door  occupations  should  be  chosen  for  rheumatic  boys. 

The  tendency  to  recurrence  is  so  strong  in  this  disease  that  a  child  of 
rheumatic  antecedents,  who  has  shown  in  the  various  ways  mentioned  a 
marked  predisposition  to  rheumatism,  and  who  has  had  an  attack,  even 
though  a  mild  one,  should,  if  possible,  spend  the  winter  and  spring  in 
some  warm,  dry  climate,  or  even  remain  there  permanently.  Otherwise  in 
most  such  children,  it  is  only  a  question  of  time  when,  with  the  repeated 
attacks,  the  heart  will  become  involved. 

To  avert  the  danger  of  cardiac  complications  during  an  attack  of  rheu- 
matism, or  to  limit  their  extent,  there  are  two  things  which  should  invari- 
ably be  insisted  on  :  first,  to  confine  to  the  house  and  in  a  warm  room  every 
child  with  rheumatic  pains,  no  matter  how  mild ;  secondly,  if  fever  is  also 
present,  to  keep  the  child  in  bed  while  it  continues,  even  though  it  may 
never  be  above  100°  F.  Absolute  rest  and  the  equable  temperature  thus 
secured  are  unquestionably  of  more  importance  than  anything  else  in  pro- 
tecting the  heart  during  a  rheumatic  attack.  With  these  precautions  must 
be  combined  an  early  diagnosis.  In  very  many,  perhaps  in  most  cases,  the 
harm  is  done  before  the  true  nature  of  the  disease  is  suspected,  the  symp- 
toms being  dismissed  as  of  slight  importance  because  the  articular  mani- 
festations are  not  very  severe.  Children  who  have  once  had  rheumatism 
should  be  closely  watched  during  chorea  and  other  diseases  related  to 
rheumatism,  the  heart  should  be  frequently  examined,  and  the  physician 
should  be  on  the  alert  for  the  first  articular  symptoms. 

Aside  from  the  measures  just  mentioned,  the  treatment  of  rheumatism 
in  childhood  is  to  be  conducted  very  much  like  that  of  adult  life.  In  the 
most  acute  attacks  either  salicylate  of  soda,  oil  of  wintergreen,  or  salicin 
should  be  given ;  as  the  majority  of  cases  are  not  very  acute,  marked  im- 
provement is  by  no  means  always  obtained  by  these  drugs.      Alkalies 


DIABETES  MELLITUS.  1091 

should  be  given  in  all  cases,  but  particularly  in  those  in  which  there  is 
hyperacidity  of  the  urine.  Either  the  acetate  or  citrate  of  potassium  or 
the  bicarbouate  of  sodium  may  be  used,  a  sufiicient  quantity  being  admin- 
istered to  render  the  urine  aliialine. 

Quite  as  important  as  these  drugs  is  the  use  of  general  tonics,  particu- 
larly iron  and  cod-liver  oil.  These  should  be  given  not  only  between 
attacks  to  fortify  patients  against  their  recurrence,  but  also  in  subacute 
cases  which  are  sometimes  influenced  very  little  or  not  at  all  either  by 
salicylates  or  alkalies. 


CHAPTER   II. 
DIABETES  MELLITUS. 

In  this  chapter  will  be  attempted  only  a  description  of  the  peculiar 
features  which  diabetes  presents  when  affecting  young  patients.  It  is  a 
very  infrequent  disease  in  children.  Of  1,3G0  cases  of  diabetes  collected 
by  Pavy,  only  eight  were  under  ten  years  of  age.  In  a  series  of  700  cases 
collected  by  Prout,  only  one  case  was  under  ten  years.  In  a  series  of  380 
cases  collected  by  Meyer,  only  one  case  was  under  ten  years  of  age. 

Etiology. — Stern,  in  a  series  of  117  collected  cases  of  diabetes  in  chil- 
dren, states  that  47  were  females  and  31  males,  the  sex  in  the  other  cases 
not  being  given.  Although  extremely  rare,  cases  have  been  observed 
during  the  first  two  years,  and  even  during  the  first  year  of  life.  Sta- 
tistics on  this  point  are  not  altogether  trustworthy,  since  some  cases  of 
temporary  glycosuria  have  certainly  been  included. 

Among  the  etiological  factors,  heredity  is  one  of  the  most  important. 
Pavy  reports  the  case  of  a  child  dying  of  diabetes  at  two  years  in  whose 
family  the  disease  had  existed  for  three  generations.  Inherited  gout, 
insanity,  and  nervous  diseases  generally,  may  be  looked  upon  as  factors  in 
the  production  of  diabetes.  Several  of  the  cases  reported  in  children 
have  been  preceded  by  injuries  received  upon  the  head.  In  a  few  cases 
the  disease  has  followed  the  consumption  of  large  quantities  of  sugar  for 
a  long  time.     In  very  many  cases  no  adequate  cause  can  be  found. 

Symptoms.— The  most  important  early  symptoms  are  thirst,  polyuria, 
and  wasting ;  their  development  is  often  quite  rapid.  The  thirst  is  in- 
tense, often  leading  children  to  drink  four  or  five  pints  of  fluid  a  day. 
The  amount  of  urine  passed  varies  from  one  to  eight  quarts  daily.  The 
specific  gravity  is  from  1,026  to  1,040,  and  the  amount  of  sugar  is  from 
five  to  ten  per  cent,  rarely  more.  Albumin  is  not  infrequently  present. 
Incontinence  of  urine  is  an  important  symptom,  and  often  one  of  the 
earliest  to  be  noticed.  The  wasting  is  usually  quite  rapid,  so  that  a  child 
may  lose  as  much  as  six  or  eight  pounds  in  a  month.      It  is  generally  ac- 


1092  OTHER  GENERAL  DISEASES. 

companied  by  anasmia.  The  appetite  may  be  poor ;  at  times,  however,  it 
is  voracious.  Other  symptoms  of  less  importance  are  a  dry  mouth,  scanty 
perspiration,  irregular  sleep,  occasional  epistaxis,  furuncles  and  abscesses, 
decayed  teeth,  and  genital  irritation. 

The  course  of  the  disease  is  much  more  rapid  in  children  than  in 
adults,  and,  as  a  rule,  the  younger  the  child  the  more  rapid  its  progress. 
The  majority  of  cases  prove  fatal  in  from  two  to  four  months  from  the 
time  the  symptoms  are  sufficiently  marked  to  make  the  diagnosis  possible. 
Very  few  last  more  than  six  months ;  occasionally,  however,  one  of  the 
milder  type  may  be  prolonged  from  one  to  two  years. 

The  progress  of  the  disease  is  marked  by  continuous  wasting,  which 
may  result  in  a  marked  degree  of  marasmus,  and  prove  fatal.  Some  are 
carried  off  by  intercurrent  pneumonia  or  tuberculosis,  but  the  majority 
die  comatose.  When  coma  develoj^s,  the  case  may  be  considered  hopeless, 
and  death  is  likely  to  be  postponed  but  a  few  days.  The  cause  of  diabetic 
coma  has  not  yet  been  satisfactorily  explained,  but  it  is  usually  believed  to 
be  due  to  acetonemia. 

Diagnosis. — Diabetes  is  apt  to  be  overlooked,  because  of  the  common 
neglect  of  urinary  examinations  in  children.  The  prominent  symptoms — 
thirst,  polyuria,  and  w'asting — when  associated,  should  alw^ays  attract  at- 
tention. Incontinence  of  urine,  accompanied  by  marked  wasting,  is  always 
suspicious.  In  some  cases  genital  irritation  may  be  the  most  prominent 
early  symptom.  A  positive  diagnosis  is  made  only  by  an  examination  of 
the  urine. 

Prognosis. — In  few  diseases  is  the  prognosis  so  bad  as  in  diabetes  in 
children.  So  high  an  authority  as  Senator  declares  that  diabetes  in  chil- 
dren is  hopeless  and  all  treatment  is  useless.  From  a  study  of  seventy- 
seven  cases.  Stern  reaches  the  same  conclusion.  There  are,  however,  cases 
on  record  in  which  recovery  is  believed  to  have  taken  place,  even  when  the 
amount  of  sugar  passed  was  large. 

Treatment. — The  indications  for  treatment  are  the  same  in  children 
as  in  adults:  first,  diet;  secondly,  stimulants;  thirdly,  general  hygienic 
measures;  and,  finally,  the  use  of  drugs,  of  which  at  the  present  time  the 
favourites  are  codeine,  salicylate  of  soda,  and  the  bromide  of  arsenic. 


I  JTDEX. 


Abdomen,  examination  of,  37;  growth  of,  24; 
in  rickets,  229. 

Abscess,  alveolar,  243;  cerebral,  '725:  etiology, 
725 ;  lesions,  725 ;  symptoms,  726 ;  diagnosis, 
727  ;  from  meningitis,  727  ;  prognosis,  727  ; 
treatment,  727  ;  cerebral,  in  acute  otitis,  883  ; 
ischio-rectal,  407 ;  mammary,  115;  hepatic, 
410;  peritoneal,  417 ;  peritonsillar,  270;  peri- 
typhlitic  (see  Appenuicitis),  389 ;  psoas,  in 
spinal  caries,  842 ;  retro-oesophageal,  276 ; 
etiology,  276  ;  symptoms,  277  ;  diagnosis,  277  ; 
prognosis,  278;  treatment,  278;  retro-oeso- 
phageal, in  Pott's  disease,  262,  842;  retro- 
pharyngeal, in  Pott's  disease,  842;  retro- 
pharynareal,  of  infancy,  258;  etiology,  259; 
symptoms,  259;  prognosis,  260;  diagnosis, 
261 ;  treatment,  261 ;  subphrenic,  427. 

Abscesses,  multiple,  in  malignant  endocarditis, 
578 ;  multiple,  in  newly-born,  83. 

Acetonemia  in  diabetes  meilitus,  1092. 

Acetonuria,  603. 

Acid,  hydrochloric,  increased  by  lavage,  299 ; 
hydrochloric,  in  gastro-enteric  infection,  330  ; 
hydrochloric,  in  stomach  digestion,  280;  lac- 
tic, in  stomach  digestion,  280. 

Adenie  (see  Hodgkin's  Disease),  831. 

Adenitis,    acute    non-suppurative,    822;    acute 
simple,  with  otitis  media,  821 ;  acute  suppu- 
rative, axillarj',  821 ;  acute  suppurative,  cer- 
vical, 821 ;  acute  suppurative,  inguinal,  821 
cervical,  in    diphtheria,   969;    in    influenza 
1071 ;  in  measles,  921 ;  retro-oesophageal,  276 
retro-pharyngeal,    258;    simple   acute,    819 
etiology,  820 ;   lesions,  820 ;  symptoms,  820 
diagnosis,  822 ;  treatment,  822  ;  simple  chron- 
ic,  822;    syphilitic,    823;    tuberculous,   824; 
etiology,  824 ;   lesions,  825 ;  symptoms,  826 ; 
prognosis,    829 ;    diagnosis,    829 ;    treatment, 
829  ;  treatment,  surgical,  830. 

Adenoid  vegetations  of  pharynx,  263,  431 ; 
etiology,  263  ;  symptoms,  263  ;  diagnosis, 
266;  treatment,  266 ;  asthma  from,  474  ;  cause 


of  acute  otitis,  885;  causing  acute  nasal  ca- 
tarrh, 430;  chronic  laryngitis  with,  456;  in 
rickets,  230 ;  removal  advised  in  tuberculous 
adenitis,  830;  with  adenitis,  823. 

Adenoma  of  umbilicus,  112. 

Agenesis,  cortical,  741. 

Airing,  when  allowed  out  of  doors,  8. 

Air-space  required  by  infants,  10. 

Alalia,  692. 

Albinism,  stigma  of  degeneration,  757. 

Albumin  water,  preparation  of,  292. 

Albuminuria,  functional  or  cyclic,  596;  in 
chronic  cardiac  disease,  582;  in  chronic  ne- 
phritis, 621;  in  influenza,  1073;  in  measles, 
921 ;  in  pertussis,  942 ;  in  scarlet  fever,  901 ; 
in  typhoid  fever,  1013. 

Alcohol,  as  stimulant,  49  ;  as  tonic,  50 ;  eff'ect 
on  breast  milk,  164  ;  use  of,  in  diet  of  nurse, 
135. 

Amyloid  degeneration,  in  chronic  bone  disease, 
838  ;  of  the  intestines,  360  ;  of  the  liver,  360 ; 
of  the  spleen,  360. 

Anaemia,  cardiac  murmurs  in,  589 ;  following 
diphtheria,  972;  pernicious,  803;  etiology, 
803 ;  lesions,  804 ;  symptoms,  804 ;  blood, 
804 ;  diagnosis,  804  ;  treatment,  805  ;  pseudo- 
leuetEmic,  of  infancy,  801  ;  etiology,  801  ; 
lesions,  801 ;  symptoms,  802 ;  blood,  802 ; 
prognosis,  803 ;  diagnosis,  803 ;  treatment, 
805;  simple,  797;  etiology,  797;  symptoms, 
798  ;  prognosis,  798  ;  treatment,  805 ;  splenic 
(see  A.  Simple),  798  ;  with  adenoids,  265;  in 
malaria,  1075;  in  malnutrition,  198;  in  ma- 
rasmus, 207:  in  rheumatism,  1088;  in  rickets, 
230;  in  scurvy,  214;  in  tuberculosis,  1042; 
preceding  tuberculosis,  1035. 

Anaesthesia,  partial,  in  multiple  neuritis,  788. 

Anasarca,  general,  in  acute  difl'use  nephritis, 
616  ;  in  chronic  cardiac  disease,  582. 

Aneurism,  591. 

Angina,  catarrhal,  in  measles,  920 ;  in  scarlet 
fever,  899. 


1093 


1094 


INDEX. 


Anglo-Swiss  food,  156. 

Ankle,  enlarged  epiphyses  in  rickets,  228. 

Anodynes,  51. 

Anorexia,  hysterical,  688. 

Antipyrine,  in  chorea,  679;  in  catarrhal  croup, 
441 ;  in  pertussis,  946 ;  scarlatiniforni  rasli 
from,  905. 

Antijiyretic  drugs,  48. 

Antipyretics,  46 ;  in  acute  broncho-pneumonia, 
511. 

Antitoxine,  in  the  treatment  ot  tetanus,  90  ;  re- 
sults without,  in  membranous  laryngitis,  449 ; 
with,  998  (see  Diphtheria  Antitoxine)  ; 
streptococcus,  1007. 

Anuria,  604. 

Anus,  fissure  of  the,  404;  imperforate,  116. 

Aorta,  abnormal  origin  of,  564;  aneurism  of, 
592;  atheroma  of,  592 ;  congenital  narrowing 
of,  in  chlorosis,  800 ;  hypoplasia  of,  591  ; 
thrombosis  of,  593. 

Aortic  insufficiency,  585 ;  stenosis,  584. 

Aphasia,  functional,  692 ;  in  acquired  cerebral 
paralysis,  747  ;  after  typhoid  fever,  1013 ;  mo- 
tor, in  cerebral  tumour,  730,  731. 

Aphonia,  hysterical,  687 ;  in  diphtheritic  pa- 
ralysis, 791. 

Appendicitis,  389  ;  etiology,  389  ;  lesions,  389  ; 
catarrhal  form,  389  ;  ulcerative  or  perforative 
form,  390 ;  symptoms,  391 ;  catarrhal  form,  391; 
perforative  form,  391 ;  prognosis,  393  ;  diag- 
nosis, 393  ;  from  colic,  393  ;  from  acute  in- 
digestion, 393;  from  intussusception,  394; 
from  psoitis,  394  ;  treatment,  394. 

Arm,  paralysis  of,  at  birth,  110. 

Arnold  sterilizer,  144. 

Arsenic,  as  a  tonic,  50  ;  dosage  in  chorea,  679. 

Arteries,  hypogastric,  in  foetal  circulation,  558  ; 
hypoplasia  of,  591 ;  umbilical,  in  foetal  circu- 
lation, 558. 

Arthritis,  acute,  of  infants,  835  :  etiology,  835  ; 
symptoms,  835 ;  diagnosis,  836  ;  treatment, 
836  ;  acute  suppurative,  syphilitic,  852  ;  gon- 
orrhoea!, 638,  642;  rheumatic,  1086. 

Artlirogryposis  (see  Tetanv),  668. 

Artificial  feeding,  circumstances  favouring,  158  ; 
versus  wet-nursing,  158. 

Ascaris  lumbricoides  (see  Worms,  Intestinal), 
398. 

Ascites,  426  ;  causes,  426  ;  detection  of,  426  ; 
chylous,  426;  in  acute  diffuse  nephritis,  616; 
in  cirrhosis  of  liver,  412;  rare  with  amyloid 
liver,  413;  with  chronic  peritonitis,  419; 
with  tuberculosis  of  the  peritonreum,  421. 

Asphyxia,  death  from,  in  young  children,  44  ; 
from  overlying,  42 ;  from  aspiration  of  food, 
43 ;  from  enlarged  thymus,  43 ;  in  convul- 
sions, 656 ;  in  retro-pharyngeal  abscess,  260; 


in  the  newly-born,  67  ;  etiology,  67  ;  lesions, 
67;  symptoms,  68;  diagnosis,  69;  prognosis, 
69  ;  treatment,  69  ;  from  tuberculous  bronchial 
lymph  nodes,  1048;  methods  of  resuscitation, 
71  ;  sudden,  from  tongue-swallowing,  242 ; 
sudden,  in  retro-oesophageal  abscess,  277. 

Aspiration  of  chest  in  empyema,  553. 

Asthma,  473;  etiology,  474;  symptoms,  474; 
symptoms  of  attacks  resembling  capillary 
bronchitis,  475 ;  symptoms  following  attacks 
of  bronchitis,  475 ;   symptoms  of  hay  fever, 

475  ;  symptoms  of  adult  type,  476  ;  diagnosis, 

476  ;  prognosis,  476  ;  treatment,  476  ;  catar- 
rhal, 475;  with  adenoids,  265;  long  uvula, 
cause  of,  258 ;  simulated  by  tuberculous  bron- 
chial glands,  1047. 

Astigmatism,  stigma  of  degeneration,  758. 

Ataxia,  Friedreich's,  780  ;  in  multiple  neuritis, 
788. 

Atelectasis,  acquired.  539 ;  from  compression, 
539;  from  obstruction,  540;  in  delicate  in- 
fants, 540;  causing  sudden  death,  43;  con- 
genital, 72  ;  lesions,  72  ;  symptoms,  73  ;  diag- 
nosis, 74  ;  treatment,  75 ;  in  marasmus,  205. 

Atheroma,  591. 

Athetoid  movements,  680 ;  in  acquired  cerebral 
paralysis,  748 ;  in  birth  paralysis,  745. 

Athetosis,  680. 

Athrepsia  (see  Marasmus),  204. 

Atomizer,  55 ;  steam,  59. 

Atresia  ani.  307. 

Atrophy,  infantile  (see  Marasmls),  204;  mus- 
cular, facial  type,  785 ;  in  multiple  neuritis, 
788 ;  juvenile  form,  785 ;  progressive  mus- 
cular, hand  type,  782  ;  peroneal  type,  785. 

Atropine,  hypodermically  in  cholera  infantum, 
336. 

Aura  of  epilepsy,  662. 

Autopsies,  principal  lesions  found  in,  39. 

Babcock's  centrifugal  machine,  133,  140. 

Bacillus,  of  diphtheria,  951 ;  distribution  in  the 
body,  955  ;  in  milk,  145  ;  in  healthy  throats, 
978 ;  in  laryngeal  diplitheria,  445  ;  non-viru- 
lent, 978;  of  Eberth,  in  typhoid  fever,  1008; 
of  Friedliinder,  in  acute  broncho-pneumonia, 
482;  Klebs-Loeffler  (see  B.  Diphtheri.e), 
951 ;  of  Pfeifter,  in  influenza,  1069;  pseudo- 
diphtheria,  978;  of  tuberculosis,  1016;  in 
acute  broncho-pneumonia,  483  ;  in  empyema, 
549  :  paths  of  infection,  1020. 

Backwardness,  692. 

Bacteria,  in  etiology  of  diarrhoea,  318  ;  in  hu- 
man milk,  137  ;  intestinal,  282. 

Bacterium  coli  commune,  282 ;  in  appendicitis, 
389  ;  in  milk,  145  ;  in  peritonitis,  416. 

Bacterium  lactis  aerogenes,  282. 


INDEX. 


1095 


Balanitis,  638. 

Band,  abdominal,  1,  3. 

Barley  water,  directions  for  making,  154 ;  use 
during  iirst  year,  180. 

Barlow'.s  disease  (see  Scorbutus),  210. 

Bath,  at  birth,  1, 2  ;  cold,  48  ;  in  acute  broncho- 
pneumonia, 511 ;  in  asphyxia  of  newly-born, 
70  ;  hot,  54  ;  hot  air,  54  ;  vapour,  54  ;  mus- 
tard, 54  ;  bran,  55 ;  tepid,  55  ;  shower,  55  ; 
cold  sponge,  55  ;  hot,  in  asphyxia  of  newly- 
born,  70  ;  in  typhoid  fever,  1016. 

Bed-wetting,  644. 

Beef,  broth,  154;  extracts,  153  ;  juice,  expressed, 
153 ;  juice,  without  cooking,  153 ;  prepara- 
tions of,  153  ;  raw  scraped,  154. 

Belladonna,  51 ;  elimination  of,  in  milk,  136  ; 
scarlatiniform  rash,  905. 

Bile-ducts,  congenital  malformations  of,  75. 

Bile,  physiological  action  of,  281. 

Birth  paralyses,  105  ;  cerebral,  105  ;  spinal,  105 ; 
peripheral,  105. 

Bladder,  contraction  of,  causing  enuresis,  645; 
control  acquired,  645 ;  exstrophy  of,  637 ; 
haemorrhage  from,  in  newly  born,  104;  stone 
in,  650 ;  training  to  control,  4. 

Bleeders,  808. 

Blindness,  hysterical,  686  ;  stigma  of  degenera- 
tion, 758  ;  transient,  in  pertussis,  942. 

Blisters,  52. 

Blood,  circulation  of,  in  early  life,  558 ;  cor- 
puscles, red,  795  ;  corpuscles,  white,  796  ;  dis- 
eases of,  795  ;  hemoglobin,  795  ;  in  chlorosis, 
800 ;  in  diphtheria,  962 ;  in  leueajmia,  807 ; 
iu  pernicious  anaemia,  804  ;  in  pseudo-leucre- 
mic  anaemia,  802 ;  in  simple  anaemia,  799  ; 
leucocytes  of,  varieties,  796 ;  plasmodium 
malariaj  in,  1075  ;  specific  gravity,  795. 

Blood-serum,  Loeffler's,  952. 

Blood-shadows,  797. 

Blood-vessels,  diseases  of,  591 ;  aneurism,  591  ; 
arterial  hypoplasia,  591 ;  atheroma,  591 ;  em- 
bolism, 592  ;  thrombosis,  592. 

Boat-belly  in  tuberculous  meningiti.s,  718. 

Boil  (see  Furunculosis),  871. 

Bone-marrow  ia  leucaemia,  806. 

Bones,  diseases  of,  835 ;  in  hereditary  syphilis, 
1055;  in  late  syphilis,  1063;  lesions  of,  in 
rickets,  218 ;  microscopical  changes  of,  in 
rickets,  219 ;  syphilitic  diseases  of,  851 ;  tu- 
berculous diseases  of,  836 ;  etiology,  837  ;  le- 
sions, 837. 

Bothriocephalus  latus,  397. 

Bottles,  nursing,  choice  and  care  of,  178. 

Bowels,  haemorrhages  from  (see  Hemorrhage, 
Intestinal)  ;  movements  of,  irregularity  in 
times  for,  374;  training  to  control  move- 
ments, 4. 


Bow-legs  in  rickets,  227. 

Bradycardia,  590. 

Brain,  diseases  of,  699  ;  abscess  of,  725 ;  atropiiy 
and  sclerosis  of,  742;  atrophy  and  sclerosis 
of,  in  acquired  cerebral  paralysis,  746  ;  cysts 
of,  in  infantile  cerebral  paralysis,  740;  mal- 
formations of,  699 ;  tuberculosis  of,  103 ; 
tumour  of,  728;  water  on  the,  715;  weight 
of,  651. 

Bran  bath,  55. 

Breast,  abscess  of,  in  newly-born,  115. 

Breasts,  care  of,  during  lactation,  160;  secretion 
of,  in  newly  born,  114. 

Breast-feeding,  160  ;  schedule  for,  162. 

Breast  milk  (see  Milk,  Woman's). 

Breath,  fetid,  in  scurvy,  214;  offensive,  in 
ulcerative  stomatitis,  248. 

Breathing,  noisy,  with  adenoids,  264 ;  stridu- 
lous,  in  diseases  of  the  larynx,  440,  443,  446  ; 
in  retro-cesophageal  abscess,  277. 

Bright's  disease  (see  Nephritis),  615. 

Bromides,  elimination  of,  in  milk,  137. 

Bronchi,  catarrhal  spasm  of,  475;  diphtheria 
of,  959 ;  foreign  bodies  in,  458 ;  lesions  of,  in 
acute  broncho-pneumonia,  484 ;  lymph  nodes 
of,  in  tuberculosis,  1020;  tube  casts  of,  471. 

Bronchial  glands  (see  also  Lymph  Nodes,  Bron- 
chial), enlarged,  cause  of  asthma,  474;  in 
acute  bronclio-pneumonia,  492  ;  retiex  cough 
from,  473. 

Bronchitis,  acute  catarrhal,  462;  etiology,  462  ; 
lesions,  463 ;  symptoms  in  infants,  463 ; 
symptoms  in  older  children,  465;  diagnosis 
from  broncho-pneumonia,  465;  treatment, 
466  ;  abortive  measures,  467  ;  attacks  of  suf- 
focation, 469  ;  cardiac  stimulants,  468:  coun- 
ter-irritation, 467  ;  emetics,  468 :  expectorants, 
468;  general  management,  467;  inhalations, 
468 ;  in  infants,  mild  cases,  468 ;  in  infants, 
severe  cases,  469;  in  older  children,  469; 
local  applications,  467  ;  opium,  468  ;  prophy- 
laxis, 466;  protracted  cough  in  convales- 
cence, 470  ;  respiratory  stimulants,  468 ;  re- 
spiratory failure,  469  ;  asthma  following, 475; 
capillary  (see  Broncho-pneumonia,  Acute), 
481,  494  ;  attacks  of  asthma  resembling, 
474;  chronic,  471;  etiology,  471;  symptoms, 
471  ;  dijfgnosis,  472;  treatment,  472;  chronic, 
bronchiectasis  in,  472 ;  chronic,  in  rickets, 
222 ;  diphtheritic,  broncho-pneumonia  in, 
505;  fibrinous,  470;  treatment,  471;  in  per- 
tussis, 941 ;  in  typhoid  fever,  1013 ;  spas- 
modic (see  Asthma),  475. 

Bronchiectasis  in  chronic  bronchitis,  472 ;  iu 
broncho-pneumonia,  chronic,  534. 

Broncho-pneumonia,  acute,  481  ;  bacteriology, 
482;    complications,   505;   cyanosis   in,   494, 


1096 


INDEX. 


496 ;  complicating  influenza.  1072  ;  diph- 
theria, 962;  measles,  919;  pertussis,  941; 
pseudo-diphtheria,  1005  ;  rickets,  222 ;  diag- 
nosis 506  ;  from  congenital  atelectasis,  506  ; 
from  severe  bronchitis,  506 ;  from  lobar 
pneumonia,  507  ;  from  malarial  fever,  507  ; 
etiology,  481  ;  age,  481 ;  previous  condition, 
481 ;  previous  disease,  481 ;  season,  481 ;  sex, 
481 :  duration  of,  499  ;  lesions,  483  ;  in  acute 
congestive  form  (acute  red  pneumonia),  485  ; 
in  mottled  red  and  gray  pneumonia,  487  ;  in 
gray  pneumonia  (persistent  broncho-pneu- 
monia), 489;  associated,  in  the  lung,  492  ;  ab- 
scesses of  lung,  493  ;  bronchial  glands,  492  ; 
emphysema,  493 ;  gangrene,  493  ;  pleurisy, 
492 ;  intra-alveolar  haemorrhage,  486  ;  pul- 
monary collapse,  484 ;  seat  of  the  disease, 
485 ;  physical  signs,  chart  of,  500 ;  without 
consolidation,  499  ;  with  areas  of  partial  con- 
solidation, 499  ;  with  areas  of  consolidation 
more  or  less  complete,  501  ;  day  of  appear- 
ance, 502  ;  protracted  or  persistent  form,  502 ; 
secondary  pneumonia  with  measles,  504 ;  ileo- 
colitis, 505 ;  influenza,  505  ;  pertussis,  503 ; 
diphtheria,  504 ;  pleurisy  in,  487  ;  prognosis, 
507;  mortality  tables,  508;  protracted  cases, 
502 ;  pathological  differentiation  from  lobar 
form,  477 ;  relative  frequency  of,  479 ;  res- 
piration in,  494,  496  ;  symptoms,  493  ;  acute 
congestive  type,  493  ;  acute  disseminated 
type,  494 ;  common  type,  495  ;  temperature 
charts  of,  497  ;  temperature  in,  493,  494,  495 ; 
terminations,  491  ;  treatment,  509  ;  by  antipy- 
retics, 511 ;  cold,  511 :  emetics,  510  ;  hygiene, 
510;  inhalations,  512;  stimulaats,  510  ;  of  at- 
tacks of  collapse,  512;  of  nervous  symptoms, 
512;  of  protracted  cases,  512;  prophylaxis, 
509 ;  summary  of,  513. 

Broncho-pneumonia,  chronic,  534 ;  etiology, 
534;  lesions,  535;  symptoms,  535;  physical 
signs,  536 ;  course,  536 ;  prognosis,  536  ;  diag- 
nosis, 536  ;  from  tuberculosis,  536  ;  treatment, 
537. 

Broncho-pneumonia,  tuberculous,  1023,  1036  ; 
rapid  cases,  1037  ;  protracted  cases,  1038  (see 
also  Tuberculosis,  Pneumonia). 

Broths,  directions  for  making,  154. 

Bubo,  with  gonorrhoeal  urethritis,  638 ;  vulvo- 
vaginitis, 642. 

Buhl's  disease,  91. 

Calamine  lotion,  869. 

Calculi,  biliary.  414  ;  renal,  630  ;  pyelitis  with, 

629  ;  vesical,  650. 
Calomel  fumigations,  448  ;  apparatus  for,  448  ; 

salivation  of  nurses,  448  ;  statistics  of,  449. 
Calomel,  how  best  given,  46. 


Cancrum  oris  (see  Stomatitis,  gangrenous), 
254. 

Carbohydrates,  function  of,  in  diet,  125. 

Carcinoma  of  brain,  728  ;  of  kidney,  624. 

Cardiac  cough,  473. 

Carnrick's  soluble  food,  156. 

Casein  in  the  faeces,  283  ;  stools  in  difficult  di- 
gestion of,  365. 

Casts  in  urine  of  chronic  nephritis,  621. 

Catarrh,  Eustachian,  in  hypertrophy  of  tonsils, 
273;  fcetid  (see  Rhinitis,  Atrophic),  435 
gastric,  298;  gastro-intestinal,  316;  nasal 
acute,  428 ;  etiology,  428 ;  symptoms,  429 
diagnosis,  429  ;  treatment,  429  ;  prophylaxis, 
430 ;  chronic,  431  ;  with  adenoid  growths,  266 
431 ;  foreign  bodies  in  nose,  431 ;  nasal  polypi 
432 ;  rhinitis,  simple  chronic,  432 ;  hypertro- 
phic, 434;  atrophic,  435;  syphilitic,  435 
rhino-pharyngeal,  with  adenoids,  263. 

Catheters,  sizes  required  for  infants,  594. 

Cellulitis  of  abdominal  wall  with  peritonitis, 
416  ;  of  neck,  in  scarlet  fever,  900. 

Centrifugal  machine,  133,  140. 

Cephalhematoma,  external,  95 ;  internal,  96 ; 
symptoms,  96  ;  diagnosis,  96  ;  treatment,  97. 

Cereals,  154 ;  allowed  from  third  to  sixth  year, 
188. 

Cerebellum,  abscess  of,  725 ;  tumours  of,  732. 

Cerebral  paralysis,  740 ;  from  haemorrhage,  105  ; 
etiology,  105  ;  lesions,  106  ;  symptoms,  107  ; 
prognosis,  108  ;  treatment,  108. 

Cerebrum,  abscess  of,  725 ;  tumour,  728. 

Chest,  circumference  of,  20 ;  development  of, 
24;  in  rickets.  225;  lateral  depressions  of,  in 
adenoids,  265  ;  lateral  furrowing  of,  in  rickets, 
222. 

Cheyne-Stokes  respiration  in  acute  meningitis, 
711 ;  in  tuberculous  meningitis,  718. 

Chicken  pox  (see  Varicella),  929. 

Chloral,  dosage  and  administration,  57. 

Chlorosis.  799;  etiology,  800  ;•  lesions,  800; 
.symptoms,  '800 ;  blood  in,  800 ;  prognosis, 
801 ;  diagnosis,  801 ;  treatment,  805. 

Cholera,  bacillus  of,  in  milk,  145. 

Cholera  infantum,  316  (see  also  Gastro-en- 
TERic  Infection,  Acute),  332. 

Chorea,  673  ;  acute  endocarditis  in,  576 ;  course 
and  duration,  677 ;  diagnosis,  677 ;  endocar- 
ditis in,  677;  etiology,  673;  following  birth 
paralysis,  745;  typhoid  fever,  1013;  habit, 
679 ;  heart  murmurs  in,  077 ;  prognosis  of, 
078 :  hysterical,  687 ;  in  adenoids,  265 ;  in 
rheumatism,  1088  ;  pathology,  675  ;  post- 
hemiplegic, 681 ;  in  cerebral  palsy,  748 ;  prog- 
nosis, 678 ;  relation  to  rheumatism,  074 ;  speech 
in,  677,  692 ;  symptoms,  076  ;  treatment,  678 ; 
urine  in,  677. 


INDEX. 


1097 


Circulation,  changes  in,  at  birth,  558 ;  foetal, 
558  ;  in  early  life,  558. 

Circulatory  system,  diseases  of  the,  558. 

Claw-hand,  782. 

Cleft  palate,  238. 

Clothing  at  birth,  2  ;  in  summer,  G  ;  at  niglit,  3  ; 
in  summer  diarrhoea,  32G. 

Club-foot  with  spina  bifida,  701. 

Codeine,  doses  of,  51. 

Cod-liver  oil  as  tonic,  50. 

Cold,  as  an  antipyretic,  47  ;  ice  cap,  47  ;  spong- 
ing, 47;  pack,  47  ;  bath,  48;  irrigation  of  the 
colon,  48 ;  in  the  head,  with  adenoids,  264  ; 
therapeutics  of,  53. 

Cold  sores,  239. 

Colic,  habitual,  from  e.\ce.'5.si%'e  proteids,  179  ; 
intestinal,  370 ;  renal,  630. 

Colitis,  acute  (see  Ileo-colitis,  Actte),  337  ; 
membranous,  349 ;  membranous  gastritis 
with,  294. 

Collapse,  in  acute  broncho-pneumonia,  treat- 
ment of,  512;  in  acute  peritonitis,  418  ;  in  ap- 
pendicitis, 392  ;  in  corrosive  gastritis,  296  ;  in 
ulcer  of  stomach,  305. 

Collapse,  pulmonary  (see  Atelectasi.*,  Ac- 
quired), 539. 

Colles's  law,  1054. 

Colon,  abnormal  position  of,  308 ;  congenital 
atresia  of,  115 ;  cysts  of  mucosa,  355  ;  dilata- 
tion of,  378;  in  rickets,  229;  follicular  ulcers 
of,  341 ;  hypertrophy  of,  378 ;  irrigation  of,  48, 
63  ;  in  gastro-enteric  infection,  329 ;  in  intes- 
tinal indigestion,  369 ;  membranous  inflam- 
mation of,  345;  transverse,  dilatation  of,  in 
chronic  ileo-colitis,  357. 

Colostrum,  127;  corpuscles  of,  127;  composi- 
tion of,  128. 

Coma,  in  tuberculous  meningitis,  718;  in  dia- 
betes mellitus,  1092. 

Compression-myelitis  (see  Myelitis),  768. 

Condensed  milk,  cause  of  rickets,  215  ;  compo- 
sition of,  149  ;  dilution  of,  for  infants,  149 ; 
fresh,  149,  150. 

Congenital,  ichthyosis,  859 ;  myotonia,  682 ; 
rickets,  232 ;  syphilis,  1058  ;  tuberculosis,  1018. 

Conjunctiva,  catarrhal  inflammation  in  measles, 
915  ;  haemorrhage  from,  in  newly-born,  104. 

Constipation,  a  cause  of  chlorosis,  800 ;  causes 
of,  in  rickets,  229 ;  chronic,  372 ;  etiology, 
372 ;  symptoms,  373 ;  diagnosis,  373 ;  treat- 
ment, 374  ;  food,  374  ;  mechanical,  375 ;  sup- 
positories, 376  ;  enemata,  376 ;  medicinal, 
377  ;  dilatation  of  colon  in,  378 ;  from  anal 
fissure,  404;  early  symptom  of  rickets,  223; 
from  deficient  fat  in  food,  179  ;  in  appendi- 
citis, 393 ;  in  intestinal  indigestion,  chronic, 
364,  366  ;  in  intussusception,  384. 


Contractures,  hysterical,  687. 

Convulsions,  653;  etiology,  653;  pathology, 
655  ;  symptoms,  655  ;  diagnosis,  656  ;  in 
acute  disease,  657  ;  in  brain  di.sease,  657  ;  in 
epilepsy,  657  ;  in  gastro-intestinal  disease, 
657 ;  prognosis,  658  ;  treatment,  658 ;  at- 
tributed to  dentition,  244;  causing  death 
without  other  symptoms,  44 ;  chloral  in, 
659 ;  epileptic,  662 ;  hysterical,  688 ;  in  ac- 
quired cerebral  paralysis,  747 ;  in  cerebral 
hasmorrhages,  107  ;  in  congenital  atelectasis, 
73 ;  in  pertussis,  941 ;  in  rickets,  231 ;  mor- 
phine in,  659. 

Cooley  creamer,  143. 

Cord,  spinal,  diseases  of,  759 ;  malformations  of, 
759 ;  position  of,  at  birth,  765 ;  meningitis, 
765;  myelitis,  766;  pressure-paralysis  of, 
768 ;  tumours  of,  778 ;  weight  of,  651. 

Cord,  umbilical,  care  of,  1 ;  separation  of,  2. 

Cornea,  ulcers  of,  in  chronic  ileo-colitis,  357. 

Corpuscles  of  blood,  795. 

Coryza,  428  ;  early  symptoms  of  measles,  913  ; 
syphilitic,  4S5, 1059. 

Cough,  hy.sterical,  687  ;  reflex,  472  ;  from  pha- 
ryngeal irritation,  472  ;  from  elongated  uvula, 
472;  from  pharyngeal  mucus,  472;  from 
aural  irritation,  472 ;  from  gastric  irritation, 
472  ;  from  dental  irritation,  473  ;  from  cardiac 
disease,  473;  of  puberty,  473;  periodical,  at 
night,  473  ;  from  Pott's  disease,  473  ;  symp- 
toms, 473  ;  diagnosis^  473  ;  treatment,  473 ; 
spasmodic,  in  retro-cesophageal  abscess,  277  ; 
in  tuberculous  bronchial  glands,  1047;  whoop- 
ing (see  Pertussis),  936. 

Counter-irritants,  52. 

Cow's  milk  (see  Milk). 

Cranio-tabes,  early  symptoms  in  rickets,  223. 

Cranium,  syphilitic  nodes  on,  856. 

Cream,  141  ;  to  secure  difi'erent  percentages 
of,  142, 174. 

Cream-gauge,  132,  140. 

Crede's  method  of  preventing  ophthalmia  ne- 
onatorum, 1 ;  treatment  of  ophthalmia,  86. 

Cretinism,  sporadic,  752 ;  etiology,  752 ;  symp- 
toms, 752 ;  diagnosis,  754 ;  prognosis  and 
treatment,  754. 

Croup,  bronchial,  470;  catarrhal,  439;  kettle, 
58  ;  membranous,  445;  membranous,  in  scar- 
let fever,  S99 ;  spasmodic,  439  :  true,  445. 

Cry,  causes  and  varieties  of,  33  ;  in  disease,  34  : 
in  colic,  371 ;  in  retro-pharyngeal  abscess, 
260  ;  from  insufficient  food,  163. 

Cryptorchidism,  637. 

Cups,  dry,  indications  for,  53 ;  wet,  condemned, 
54. 

Curds  and  whey,  152. 

Cyanosis,   in    acute    broncho-pneumonia,   494, 


1098 


INDEX. 


496;  in  acute  inanition,  195;  in  chronic 
cardiac  disease,  582 ;  in  congenital  atelectasis, 
73 ;  in  congenital  disease  of  heart,  565 ;  in 
diphtheritic  paralysis,  791 :  in  malaria,  1078, 
1080  ;  of  face,  from  pressure  at  root  of  lung, 
1048. 

Cyclic  vomiting,  287. 

Cyst,  of  brain,  728 ;  of  brain  in  infantile  cere- 
bral paralysis,  740 ;  of  intestinal  mucosa, 
355. 

Cysticercus,  396. 

Dactylitis,  scrofulous,  849;  syphilitic,  857; 
tuberculous,  849  ;  symptoms,  850 ;  diagnosis, 
851 ;  treatment,  851. 

Deaf-mutism,  758;  stigma  of  degeneration, 
758. 

Deafness  following  mumps,  949  ;  with  adenoids, 
264;  with  hypertrophy  of  tonsils,  272;  sud- 
den, in  late  syphilis,  1063. 

Death,  most  frequent  causes  of,  at  different 
ages,  41 ;  sudden,  causes  of,  42. 

Deformities,  hysterical,  687  ;  in  rickets,  223. 

Degeneration,  .stigmata  of,  757. 

Deltoid,  paralysis  of,  at  birth,  109. 

Dentition,  27 ;  eruption  of  first  teeth,  28  ;  erup- 
tion of  permanent  teeth,  29 ;  delayed,  28 : 
before  birth,  28 ;  difficult,  243 ;  symptoms, 
244 ;  treatment,  245 ;  in  rickets,  230 ;  in  the 
etiology  of  diarrhoea,  310  ;  often  delayed  in 
malnutrition,  188. 

Dermatitis,  exfoliative,  of  newly  born,  858 ; 
gangrenous,  872  ;  treatment,  873. 

Development,  conditions  interfering  with,  30  ; 
mu.scular,  25;  of  body,  15. 

Dew's  method  of  inducing  artificial  respiration, 
70. 

Dextro-cardia,  565. 

Diabetes  insipidus,  604;  symptoms,  605;  di- 
agnosis, 606  ;  treatment,  606. 

Diabetes  mellitus.  1091 ;  symptoms,  1091  :  prog- 
nosis, 1092;  treatment,  1092. 

Diacetonuria,  603. 

Diagnosis,  general  considerations  in,  31. 

Diapers,  3. 

Diaphragm,  hernia  through,  116. 

Diarrhoea,  acute,  eliminative,  312;  from  drugs, 
311 ;  from  intestinal  indigestion,  312 ;  from 
nervous  influences,  312;  mechanical,  311; 
varieties  of,  311 ;  etiological  factors  in,  308  ; 
inflammatory  (see  Ileo-colitis,  Acute),  337  ; 
in  chronic  intestinal  indigestion,  364  ;  in  in- 
testinal tuberculosis,  362  ;  mycotic,  316  ;  sum- 
mer, 316. 

Diastatic  ferment  of  pancreas,  281 ;  of  bile, 
281. 

Diathesis,  lymphatic,  with  adenoids,  263. 


Diet  (see  also  Feeding),  a.s  cause  of  chronic 
constipation,  372;  cause  of  rickets,  215;  in 
acute  gastro-enteric  infection,  326 ;  in  acute 
ga.stric  indigestion,  292  ;  in  chronic  constipa- 
tion, 374;  in  chronic  gastric  indigestion,  300; 
in  cyclic  vomiting,  289 ;  in  eczema,  867 ;  in 
intestinal  indigestion,  368 ;  in  malnutrition, 
203 ;  in  rickets,  234 ;  in  scurvy,  215 ;  of  nurse, 
efiect  on  milk,  135,  136. 

Dietary  of  the  infant,  126. 

Digestion,  gastric,  279  ;  duration  of,  280 ;  in 
infancy,  278  ;  intestinal,  281. 

Digestive  system,  diseases  of  the,  238. 

Digitalis,  dosage  for  infant,  635. 

Dilatation  of  the  stomach,  302. 

Diphtheria,  951 ;  bacillus  (see  Bacillis  of 
Diphtheria),  504;  broncho- pneumonia  in, 
962,  970;  blood  in,  962;  cardiac  failure  in, 
968 ;  cardiac  thrombi  in,  961  ;  catarrhal,  956, 
963 ;  cervical  lymph  nodes  in,  960 ;  com- 
plications and  sequela,  970;  convalescence, 
1001 ;  croupous  bronchitis  in,  470  ;  diagno- 
sis, 972  ;  bacteriological,  976  ;  technique  of, 
976 ;  reliability  of,  977  ;  clinical,  972 ;  from 
pseudo-diphtheria,  974;  disinfection  after, 
985 ;  distribution  and  mode  of  communica- 
tion, 952  ;  embolism  in,  971 :  entero-colitis  in, 
971 ;  etiology,  961  ;  hasmorrhages,  971 ;  incu- 
bation, 955 ;  lesions,  955 ;  membrane,  956  ; 
membrane,  seat  and  distribution  of,  957 ; 
membranous  gastritis  in,  294;  proctitis  in, 
405  ;  myocarditis  in,  588,  969  ;  nasal  syringing 
in,  987  ;  nephritis  in,  961,  971 ;  of  oesophagus, 
275 ;  otitis  in,  879,  970 ;  paralysis  after,  962 ; 
paralysis  in,  790 ;  predisposing  causes,  954 ; 
prognosis,  980  ;  prophylaxis,  981 ;  quarantine, 
982  ;  septicemia  in,  969  ;  sick-room  in,  985  ; 
simulated  after  tonsillotomy,  274 ;  sloughing 
in,  969  ;  spleen  in,  961  ;  symptoms,  963 ;  sjnnp- 
toms,  without  membrane,  963  ;  .symptoms, 
with  limited  membrane  (tonsillar),  964 ; 
symptoms,  severe  cases,  965  ;  symptoms, 
mixed  infection  (septic),  969  ;  thrombosis  in, 
971 ;  toxaemia,  968;  toxines  of,  956  ;  treatment, 
986 ;  general,  986  ;  stimulants.  986  ;  local,  987  ; 
serum,  988 ;  of  children  exposed,  983  ;  of  sus- 
pected cases,  983  ;  supplementary  to  antitox- 
ine,  1000;  virulent  bacilli  in  healthy  throats, 
978 ;  visceral  lesions,  960 ;  false  (see  Pseudo- 
Diphtheria),  1002;  laryngeal,  445,  967;  nasal, 
467,  964,  966 ;  pseudo  (see  Pseudo-Diph- 
theria), 951,  1002  ;  scarlatinal  (see  Pseudo- 
Diphtheria),  1002;  scarlatinal,  899  ;  scarla- 
tiniform  erythema  in,  905  ;  streptococcus  (see 
Pseudo-Diphtheria),  1002;  tonsillar,  964. 

Diphtheria  antitoxine,  dosage  of,  990  ;  effect 
on  membrane,  992 ;  history  of,  988 ;  immu- 


INDEX. 


1099 


nizing  dose  of,  984,  985 ;  influence  on  mor- 
tality of  cities,  995  ;  limitations  of,  992  ;  local 
and  general  etfects  of,  991 ;  other  treatment 
with,  1000;  production  of,  989;  real  and 
alleged  dangers  from,  993  ;  results  in  hospital 
practice,  993  ;  results  in  laryngeal  cases,  998  ; 
results  in  private  practice,  994 ;  modified  by 
time  of  injection  and  age  of  patient,  997  ;  of 
intubation  with  and  without,  999 ;  strength 
of,  989 ;  syringe  for,  990 ;  time  of  adminis- 
tration, 991. 
Diplegia,  in  birth  paralysis,  742 ;  in  meningeal 

hffiinorrhage,  107  ;  spastic,  740. 
Disea.se,  peculiarities  of,  in  children,  30;  eti- 
ology,  30;    symptomatology    and   diagnosis, 
31 ;   pathology,   38  ;   prognosis,   40  ;  prophy- 
laxis, 44 ;  therapeutics,  45. 
Diverticulum,  Meckel's,  112,  308. 
Dobell's  solution,  56. 
Dover's  powder,  dosage  of,  51. 
Drop.sy  (see  also  Q^dema);  in  acute  diffuse  ne- 
phritis, 016;  in  chronic  cardiac  disease,  582; 
in  chronic  nephritis,  621 ;  in  newly  born,  118 ; 
in  tuberculosis,  1041 ;  without  renal  disease, 
634. 
Drugs,  administration  of,  46  ;  elimination  of,  in 
breast  milk,  136 ;   well  borne,  52 ;    not  well 
borne,  52. 
Duct,  omphalo-mesenteric,  112, 116. 
Ductus,  arteriosus,  closure  of,  558  ;  in  foetal  cir- 
culation, 558;  patent,  564;  venosus,  closure 
of,  558 ;  in  foetal  circulation,  558. 
Duodenum,    catarrhal    inflammation    of,   297; 

congenital  atresia  of,  115. 
Dura  mater,  haematoma  of,  703;  thrombosis  of 

the  sinuses  of,  723. 
Dysentery  (see  Ileo-cohtis,  Acute),  337. 
Dysphagia,  hysterical,  687  ;  in  retro-pharyngoal 

ab.scess,  260. 
Dyspnoea,  evidences  of,  33;  from  tuberculous 
bronchial  lymph  nodes,  1048;  in  acute  ca- 
tarrhal laryngitis,  443;  in  catarrhal  spasm  of 
larynx,  440;  in  membranous  laryngitis,  446; 
in  chronic  cardiac  disease,  581 ;  in  retro- 
pharyngeal abscess,  259 ;  inspiratory,  in 
rctro-oesophageal  ab.scess,  277 ;  pressure  of 
abscess  on  pneumogastric,  277  ;  spasmodic,  in 
asthma,  473. 

Ear,  anomalies  of,  as  stigmata  of  degeneration, 
757;  hiemorrhage  from,  in  newly  born,  104; 
middle,  inflammation  of  (see  Otitis),  879. 

Ears,  development  of  hearing,  26. 

Eberth's  bacillus  of  typhoid  fever,  1008. 

Ecchymoses  in  purpura,  810,  811 ;  in  scurvy, 
209;  in  leucamia,  807. 

Echinococcus  of  liver,  414. 


Eclampsia  (see  Convulsions),  653. 
Ecthyma  gangrenosa,  872. 

Ectocardia,  565. 

Eczema,  862 ;  etiology,  862 ;  varieties,  864 ; 
diagnosis,  866;  prognosis,  866;  treatment, 
867  ;  dietetic,  867  ;  of  kidneys,  868 ;  of  bowels, 
868;  general,  868;  local,  869;  exacerbations 
during  dentition,  244;  intertrigo,  865  ;  pustu- 
lar, of  scalp,  865  ;  rubrum,  804 ;  seborrhceic, 
862,  865 ;  simple  chronic,  864. 

Emboli,  infectious,  in  malignant  endocarditis, 
578. 

Embolism,  592;  in  diphtheria,  971. 

Emphysema,  541 ;  etiology,  541 ;  lesions,  542 ; 
in  acute  vesicular,  542 ;  in  interstitial,  inter- 
lobular, 542;  symptoms,  543;  acute,  in  bron- 
chitis of  infants,  465  ;  in  acute  broncho-pneu- 
monia, 493  ;  in  pertussis,  941. 

Empyema,  548;  bacteriology,  548;  lesions, 
549 ;  symptoms,  551 ;  diagnosis,  551  ;  by 
exploratory  puncture,  551 ;  from  unresolved 
pneumonia,  552 ;  from  pleuro-pneumonia,  552 ; 
from  tuberculosis,  552 ;  prognosis,  552  ;  acute 
peritonitis  complicating,  416;  following 
pleuro-pneumonia,  532;  spontaneous  cure, 
553 ;  treatment,  553 ;  by  aspiration,  553  ;  punc- 
ture with  trocar  and  canula,  554;  simple  in- 
cision and  drainage,  554 ;  resection  of  a  rib, 
556;  methods  of  expanding  lung  after,  557; 
tuberculous,  1023  ;  acute  broncho-pneumonia, 
492. 

Encephalocele,  699  ;  symptoms,  700;  treatment, 
701. 

Endarteritis,  syphilitic,  of  brain,  1057 ;  tuber- 
culous, 715. 

Endocarditis,  acute  simple,  574 ;  etiology,  574; 
lesions,  575 ;  symptoms,  576  ;  diagnosis,  576  ; 
prognosis,  577  ;  treatment,  577 ;  acute  simple, 
in  chorea,  576 ;  chronic  (see  also  Heart, 
Valvular  Disease),  579 ;  foetal,  562 ;  in 
chorea,  677  ;  in  rheumatism,  1087 ;  malignant, 
578 ;  etiology,  578 ;  lesions,  578 ;  symptoms, 
578  ;  diagnosis,  579 ;  treatment,  579. 

Enemata,  65;  nutrient,  65;  drugs  by,  65;  as- 
tringent, in  chronic  iJeo-colitis,  359;  in 
chronic  constipation,  376  ;  in  colic,  371 ;  ice- 
water  in  cholera  infantum,  337 ;  injuries  to 
rectum  from,  404. 

Enteritis  follicularis  (see  Ileo-colitis,  Acute), 
337. 

Entero-colitis,  in  diphtheria,  971  (see  Ileo- 
colitis, Acute),  337. 

Enuresis,  644;  etiology,  645;  symptoms,  646; 
prognosis,  646;  treatment,  646;  stigma  of 
degeneration,  758. 

Ependymitis,  acute,  in  hydrocephalus,  736 ;  fol- 
lowing spina  bifida,  764. 


1100 


INDEX. 


Epidemic,  haemoglobinuria,  90 ;  meningitis  (see 
Meningitis,  Acute). 

Epidermis,  exfoliation  of,  in  congenital  ichthy- 
osis, 866  ;  exfoliation  of,  in  newly  born,  858. 

Epilepsy  660;  aura  in,  662;  course,  664;  diag- 
nosis, 665  ;  etiology  of,  660 ;  hysterical,  687  ; 
idiopathic,  660  ;  in  acquired  cerebi-al  paraly- 
sis, 748 ;  in  birth  paralysis,  745  ;  insanity  fol- 
lowing, 756  ;  intestinal  putrefaction  in,  661 ; 
Jacksonian,  in  cerebral  tumour,  731 ;  men- 
tal condition  in,  664;  pathology,  661;  prog- 
nosis, 665;  status  epilepticus,  665;  stigma  of 
degeneration,  758  ;  symptomatic,  664 ;  symp- 
toms, 662  ;  grand  mal,  662  ;  petit  mal,  663  ; 
treatment,  general,  666 ;  during  an  attack, 
668. 

Epiphyseal  separation  in  acute  arthritis,  836; 
in  scurvy,  212  ;  in  syphilis,  851. 

Epiphyses,  enlargement  of,  in  rickets,  227  ;  in 
syphilis,  852,  857. 

Epiphysitis,  acute  (see  Arthritis,  Acute),  835  ; 
syphilitic,  851,  1061. 

Epispadias,  636. 

Epistaxis,  437  ;  in  anaemia,  799  ;  in  pertussis, 
938  ;  in  purpura,  813 ;  in  scurvy,  212. 

Epitrochlear  lymph  nodes  in  syphilis,  1063. 

Erb's  paralysis,  110. 

Erysipelas  in  newly  born,  83. 

Erythema,  following  diphtheria  antitoxine, 
992 ;  in  influenza,  1073  ;  intertrigo,  865 ;  in 
intestinal  indigestion,  367  ;  in  rheumatism, 
1089 ;  of  the  buttocks  in  marasmus,  207 ; 
Kcarlatiniform,  causes,  905. 

Erythroblasts,  802. 

Estlandei''s  operation,  557. 

Eustachian  tube  in  acute  otitis,  879  ;  inflanuna- 
tion  of,  in  influenza,  1071 ;  obstruction  of,  in 
hypertrophy  of  tonsils,  272. 

Exercise,  importance  of,  7 ;  caution  regarding, 
in  heart  disease,  587  ;  in  anaemia,  806. 

Expectorants  in  bronchitis,  468. 

Eye,  anomalies  of,  as  stigmata  of  degeneration, 
757;  keratitis,  interstitial,  in  syphilis,  1063; 
care  of,  at  birth,  1,  3 ;  diphtheritic  paralysis 
of,  790;  early  use,  25;  ectropion  of,  in  con- 
genital ichthyosis,  859  ;  inflammation  of,  in 
newly  born,  85;  in  measles,  921 ;  nystagmus, 
681. 

Face,  asymmetry  of,  as  stigma  of  degeneration, 
757 ;  expression  of,  in  disease,  33 ;  cyanosis 
and  oedema  of,  from  pressure  at  root  of  lung, 
1048. 

Facial  paralysis,  at  birth,  108 ;  acquired,  periph- 
eral, 792;  in  otitis,  884. 

Fseces,  283 ;  of  milk  diet,  283 ;  of  mixed  diet, 
284 ;  incontinence  of,  407. 


Fat,  determination  of,  in  milk,  133 ;  in  the 
fffices,  284;  test  for,  314;  lack  of,  a  cause  of 
rickets,  215;  lack  of,  causing  constipation, 
372;  in  woman's  milk,  131;  percentages  of, 
in  modification  of  cow's  milk,  171 ;  symptoms 
from  deficiency  of  in  food,  179 ;  symptoms 
from  excess  in  food,  179 ;  function  of,  in  diet, 
124. 

Fatty  degeneration  of  the  newly-born,  91. 

Fauces,  syphilitic,  ulceration  of,  1057. 

Feeble-mindedness,  750. 

Feeding,  artificial,  fundamental  principles  of, 
169;  rules  for,  178;  schedule  for  first  year, 
178;  number  of  feedings,  twenty-four  hours, 
178;  intervals  by  day,  178;  night  feedings, 
178 ;  quantity  for  one  feeding,  178 ;  quan- 
tity for  twenty-four  hours,  178 ;  versus  wet- 
nursing,  158;  breast,  schedule  for,  162;  other 
than  milk,  first  year,  180 ;  difficult  cases,  first 
year,  180;  daily  dietary  at  eighteen  months, 
186  ;  for  healthy  infants,  second  year,  185 ; 
difficult  cases,  second  year,  187;  from  third 
to  sixth  year,  188  ;  articles  allowed,  188;  arti- 
cles forbidden,  189;  dietary,  from  third  to 
sixth  years,  190;  during  acute  illness,  190; 
in  infants,  190;  older  children,  192;  during 
very  hot  days,  324 ;  by  gavage,  in  acute  ill- 
nes.s,  191 ;  in  acute  gastro-enteric  infection, 
326;  in  acute  intestinal  indigestion,  315; 
methods  of,  in  etiology  of  diarrhoea,  310  ; 
mixed,  indications  for,  169;  simple  rules  in, 
190. 

Feet,  anomalies  of,  as  stigmata  of  degeneration 
757. 

Feser's  laetoscope,  140, 

Fever,  from  insufficient  nourishment,  162;  in- 
anition, 118  ;  toxic,  in  intestinal  indigestion, 
367  (see  also  Temperature). 

Finger  (see  Dactylitis). 

Fingers,  clubbing  of,  in  chronic  cardiac  dis- 
ease, 582 ;  in  congenital  heart  disease,  566. 

Fissure  of  the  anus,  404. 

Fistula,  congenital,  of  the  neck,  274. 

Flatulence,  cause  of  colic,  370 ;  in  intestinal  in- 
digestion, 366. 

Foetal  circulation,  558  ;  endocarditis,  562. 

Ftetus,  evidences  of  .syphilis  in,  1058. 

Follicles,  solitary  (see  Lymph  Nodules);  soli- 
tary, of  intestine,  often  enlarged  in  marasmus, 
205. 

Follicular  ulceration  of  intestine,  341. 

Fomentations,  hot,  53. 

Fontanel,  bulging,  in  acute  meningitis,  711  ; 
bulging  of,  in  meningeal  haemorrhage,  107  ; 
bulging  of,  in  tuberculous  meningitis,  715; 
in  hydrocephalus,  737  ;  closure  of,  22 ;  in  cre- 
tinism, 754  ;  in  rickets,  224. 


INDEX. 


1101 


Food,  constituents,  123  ;  proteids,  123  ;  fats,  124 ; 
carboliydratea,  125 ;  mineral  salts,  126  ;  water, 
126 ;  farinaceous,  a  cause  of  eczema,  863  ;  in 
chronic  indigestion,  301;  second  year,  185; 
improper,  in  etiology  of  diarrlicea,  310  ;  re- 
gurgitation of,  causes  and  treatuieut,  179. 

Food-fistula  between  oesophagus  and  larynx, 
276. 

Food-diseases,  209. 

Foods,  infant,  155;  milk,  156;  malted,  156; 
farinaceous,  156;  predigested,  danger  of 
long  use,  123;  proprietary,  dangers  of,  122; 
cause  of  rickets,  215;  cause  of  scurvy,  210; 
faults  of,  125. 

Foramen  ovale,  closure  of,  559 ;  function  of,  in 
foetal  life,  558;  patent,  564. 

Fractures,  green-stick,  in  rickets,  219,  227. 

Franco-Swiss  food,  156. 

Freeman's  pasteurizer,  145. 

Friedlander's  bacillus  in  acute  bronclio-pneu- 
monia,  482. 

Friedreicli's  ataxia,  780. 

Fruit,  best  time  for  giving,  186  ;  during  second 
year,  186  ;  allowed  during  third  to  sixth  year, 
189 ;  forbidden  during  third  to  sixth  year, 
189. 

Fumigations  of  calomel,  448. 

Furunculosis,  871;  treatment,  871 ;  in  diabetes 
mellitus,  1092. 

Gangrene,  of  the  face,  254;  of  intestine,  in  in- 
tussusception, 381 ;  of  lung  in  acute  broncho- 
pneumonia, 493  (  in  lobar  pneumonia,  516  ; 
in  scarlet  fever,  903 ;  in  measles,  920. 

Gastralgia,  290;  in  malaria,  1079;  in  spinal 
caries,  840. 

Ga.stritis,  acute,  293;  etiology,  293;  lesions, 
293;  catarrhal,  293;  gastro-malacia,  293; 
follicular,  294;  membranous'  294;  corrosive, 
295;  symptoms,  295;  catarrhal,  295;  corro- 
sive, 296;  treatment,  296 ;  chronic,  298;  fol- 
licular ulcers  in,  304 ;  toxic  (see  Ga.stritis, 
Cokkosive),  295. 

Gastro-enteric  infection,  acute,  316;  etiology, 
317;  lesions,  319;  simple  form,  320;  symp- 
toms, 320;  diagnosis,  321;  from  acute  indi- 
gestion, 323  ;  from  ileo-colitis,  323 ;  prognosis, 
323;  prophylaxis,  324;  treatment,  liygienic, 
325;  dietetic,  326;  medicinal,  327;  mechan- 
ical, 327 ;  cholera  infantum,  332 ;  symptoms, 
332 ;  diagnosis,  335  ;  prognosis,  335 ;  treat- 
ment, 335. 

Gastro-entcritis,  316;  in  newly  born,  82. 

Gavage,  62  ;  in  acute  illness,  191 ;  in  acute  in- 
anition, 196;  in  chronic  indigestion,  301; 
in  diphtheria,  986 ;  in  mara-sums,  207 ;  in 
premature  infants,  14;  in  thrush,  263. 


Genital  irritation,  649. 

Genital  organs,  diseases  of,  635 ;  anomalies  of, 
as  stigmata  of  degeneration,  757 :  care  of,  in 
newly-born,  4 ;  malformations  of,  635 ;  female, 
gangrene  of,  254 ;  female,  diseases  of,  640 ; 
liEemorrhage  from,  in  newly  born,  104 ;  males, 
diseases  of,  638. 

Gcrber's  food,  156. 

Gingivitis,  hajmorrhagic,  in  scurvy,  212,  214. 

Glands,  bronchial  (sec  Lymph  Nodes,  Bron- 
chial). 

Glands,  lymphatic  (see  Lymph  Nodes),  816. 

Glioma  of  brain,  728;  of  spinal  cord,  778. 

Glio-sarcoma  of  brain,  728. 

Glossitis,  241. 

Glottis,  oedema  of  the,  455  ;  spasm  of,  idiopathic, 
671. 

Glycosuria,  599. 

Gonococcus,  ditferenliation  of,  642 ;  in  gonor- 
rhoeal  stomatitis,  253;  in  specific  urethritis, 
638  ;  in  vulvo- vaginitis,  642. 

Gout,  eczema  in  children,  863;  uric-acid  de- 
posits in  urine,  602. 

Granuloma  of  umbilicus.  111. 

Grippe  (see  Influenza),  1069. 

Growing  pains,  rheumatic,  1087. 

Growth,  conditions  interfering  with,  30 ;  ot 
body,  15  ;  extremities,  21 ;  trunk,  21. 

Gumma,  syphilitic  (see  Syphilis  Lesions), 
1055 ;  in  syphilitic  bone  disease,  855 :  of 
brain,  728. 

Gums,  abscess  of,  243;  bleeding  in  ulcerative 
stomatitis,  249;  inspection  of,  35;  lancing, 
245;  spongy  and  bleeding,  in  scurvy,  211, 
214;  in  ulcerative  stomatitis,  249. 

Habit-chorea,  679. 

TIabit-spasm,  679. 

Habits,  injurious,  695. 

Ilffiinatemesis,  305. 

Hajmatoma  of  the  sterno-mastoid,  94. 

Ilffimatozoon  malaria^  1075. 

Hematuria,  598 ;  in  newly  born,  103 ;  in  pur- 
pura, 812;  in  pyelitis,  628;  in  tumours  of 
kidney,  624. 

Haemoglobin,  795. 

Hremoglobinuria,  599  ;  epidemic,  90  ;  paroxys- 
mal, 509. 

Hmmophilia,  SOS. 

lUvmoptysis  in  tuberculosis,  1041. 

Hannorrhage,  from  stomach,  305 ;  in  haemo- 
philia, 809  ;  intra-alveolar,  in  acute  broncho- 
pneumonia, 487 ;  internal,  causing  sudden 
death,  42  ;  intestinal,  from  tuberculous  ulcer, 
362;  in  typhoid  fever,  1012;  meningeal,  caus- 
ing birth  paralysis,  741  ;  in  acquired  cerebral 
paralysis,  746  ;  in  acute  broneho-iincuinonia, 


1102 


INDEX. 


605  ;  in  convulsions,  656  ;  meningeal,  in  per- 
tussis, 940 ;  meningeal,  in  purpura,  811 ;  nasal, 
in  diphtheria,  971 ;  pulmonary,  in  cardiac 
cases,  582 ;  rectal,  from  ulcer,  406 ;  in  leucaemia, 
807  ;  in  measles,  921  ;  in  pertussis,  940 ;  in 
pernicious  anaemia,  804 ;  in  purpura,  811 ;  in 
the  newly  born,  93 ;  ha^matoma  of  the  sterno- 
mastoid,  94 ;  cephalliEematoma,  95  ;  s'isceral, 
97;  in  scurvy,  212,  214;  subperiosteal,  in 
scurvy,  212  ;  in  syphilis,  1061. 

Hcemorrhagic  disease  of  the  newly  born,  98 ; 
etiology,  99 ;  lesions,  101 ;  symptoms,  102 ; 
diagnosis,  104;  prognosis,  104;  treatment, 
104  ;  Gaertner's  bacillus  in,  100. 

Hajmorrhoids,  407 ;  in  chronic  constipation, 
373. 

Hair,  anomalies,  stigmata  of  degeneration,  757. 

Hand,  progressive  muscular  atrophy  of,  782. 

Hands,  anomalies,  stigmata  of  degeneration, 
757. 

Hare-lip,  238. 

Hawley's  food,  156. 

Hay  fever,  475. 

Head,  circumference  of,  20  ;  closure  of  sutures, 
22 ;  closure  of  fontanels,  22 ;  shape  of,  23 ; 
in  rickets,  223;  examination  of,  37;  hydro- 
cephalic, characteristics  of,  737 ;  rotary  and 
nodding  spasm  of,  681 ;  sweating  of,  in  rick- 
ets, 228. 

Headache,  frequent  with  adenoids,  264;  varie- 
ties, 689  ;  diagnosis,  690  ;  treatment,  690. 

Hearing,  when  developed,  26. 

Heart,  diseases  of,  558  ;  aneurism  of,  589  ;  aortic 
disease,  congenital,  564;  area  of  absolute 
cardiac  dulness,  561  ;  of  relative  dulness, 
560 ;  auscultation  of,  37 ;  dilatation  of,  in 
valvular  disease,  580;  diphtheritic  paraly- 
sis of,  790,  791  ;  examination  of,  560 ;  hy- 
pertrophy of,  in  congenital  disease,  567  ;  hy- 
pertrophy of,  in  valvular  disease,  580 ;  in 
measles,  921 ;  in  scarlet  fever,  903 ;  malfor- 
mations of,  562  ;  peculiarities  of,  in  early 
life,  558 ;  persistent  foetal  conditions,  562 ; 
position  of  apex  beat,  560 ;  in  infancy.  461  ; 
size  and  growth  of,  559  ;  sounds  of,  redupli- 
cation, 562  ;  relative  intensity,  561 ;  sudden 
failure  of,  in  diphtheria,  968;  thrombus  of, 
ante-mortem,  592 ;  transposition  of,  565  ;  con- 
genital anomalies  of,  etiology,  562 ;  diagno- 
sis, 566 ;  from  acquired  disease,  568 ;  from 
ansemic  murmurs,  568 ;  lesions,  562 ;  fre- 
quency of,  562 ;  secondary,  565  ;  prognosis, 
568 ;  symptoms,  565  ;  treatment,  569  ;  func- 
tional disorders  of,  590 ;  symptoms,  590  ;  di- 
agnosis, 591  ;  prognosis,  591 ;  treatment,  591  ; 
murmurs  of,  583  ;  anremic,  589  ;  in  congenital 
disease,  566 ;   in  chorea,  677  ;   in  marasmus. 


207  ;  prognosis  of,  586  ;  valves,  aortic  insuf- 
ficiency, 585  ;  murmur  of,  585  ;  aortic  stenosis, 
584 ;  murmur  of,  584 ;  mitral  insuificiency, 
683 ;  murmur  of,  583 ;  mitral  stenosis,  584 ; 
murmur  of,  584 ;  congenital  absence  of, 
valves,  565 ;  tricuspid,  insufficiency,  685 ; 
murmur  of,  585;  valvular  disease  of  (see 
also  ENnocARDiTis),  574 ;  chronic  valvular 
disease  of,  579  ;  lesions,  579  ;  etiology,  580  ; 
symptoms,  581 ;  clinical  varieties,  583  ;  prog- 
nosis, 586  ;  diagnosis,  587  ;  treatment,  587  ; 
ventricle,  left,  signs  of  dilatation,  584 ;  signs 
of  hypertrophy,  583 ;  right,  signs  of  hyper- 
trophy, 667. 

Hectic  fever  in  tuberculosis,  1040. 

Height,  21  ;  from  birth  to  sixteenth  year,  20. 

Hemianopsia  in  cerebral  tumour,  731. 

Hemichorea,  676. 

Hemiplegia  in  acquired  cerebral  paralysis,  747  ; 
in  birth  paralysis,  742 ;  in  meningeal  hoBinor- 
rhage,  107  ;  in  cerebral  tumour,  731 ;  spastic, 
740. 

Hermaphroditism,  false,  636. 

Hernia,  cerebri,  700;  diaphragmatic,  116;  um- 
bilical, 113. 

Herpes,  labialis,  239 ;  of  the  vulva,  643. 

Herpetic  stomatitis,  246. 

Hiccough,  682 ;  in  acute  peritonitis,  418  ;  in  ap- 
pendicitis, 392. 

Hip,  articular  ostitis  of,  843 ;  symptoms  and 
stages,  844 ;  physical  examination,  844 ;  diag- 
nosis, 846  ;  prognosis,  847  ;  treatment,  847. 

Hip-joint  disease  (see  Hip,  Articular  Ostitis 
of),  843. 

History-taking,  32. 

Hives  (see  Urticaria),  874. 

Hoarseness  with  adenoids,  264 ;  in  catarrhal 
spasm  of  larynx,  440  ;  in  syphilis.  1060. 

Hodgkin's  disease,  831. 

Horlick's  food,  156. 

Hubbell's  prepared  wheat,  156. 

Hutchinson's  teeth  in  late  hereditary  syphilis, 
1062. 

Hydatids  of  liver,  414. 

Hydrencephalocele,  699  ;  symptoms,  700 ;  treat- 
ment, 701. 

Hydrencephaloid,  334  ;  treatment,  337. 

Hydrocele,  639  ;  treatment  of,  640. 

Hydrocephalus,  734;  in  chronic  basilar  menin- 
gitis, 722 ;  with  spina  bifida,  736,  761 ;  acute, 
734  (see  Meningitis,  Tuberculous),  716; 
chronic,  external,  734;  internal,  734;  eti- 
ology, 734 ;  lesions,  735  ;  symptoms,  736  ; 
prognosis,  739 ;  diagnosis,  739 ;  treatment, 
740 ;  shape  of  head,  737 ;  congenital,  702 ; 
intra-uterine,  700;  spurious,  334;  treatment, 
337 ;  syphilitic,  1057. 


INDEX. 


1103 


Hydronephrosis,  607 ;  traumatic,  631 ;  with 
malformations  of  kidney,  609;  with  renal 
calculi,  630. 

Ilydromyelus,  779. 

Hygiene  of  infancy,  1. 

Hyperaesthesia,  general,  in  acute  meningitis, 
710;  in  infantile  spinal  paralysis,  773;  hys- 
terical, 686;  in  multiple  neuritis,  788;  in 
scurvy,  209,  214 ;  in  spinal  meningitis,  766. 

Hypemietropia,  stigma  of  degeneration,  758. 

Hypertrophy  of  the  tonsils,  272 ;  pseudo-mus- 
cular, 78-3. 

Hypodermic  medication,  66. 

Hypospadias,  636. 

Hysteria,  685;  etiology,  685;  symptoms,  686; 
psychical,  686  ;  sensory,  686 ;  joint,  686 ; 
motor  and  convulsive,  687;  diagnosis,  688; 
prognosis,  688 ;  treatment,  688. 

Hystero-epilep.sy,  687 ;  treatment  of  attack,  689. 

Ice,  bag,  54 ;  cap,  47,  54 ;  coil,  54. 

Ichthyosis,  congenital,  859 ;  symptoms,  859 ; 
treatment,  860. 

Icterus,  409 ;  in  epidemic  haemoglobinuria,  96 ; 
in  gastro-duodenitis,  297  ;  varieties  in  newly 
born,  75 ;  in  malformation  of  the  bile  ducts, 
75;  physiological  or  idiopathic,  76. 

Idiocy,  750 ;  cretinoid,  752. 

Ileo-colitis,  acute,  337 ;  etiology,  338 ;  lesions, 
338;  in  catarrhal,  339;  in  ulcerative,  341 ;  in 
follicular  ulceration,  341  ;  in  membranous, 
343 ;  symptoms,  catarrhal  form,  mild,  346 ; 
severe,  347 ;  follicular  ulceration.  347  ;  mem- 
branous form,  349 ;  diagnosis,  350 ;  from  ty- 
phoid fever,  350;  from  intussusception,  350 ; 
prognosis,  351 ;  treatment,  351 ;  hygienic,  351 ; 
medicinal,  352 ;  mechanical,  352 ;  broncho- 
pneumonia complicating,  505 ;  following  per- 
tussis, 941 ;  in  influenza,  1072 ;  in  measles, 
920;  chronic,  354;  lesions,  354;  catarrhal 
form,  354;  ulcerative  form,  355;  symptoms, 
356;  diagnosis,  358;  from  general  tubercu- 
losis, 358 ;  prognosis,  S58 ;  treatment,  359. 

Ileum,  congenital  atresia  of,  115. 

Imbecility,  750. 

Imperial  granum,  156. 

Impetigo,  contagiosa,  873 ;  simple,  865. 

Inanition,  acute,  193;  etiology,  194;  symptoms, 
194;  prognosis,  195;  diagnosis,  195;  treat- 
ment, 196. 

Inanition  fever,  118. 

Incubator,  12;  in  marasmus,  209. 

Indican,  in  urine  of  chronic  constipation,  373; 
of  intestinal  indigestion,  367 ;  test  for,  in 
urine,  602. 

Indicanuria,  602. 

Indigestion,  acute  gastric,  290 :  etiology,  291 ; 
71 


symptoms,  291 ;  diagnosis  from  gastritis,  292; 
treatment,  292 ;  vomiting  in,  285  ;  chronic  gas- 
tric, 298 ;  etiology,  298 ;  lesions,  298 ;  symp- 
toms, in  infants,  298  ;  in  older  children,  300 ; 
treatment  in  infants,  300  ;  in  older  children, 
302;  with  dilatation,  303;  acute  intestinal, 
313;  etiology,  313;  symptoms,  313 ;  diagnosis, 
314 ;  prognosis,  315  ;  treatment,  315 ;  chronic 
intestinal,  363 ;  in  young  infants,  363 ;  lesions, 
364;  symptoms,  364 ;  treatment,  366;  in  older 
children,  366 ;  symptoms,  366 ;  prognosis,  368 ; 
treatment,  368. 

Infant,  alimentation  of,  when  premature,  14; 
care  of  newly- born,  1;  when  premature  or 
delicate,  10. 

Infant  feeding,  157. 

Infant  foods,  155. 

Infarctions,  uric  acid  in  kidney,  610. 

Infectious  diseases,  the  specific,  887. 

Influenza,  1069;  etiology,  1069;  lesions,  1070; 
symptoms,  1070 ;  mild  uncomplicated  type. 
1070 ;  severe  uncomplicated  type,  1070  ;  with 
catarrhal  complications,  1071 ;  with  broncho- 
pulmonary complications,  1071 ;  with  gastro- 
enteric complications,  1072 ;  in  very  young 
infants,  1072;  complications  and  sequelte, 
1073;  diagnosis,  1073 ;  prognosis,  1074 ;  treat- 
ment, 1074 ;  broncho-pneumonia,  505,  1072  ; 
epidemic,  acute  otitis  in,  879 ;  scarlatiniform 
erythema  in,  905. 

Inhalations,  58 ;  in  bronchitis,  468. 

Inheritance  a  factor  in  disease,  30. 

Injections,  rectal,  in  ileo-colitis,  353 ;  in  intus- 
susception, 387 ;  subcutaneous,  of  saline  solu- 
tion in  cholera  infantum,  336. 

Insanity,  755 ;  etiology,  756 ;  symptoms,  756 ; 
prognosis,  757  ;  following  typhoid  fever,  1013. 

Inspection  of  sick  child,  33. 

Intermittent  fever,  malarial,  1078. 

Intertrigo,  865 ;  treatment,  870. 

Intestinal  obstruction  in  newly  born,  115;  acute, 
from  intussusception,  378. 

Intestines,  disea.ses  of,  306  ;  amyloid  degenera- 
tion of,  360;  bacteria  of,  282;  digestion  in, 
281 ;  ha?morrhage  from,  in  newly  born,  103 ; 
in  tyi)hoid,  1012 ;  in  tuberculosis,  362 ;  length, 
2S1 ;  malformations  of,  308;  obstruction,  con- 
genital, of,  115 ;  obstruction  by  omphalo-mes- 
enteric  duct,  116  ;  perforation  of,  in  tubercu- 
lous peritonitis,  423 ;  in  tuberculous  ulcers, 
361  ;  in  typhoid  fever,  1009,  1013 ;  tuberculo- 
sis of,  360,  1032 ;  etiology,  360 ;  lesions,  361 ; 
diagnosis,  362;  prognosis,  363;  treatment, 
363. 

Intubation,  in  acute  catarrhal  laryngitis,  445; 
in  syphilitic  laryngitis,  458  ;  results  with  and 
without  antito.xine,   999 ;  statistics   of,  with 


1104 


INDEX. 


calomel  fumigations,  449 ;  after-  treatment  in, 
452 :  advantages  over  traclieotomy,  454. 

Intubation  set,  O'DwyerV,  451. 

Intussusception,  378 ;  varieties  of,  378 ;  etiolo- 
gy, 379;  lesions  and  mechanism,  380  ;  symp- 
toms, 381 ;  course,  duration,  termination,  384 ; 
diagnosis,  385 ;  prognosis,  385 ;  treatment, 
386;  laparotomy,  388;  in  the  dying,  279. 

Invagination  of  intestine  in  intussusception, 
381. 

Iodides,  elimination  of,  in  milk,  136. 

Iritis,  syphilitic,  1057. 

Iron,  tonic  preparations  of,  50. 

Irrigation,  intestinal,  in  chronic  indigestion, 
369  ;  as  antipyretic,  48  ;  of  the  colon,  method 
of,  63. 

Ischio-rectal  abscess,  407. 

Italians,  rickets  in,  216. 

Jacket,  oil-silk,  59. 

Jatfe'8  test  for  indican,  602. 

Jaundice  (see  also  Icteru-s),  409 ;  catarrhal,  297. 

Jaw,  necrosis  of,  from  alveolar  abscess,  243 ; 
in  gangrenous  stomatitis,  255  ;  in  ulcerative 
stomatitis,  248. 

Jejunum,  congenital  atresia  of,  115. 

Joints,  diseases  of,  835 ;  hysterical  aftections  of, 
686 ;  in  scarlet  fever,  902 ;  rheumatism  of, 
1086 ;  suppuration  of,  in  newly  born,  82 ; 
swelling  of,  in  scurvy,  209  ;  ecchymoses  about, 
in  scurvy,  209 ;  tuberculous  diseases  of,  836 ; 
etiology,  837  ;  lesions,  primary,  837  ;  second- 
ary, 838. 

Junket,  152. 

Keratitis,  interstitial,  in  late  syphilis,  1057, 1063. 

Keratoma,  difluse,  859. 

Kidney,  diseases  of,  606 ;  acute  congestion  of, 
611;  acute  degeneration  of,  612;  benign  tu- 
mours of,  627  ;  calculi  in,  630 ;  chronic  con- 
gestion of,  611 ;  contracted  (see  Nephritis, 
Chronic),  620  ;  cystic  degeneration  of,  607  ; 
floating,  610;  granular  (see  Nephritis, 
Chronic),  620  ;  hfemorrliage  from,  in  newly- 
born,  104 ;  in  scurvy,  214 ;  horseshoe,  607 ; 
hydronephrosis,  607  ;  traumatic,  631 ;  malfor- 
mations and  malpositions  of,  606  ;  malignant 
tumours  of,  623 ;  etiology,  624 ;  symptoms, 
624  ;  diagnosis,  625 ;  treatment,  625  ;  nephri- 
tis, acute  diifuse,  615  ;  acute  exudative,  613  : 
chronic,  619 ;  perinephritis,  631  ;  pyelitis, 
627  ;  pyelo-nephritis,  608  ;  pyonephrosis,  627  ; 
single,  607  ;  tuberculosis  of,  623,  1032  ;  uric- 
acid  infarction,  610 ;  waxy,  620 ;  in  diph- 
theria, 961 ;  in  scarlet  fever,  901. 

Klebs-Loeffler  bacillus  (see  Bacillus  of  Diph- 
theria), 951. 


Knee,  articular  ostitis  of,  847 ;  symptoms,  848 ; 
treatment,  849 ;  subluxation  of,  in  infantile 
spinal  paralysis,  774  ;  swelling  of,  in  scurvy, 
211 ;  white  swelling  of  (see  Knee,  Articular 
Ostitis). 

Knee-jerk,  in  acquired  cerebral  paralysis,  747  ; 
in  birth  paralysis,  745  ;  lost  in  diphtheritic 
paralysis,  791  ;  in  infantile  spinal  paralysis, 
774  ;  in  multiple  neuritis,  788. 

Knee-joint  disease  (see  Knee,  Articular  Osti- 
tis). 

Knock-knee  in  rickets,  227. 

Kumyss,  150. 

Kyphosis  in  rickets,  225  ;  treatment,  235 ;  in 
spinal  caries,  839,  840. 

Lactated  food,  156. 

Lactation,  care  of  breasts  during,  160. 

Lactometer,  author's,  132. 

Lacto-preparata,  156. 

Lactoscope,  Feser's,  140. 

La  grippe  (see  Influenza),  1069. 

Landry's  paralysis,  781. 

Laparotomy,  in  chronic  peritonitis,  with  ascites, 
420 ;  in  intussusception,  388 ;  in  tuberculous 
peritonitis,  425. 

Laryngismus  stridulus,  671  ;  symptoms,  672 ; 
diagnosis,  672  ;  treatment,  673 ;  in  rickets, 
231  ;  with  tetany,  668. 

Laryngitis,  acute  catarrhal,  442 ;  lesions,  442  ; 
symptoms,  442  ;  diagnosis  from  membranous 
laryngitis,  443 ;  prognosis,  444 ;  treatment, 
444;  catarrhal,  in  measles,  919;  chronic,  456; 
with  adenoid  vegetations  of  pharynx,  456 ; 
tuberculous,  456  ;  syphilitic,  457  ;  with  new 
growths  of  larynx,  458  ;  membranous,  445, 
919;  symptoms,  446  ;  course,  446;  prognosis, 
447 ;  diagnosis,  447  ;  treatment,  447  ;  by  calo- 
mel fumigations,  448;  operative  measures, 
449 ;  antitoxine,  449,  990,  998 ;  intubation, 
450  ;  tracheotomy,  449  ;  spasmodic,  439  ;  sub- 
mucous (oedema  of  glottis),  455. 

Laryngotomy  for  foreign  body  in  larynx,  459. 

Larynx,  diseases  of,  439;  catarrhal  spasm  of, 
439;  etiology,  439;  lesions,  439;  symptoms, 
440  ;  diagnosis,  440 ;  from  laryngismus  stridu- 
lus, 440 ;  from  membranous  laryngitis,  441 ; 
treatment,  441 :  from  long  uvula,  258 ;  with 
adenoids,  265 ;  diphtheria  of,  445,  967 ;  results 
of  antitoxine  in,  998 ;  foreign  bodies  in,  458 ; 
intubation  of,  450  ;  results  with  and  without 
antitoxine,  999;  in  measles,  919;  in  pseudo- 
diphtheria,  1003, 1005 ;  new  growths  of,  458  ; 
stenosis  of,  simulated  by  tuberculous  glands, 
1049  ;  syphilis  of,  457,  458, 1056 ;  tuberculosis 
of,  456. 

Lassar's  paste,  869. 


INDEX. 


1105 


Leptomeningitis,  acute  (see  Meningitis),  706. 

Leucaemia,  806 ;  etiology,  806 ;  lesions,  806 ; 
symptoms,  807  ;  blood,  807  ;  course  and  prog- 
nosis, 808 ;  diagnosis,  808 ;  treatment,  808. 

Leucocytosis,  definition,  797 ;  in  diphtheria, 
962;  in  acute  meningitis,  711. 

Lichen  urticatus  (see  Urticakia),  874;  tropi- 
cus, 861. 

Liebig's  food,  156. 

Limewater,  in  modification  of  cow's  milk,  172.. 

Lip,  eczema  of,  240 ;  perleche,  240 ;  diseases  of, 
239 ;  herpes  of,  239  ;  malformations  of,  238. 

Lisping,  691. 

Lithuria,  601. 

Liver,  diseases  of,  408 ;  abscess  of,  410 ;  acute 
yellow  atrophy  of,  410 ;  amyloid  degeneration 
of,  412 ;  biliary  calculi,  414 ;  cirrhosis  of,  411  ; 
congestion  of,  410  ;  displacement  of,  37  ;  en- 
larged, in  congestion,  410;  in  abscess,  410; 
in  cirrhosis  (early),  412;  in  chronic  cardiac 
disease,  582;  fatty,  413  ;  fatty,  in  eczematous 
children,  863  ;  in  marasmus,  205;  functional 
disorders  of,  409  ;  hydatids  of,  414 ;  in  rick- 
ets, 231 ;  in  syphilis,  1055,  1065;  in  tubercu- 
losis, 1041;  lardaceous,  412;  malformations 
and  malpositions  of,  409 ;  size  and  position 
of,  37,  408;  tuberculosis  of,  1031 ;  waxy,  412; 
weight  of,  in  infancy,  408. 

Loefiler's  bacillus  (see  Bacillus  of  Diph- 
theria), 951  ;  blood-serum,  952  ;  stain,  952. 

Lumbar  puncture,  713 ;  tubercle  bacilli  in  fluid, 
720. 

Lung,  diseases  of,  459 ;  abscesses  of,  in  acute 
broncho-pneumonia,  493 ;  acute  congestion 
of,  in  malaria,  1080  ;  calcareous  nodules  in, 
1027;  caseous  degeneration  of,  1024;  collapse 
of,  from  compression,  539  ;  from  obstruction, 
540 ;  in  acute  broncho-pneumonia,  484 ;  con- 
genital atelectasis  of,  72  ;  emphysema  of,  541 ; 
acute,  in  bronchitis  of  infants,  465  ;  gangrene 
of,  537 ;  etiology,  537  ;  lesions,  538 ;  symp- 
toms, 538 ;  treatment,  539 ;  gangrene  of,  in 
lobar  pneumonia,  516  ;  hicmorrhages  into,  in 
newly  born,  97 ;  inflation  of,  71 ;  miliary  tu- 
berculosis of,  1023;  peculiarities  in  disease, 
462;  in  infancy  and  early  childhood,  459; 
physical  examination  of,  460 ;  inspection, 
460  ;  palpation,  460  ;  percui^sion,  461  ;  auscul- 
tation, 461 ;  structure  of,  460. 

Lymph  nodes,  diseases  of,  816;  calcareous  cer- 
vical, 826;  bronchial,  1030;  early  infection  in 
tuberculosis,  1020;  enlarged,  in  eczema,  864; 
in  Ilodgkin's  disease,  831 ;  in  malnutrition, 
198;  frequency  of  disease  of,  39;  inflamma- 
tion of  (see  Adknitis),  819  ;  in  late  hereditary 
syphilis,  1063:  in  measles,  921;  in  pseudo- 
diphtheria,  1004;  in  scarlet  fever,  900;  sim- 


ple hyperplasia  of,  822 ;  situation  and  drain- 
age areas  of  the  groups  of  head  and  neck 
819;  syphilitic  disease  of,  823;  tuberculous 
bronchial,  1047;  lesions,  1020,  1028;  symp- 
toms, 1047  ;  physical  signs,  1049  ;  diagnosis, 
1049;  cervical,  tuberculosis  of,  824;  mesen 
teric,  360,  1021 ;  etiology,  360 ;  lesions,  362 

.  symptoms,  362 ;  diagnosis,  362 ;  treatment, 
363 ;  in  diphtheria,  960 ;  in  rickets,  230 ;  in 
tonsillitis,  270 ;  epitrochlear,  in  syphilis,  1063 
mesenteric,  often  enlarged,  in  marasmus, 
205;  in  typhoid  fever,  1009;  tuberculosis  of, 
retro-pharyngcal,  abscess  of,  258. 

Lymph  nodules  of  intestines,  ulceration  of, 
341. 

Lymphangioma  of  tongue,  239. 

Lymphatism,  816;  with  adenoids,  263. 

Lymphocytes,  796. 

Magendie,  foramen  of,  in  hydrocephalus,  734. 

Malaria,  1075 ;  etiology,  1075 ;  lesions,  1077  ; 
symptoms,  1077 ;  masked  and  irregular 
forms,  1079 ;  subacute  or  chronic  forms, 
1081 ;  diagnosis,  1081 ;  prognosis,  1082;  treat- 
ment, 1082 ;  quinine,  methods  of  adminis- 
tration, 1082 ;  dosage,  1083 ;  acute  pulmo- 
nary congestion  in,  1080  ;  contracted  in 
vtero,  1076  ;  spleen  in,  834. 

Malformations  as  cause  of  sudden  death,  42. 

Malnutrition,  197  ;  etiology,  197;  symptoms  in 
infants,  198;  symptoms  in  older  children, 
198;  diagnosis,  200;  prognosis,  201;  treat- 
ment in  infancy,  201 ;  treatment  in  older 
children,  203. 

Malnutrition,  marasmus,  204. 

Malted  milk,  156. 

Malt  extracts,  use  of,  in  diet  of  nurse,  135. 

Maltose,  substitute  for  milk  sugar;  125,  183. 

Mania,  756 ;  acute,  following  typhoid  fever, 
1013. 

Marasmus,  204 ;  etiology,  204 ;  lesions,  205 ; 
symptoms,  206  ;  complications,  207  ;  diagno- 
sis, 208  ;  from  tuberculosis,  208,  1034 ;  prog- 
nosis, 208 ;  treatment,  208 ;  fatty  liver  in, 
413 ;  general  oedema  in,  634  ;  modification  of 
milk  in,  182;  sudden  death  in,  43;  tubercu- 
losis resembling,  1033. 

A[archand's  test  for  fat  in  milk,  133. 

Massage,  66;  in  chronic  constipation,  375;  in 
malimtrition,  202 ;  of  breast.s  to  increase  milk, 
165. 

Mastitis  in  the  newly  born,  114. 

Mastoid  diseases,  cerebral  abscess  following, 
725;  in  acute  otitis,  883. 

Masturbation,  696 ;  treatment  of,  697  ;  a  cause 
of  c])ilepsy,  661 ;  of  insanity,  756;  of  func- 
tional disorder  of  heart,  590. 


1106 


INDEX. 


Matzoon,  151. 

Measles,  910;  broncho  -  pneumonia  complica- 
ting, 504 ;  complications  and  sequelse,  918 ; 
desquamation,  915  ;  diagnosis,  922  ;  digestive 
system,  920 ;  duration  of  infective  period, 
912:  ears,  879,  921;  eruption,  914;  etiology, 
910 ;  eyes,  921 ;  gangrenous  dermatitis  in,  872  ; 
German  (see  Rubella),  926  ;  hcemorrhages 
in,  921 ;  haemorrhagic,  915 ;  heart  in,  921 ; 
ileo-colitis,  920 ;  incubation,  911 ;  invasion, 
913 ;  larynx  in,  919 ;  lesions,  913  ;  lungs,  919  ; 
lymph  nodes,  921 ;  mode  of  infection,  912  ; 
mortality,  923 ;  otitis,  921 ;  predisposition, 
911 ;  prognosis,  922 ;  prophylaxis,  924 ;  pseudo- 
diphtheria  in,  1004  ;  quarantine  in,  924 ; 
symptoms,  913 ;  symptoms,  mild  cases,  916  ; 
symptoms,  moderate  cases,  916 ;  symptoms, 
severe  cases,  917  ;  throat,  920  ;  treatment,  924 ; 
tuberculosis  following,  922 ;  with  other  in- 
fectious diseaess  922. 

Meats,  allowed  from  third  to  si.xth  years,  188  ; 
forbidden  from  third  to  sixth  years,  189. 

Meckel's  diverticulum,  112,  308. 

Meconium,  composition  of,  283. 

Mediastinum,  anterior,  abscess  of,  1049  ;  tumour 
of,  due  to  tuberculous  lymph  nodes,  1049. 

Mediastinitis,  570. 

Melancholia,  756. 

Melsena,  103. 

Mellin's  food,  156. 

Membrane,  in  diphtheria,  956  ;  in  pseudo-diph- 
theria, 1003. 

Meningeal  haemorrhage,  105,  703,  746. 

Meninges,  diseases  df,  699. 

Meningitis,  acute,  706  ;  abortive  cases,  709 :  com- 
mon form,  708  ;  course,  termination,  progno- 
.sis,  712 ;  dingnosis,  712 ;  diagnosis  from  tuber- 
culous, 713  ;  eruptions  in,  711 ;  etiology,  706  ; 
from  acute  otitis,  883  ;  in  newly  born,  82  ; 
in  typhoid  fever,  1012,  1013 ;  purulent,  in 
acute  broncho-pneumonia,  505  ;  fulminating 
cases,  709  ;  lesions,  707  ;  leucocytosis  in,  711 ; 
lumbar  puncture  in,  713;  malignant  cases, 
709 ;  nervous  system  in,  710 ;  pulse,  711 ; 
respiration,  711 ;  secondary  cases,  710 ;  speech, 
711 :  special  senses,  710  ;  sporadic  cases,  710  ; 
symptoms,  708 ;  temperature,  711 ;  treatment, 
714 ;  with  lobar  pneumonia,  517 ;  with  pleuro- 
pneumonia, 532. 

Meningitis,  basilar,  715 ;  chronic,  in  infants, 
721 ;  lesions,  721 ;  symptoms,  721  ;  diagnosis, 
722 ;  treatment,  723 ;  cerebro-spinal  (see  Men- 
iKGiTis,  Acute),  706 ;  epidemic,  706  ;  syphi- 
litic, 1057 ;  spinal,  acute  and  chronic,  765 ; 
symptoms,  766 ;  treatment,  766 ;  sporadic, 
706 ;  syphilitic,  1057. 

Meningitis,  tuberculous,  715, 1031 ;  lesions,  715 ; 


etiology,  716  ;  symptoms,  717 :  duration,  719  ; 
course,  variations  of,  719 ;  diagnosis,  720 ; 
prognosis,  720 ;  treatment,  721 ;  lumbar  punc- 
ture in,  720  ;  respiratory  curve  in,  718  ;  tem- 
perature curve  in,  719. 

Meningocele  of  brain,  699 ;  symptoms,  700 ; 
treatment,  701  ;  of  cord,  760. 

Meningo-encephalitis,  741. 

Meningo-myelocele,  760. 

Menstruation,  efiect  on  nursing,  134. 

Mercury,  elimination  of,  in  milk,  137  ;  ulcer- 
ative stomatitis  from,  248 ;  in  syphilis,  1068. 

Microcephalus,  702. 

Micturition,  difficult  or  painful,  649  ;  frequency 
of,  595. 

Miliaria,  860  ;  papulosa,  861 ;  treatment,  861 ; 
rubra,  860. 

Milk,  cow's,  137  ;  addition  of  other  substances 
to,  183 ;  average  percentages  of,  171 ;  best 
from  mixed  herd,  138 ;  sources  of  contamina- 
tion, 138  ;  transportation  of,  139  ;  composition 
of,  139 ;  average  percentages  in,  from  differ- 
ent breeds,  139;  examination  of,  140;  coagu- 
lation of,  in  stomach,  280 ;  cream,  141 ;  con- 
taminated, cause  of  diarrhoea,  310  :  differences 
from  human  milk,  140  ;  diphtheria  bacilli  in, 
954;  essentials  of,  for  infant  feeding,  136; 
formulae  from  diluting,  176  ;  modification  of, 
at  home,  174 ;  cream,  174 ;  sugar  solutions, 
175  ;  formulae  from  diluted  cream,  175,  176  ; 
instructions  for  nurse,  176 ;  table  of  ingre- 
dients for  preparing,  177  ;  bottles  and  nip- 
ples, 178 ;  rules  for  artificial  feeding,  178  ; 
schedule  for  first  year,  178;  modification  for 
healthy  infants  during  first  year,  170 ;  how  to 
prepare,  176 ;  formulae  for,  177  ;  in  difficult 
cases,  181 ;  in  summer  diarrhoea,  327  ;  modifi- 
cation required  by  particular  symptoms,  179 ; 
in  acute  indigestion,  315  ;  for  difficult  cases, 
second  year,  187  ;  formula  for  healthy  infants, 
second  year,  185 ;  in  chronic  constipation, 
375;  pasteurization  of,  145;  proteids  of,  124; 
modifications  of  schedule  for  feeding,  174: 
sterilization  at  167°  F.,  145;  sterilization  of, 
at  212°  F.,  143  ;  sterilized,  scurvy  ascribed 
to,  210:  tubercle  bacilli  in,  1019;  typhoid 
contamination  of,  1008  ;  condensed  (see  Con- 
densed Milk),  149  ;  peptonized,  148  ;  pep- 
tonized, use  of,  182 :  preparation  at  each  feed- 
ing, 182  ;  dangers  from  long  use  of,  183. 

Milk-laboratories,  172. 

Milk-sugar,  uses  of,  as  food,  125  ;  solution,  how 
to  prepare,  175,  177. 

Milk,  woman's,  127  ;  physical  characters  of, 
127  ;  colostrum  of,  127  ;  daily  quantity  of,  128 ; 
average  quantity  at  one  nursing,  130 ;  compo- 
sition of,  130  ;  proteids,  124, 130, 141 ;  fat,  131 ; 


INDEX. 


1107 


sugar,  131;  salts,  131;  reaction,  132;  specific 
gravity,  132, 134 ;  average  percentages  of,  171 ; 
conditions  affecting  composition  of,  134; 
menstruation,  134;  diet,  135;  drugs,  136 ; 
pregnancy,  137  ;  nervous  impressions,  137  ; 
examination  of,  132  ;  quantity,  132  ;  determi- 
nation of  fat,  133 ;  sugar,  133 ;  proteids,  124, 
133,141;  variations  in  quality,  134 ;  apparatus 
for  examining,  134;  How  established,  127; 
how  to  modify  quantity  and  quality,  164  ;  in- 
dications of  scanty  supply,  163. 

Moditied-milk  from  milk  laboratory,  172;  sam- 
ple pre-scription,  173 ;  schedule  for  feeding 
from  birth,  174. 

Monoplegia,  in  birth  paralysis,  742 ;  in  cerebral 
haemorrhage,  107  ;  in  cerebral  tumoui-,  731. 

Morbilli  (see  Measles),  910. 

Morbus  coxarius  (see  Hip,  Articular  Ostitis 
OF),  843. 

Morbus  maculosus  Werlhofii  (see  Purpura), 
810. 

Morphine,  dosage  of,  51, 418 ;  dosage  in  convul- 
sions, 659;  hypodermically  in  cholera  infant- 
um, 336  ;  in  gastro-intestinal  infection,  331. 

Mortality  at  different  ages,  41, 42 ;  chief  causes 
of,  41. 

Morton's  fluid,  765. 

Mouth,  diseases  of  (see  also  Stomatitis),  238, 
245  ;  applications  to,  253  ;  care  of,  at  birth,  1, 
3;  haemorrhage  from,  in  newly  born,  103; 
haemorrhages  from,  in  scurvy,  214;  malfor- 
mations of,  238 ;  mucous  patches,  in  syphilis, 
1060;  syphilis  of,  253;  tapir,  785;  syringing 
of,  57. 

Mouth-breathing,  with  hypertrophy  of  tonsils, 
272;  adenoids,  264 ;  retro-pharyngeal  abscess, 
260. 

Mucous  membranes,  frequency  of  involvement 
in  childhood,  38;  in  rickets,  230. 

Mucous  patches,  syphilitic,  1060. 

Mumps,  947;  complications  and  sequelae,  949; 
diagnosis,  950 ;  etiology,  947  ;  incubation,  948 ; 
pathology  and  lesions,  947;  prognosis,  950; 
quarantine  in,  948  ;  symptoms,  948. 

Murmurs,  cardiac  (see  Heart  Murmurs). 

Muscles,  atrophy  of,  781 ;  in  infantile  spinal 
paralysis,  773 ;  in  multiple  neuritis,  788 ;  in 
myelitis,  767  ;  contractures  of,  hysterical,  687  ; 
in  acquired  cerebral  paralysis,  747  ;  in  birth 
paralyses,  744  ;  development  of,  25  ;  flabbiness 
of,  in  rickets,  228;  rigidity  of,  in  birth  pa- 
ralysis, 745 ;  spasm  of,  about  rheumatic  joint, 
1086. 

Muscular  atony,  as  cause  of  chronic  constipa- 
tion, 373. 

Muscular  atrophies,  different  types  of,  781. 

Mustard  bath,  54  ;  paste,  52  ;  pack,  52. 


Myelitis,  766;  symptoms,  767;  treatment  767; 
compression,  from  Pott's  disease,  768 ;  lesions, 
768;  symptoms,  769;  course  and  prognosis, 
769 ;  diagnosis,  770 ;  treatment,  770  ;  diffuse, 
767 ;  transverse,  767. 

Myelocytes  in  leucaemia,  807. 

Myocarditis,  588  ;  lesions,  588  ;  symptoms,  589 ; 
diagnosis,  589  ;  treatment,  589  ;  aneurLsm  in, 
589  ;  toxic,  in  diphtheria,  792,  969 ;  in  scarlet 
fever,  903. 

Myopia,  stigma  of  degeneration,  758. 

Myotonia,  congenital,  682. 

Nail-biting,  698. 

Nails  in  syphilis,  1061. 

Neck,  cellulitis  of,  in  scarlatina,  900 ;  congenital 
fistula  of,  274  ;  wry  (see  Torticollis). 

Necrosis  of  bone  in  syphilis,  852,  854. 

Negroes,  rickets  in,  216. 

Nematodes  (see  Worms,  Intestinal),  398. 

Nephritis,  acute  desquamative,  613 ;  acute  dif- 
fuse, 615;  etiology,  615;  lesions,  616;  symp- 
toms, 616;  prognosis,  617;  treatment,  618; 
acute  exudative,  613;  etiology,  613;  lesions, 
613;  symptoms,  614;  primary  ca.ses,  614; 
secondary  cases,  615;  treatment,  618;  in 
broncho-pneumonia,  506  ;  acute  parenchym- 
atous, 613;  acute  septic  interstitial,  613; 
chronic,  619;  etiology,  620;  lesions,  620; 
with  exudation,  620 ;  without  exudation,  621 ; 
prognosis,  622 ;  diagnosis,  622 ;  symptoms, 
620;  treatment,  622;  chronic  diffuse,  with 
hydronephrosis,  608  ;  chronic  interstitial, 
syphilitic,  1057  ;  in  diphtheria,  971 ;  inter- 
stitial (see  Nephritis,  Chronic),  620;  post- 
scarlatinal, 901. 

Nerves,  peripheral,  diseases  of,  785. 

Nervous  impressions,  effect  of,  on  nursing,  137. 

Nervous  system,  diseases  of,  651 ;  diseases  of, 
functional,  653 ;  general  hygiene  of,  5 ;  pe- 
culiarities of,  in  childhood,  652. 

Nestle's  food,  156. 

Neuritis,  multiple,  785;  etiology,  785;  lesions, 
786;  symptoms,  787;  course  and  prognosis, 
788;  diagnosis,  789;  treatment,  789;  after 
diphtheria,  790;  typhoid  fever,  1013  ;  in  ma- 
laria, 1079;  optic,  in  acute  meningitis,  710; 
in  cerebral  tumour,  730;  with  cerebral  ab- 
scess, 727. 

Newly  born,  diseases  of,  67;  acute  infectious 
di.sea.ses  of,  78 ;  acute  pyogenic  diseases  of, 
79 ;  blood  in,  peculiarities  of,  797 ;  care  of, 
1 ;  diseases  or  accidents  at  birth.  30;  derma- 
titis exfoliativa,  858  ;  facial  paralysis  in,  108; 
fatty  degeneration  of,  91 ;  ha'inorrhages  in, 
93;  hannorrhagic  disease  of,  98;  hyperpy- 
rexia in,  119;  inanition  fever  in,  118;  icterus 


1108 


INDEX. 


in,  75 ;  infection,  31 ;  malformations,  30 ; 
mastitis  in,  114;  ophthalmia  of,  85;  pemphi- 
gus in,  92 ;  peritonitis  in,  415 ;  sclerema  in, 
116  ;  skin  of,  858 ;  ulcer  of  stomach  in,  304. 

Nightmare,  694. 

Night-terrors,  694. 

Nipi:)les,  care  of,  during  lactation,  160;  fissure 
of,  hsematemesis  from,  306  ;  rubber,  choice  of, 
178 ;  care  of,  178. 

Nodding  spasm  of  head,  681. 

Nodes,  lymph  (see  Lymph  Nodes). 

Nodules,  subcutaneous  tendinous,  in  rheuma- 
tism, 1088. 

Noma  of  vulva,  644  (see  Stomatitis,  Gangre- 
nous), 254. 

No.se,  diseases  of,  428 ;  deformities  of,  in  heredi- 
tary syphilis,  436 ;  dilficulty  in  blowing,  with 
adenoids,  264  ;  diphtheria  of,  958 ;  discharge 
from,  with  adenoids,  264;  foreign  bodies  in, 
431 ;  haemorrhage  from,  437 ;  in  newly  born, 
103 ;  in  scurvy,  214 ;  in  hereditary  syphilis, 
436,  1056;  in  late  syphilis,  1064;  polypi  in, 
432;  pseudo-diphtheria  of,  1003;  sprays  for, 
55  ;  syringing,  56. 

Nurse,  effect  of  diet  on  milk  of,  135  ;  requisite 
qualities  in,  10 ;  wet  (see  Wet-Nurse). 

Nursery,  temperature,  ventilation,  10. 

Nursing,  at  night,  162 ;  when  discontinued, 
162:  during  acute  illness,  191;  during  first 
days  of  life,  160;  hours  for,  in  newly  born, 
161, 162';  during  illness,  168 ;  importance  of 
good  habits,  161 ;  inadequate,  symptoms  of, 
162;  maternal,  contra-indications  for,  160. 

Nursing-bottles,  choice  of,  178  ;  care  of,  178. 

Nutrient  enemata,  65. 

Nutrition,  derangements  of,  192;  acute  inani- 
tion, 193  ;  malnutrition,  197  ;  marasmus,  204; 
faulty,  diseases  due  to,  209  ;  importance  in 
pediatrics,  122. 

Nystagmus,  681 ;  in  cerebral  haamorrhage,  108  ; 
in  hydrocephalus.  739  ;  in  tuberculous  menin- 
gitis, 717  ;  stigma  of  degeneration,  758 ;  with 
tumour  of  crura  cerebri,  73. 

Oatmeal  water,  155. 

O'Dwyer's  intubation  set,  451. 

(Edema,  in  acute  diffuse  nephritis,  616  :  in 
anaamia,  799 ;  in  chronic  nephritis,  621 ;  in 
cardiac  di.sease,  582;  in  delicate  infants,  118; 
in  leucaemia,  808  ;  of  face  from  pressure  at 
root  of  lung,  1048;  general,  in  marasmus, 
207  ;  not  from  renal  disease,  634. 

CEdema  glottidis,  rare  in  acute  catarrhal  laryn- 
gitis, 442;  in  corrosive  oesophagitis,  275;  in 
quinsy,  271. 

CEsophagitis,  acute,  275  ;  catarrhal,  275  ;  eoiTO- 
sive,  275. 


Q^lsophagus,  diseases  of,  274 ;  abscess  behind, 
276  ;  congenital  narrowing  of,  275 ;  congenital 
obstruction  in,  275 ;  diphtheria  of,  960 ;  mal- 
formations of,  274  ;  pseudo-diphtheria  in,  275 ; 
stricture  of,  275 ;  thrush  in,  275. 

Oil  enemata,  65. 

Oiled-silk  jacket,  59. 

Omphalitis  in  newly  born,  80. 

Omphalo-mesenteric  duct,  116,  308. 

Onychia,  syphilitic,  1061. 

Ophthalmia,  gonorrhoeal,  85  ;  in  newly  born, 
85 ;  treatment,  86. 

O^^isthoton us,  cervical,  682;  hysterical,  688;  in 
acute  meningitis,  710  ;  in  birth  paralysis,  744; 
in  meningeal  haemorrhage,  107,  108 ;  in 
chronic  basilar  meningitis,  722 ;  in  maras- 
mus, 207  ;  in  tuberculous  meningitis,  718. 

Opium,  elimination  of,  in  milk,  136  ;  in  gastro- 
enteric infection,  330  ;  in  bronchitis,  468  ; 
preparations  and  dosage,  51. 

Optic  nerve,  atrophy  of,  in  cerebral  tumours, 
730. 

Orange  juice  in  scurvy,  215. 

Orchitis,  in  mumps.  949 ;  in  specific  urethritis, 
638 ;  syphilitic,  1057  ;  tuberculous,  1032. 

Orthopnffia,  in  chronic  valvular  disease,  581 ; 
in  functional  disorders  of  the  heart,  590. 

Osteo-myelitis,  acute  (see  Arthritis,  Acute), 
835  ;  acute,  syphilitic,  852  ;  in  newly-born, 
82 ;  tuberculous,  849  ;  symptoms,  850 ;  diag- 
nosis, 851 ;  treatment,  851. 

Osteo-periostitis,  chronic,  syphilitic,  853. 

Osteotomy  in  rickets,  237. 

Ostitis,  primary,  followed  by  joint  disease,  838 ; 
simulated  by  scurvy,  214. 

Otitis,  acute,  879 ;  etiology,  879 ;  lesions,  879  ; 
catarrhal  form,  880  ;  phlegmonous  form,  880  ; 
symptoms,  880  ;  local  appearances,  882  ;  diag- 
nosis, 882 ;  prognosis,  882 ;  complications  and 
sequelae,  882;  treatment,  884;  cerebral  ab- 
scess in  725,  883 ;  thrombosis  of  lateral  sinus 
in,  883  ;  facial  paralysis  in,  884 ;  labyrinth  in, 
884;  mastoid  disease  in,  883;  meningitis  in, 
883  ;  chronic,  in  late  syphilis,  1064 ;  reflex 
couch  from,  472 ;  frequent  attacks  of,  with 
adenoids,  264;  in  influenza,  1071 ;  in  scarlet 
fever,  900 ;  in  syphilis,  1057 ;  in  typhoid 
fever,  1013;  adenitis  complicating,  821. 
Overlying,  causing  death  by  asphyxia,  42. 
Oxyuris  vermicularis  (see  Worms,  Intestinal), 

400. 
OzcTna   in    late    syphilis,   1064  (see   Khinitis, 
Atrophic),  435;  syphilitic,  436. 

Pachymeningitis,  acute,  703  ;  chronic  (interna), 
703  ;  symptoms,  704;  treatment,  705  ;  syphi- 
litic, 1057  ;  meningeal  hsemorrhagc  from,  746 ; 


INDEX. 


1109 


hsemorrhagic,    703  ;   pseudo  -  membranous, 
703. 

Pack,  cold,  47  ;  hot,  54  ;  mustard,  52. 

Palate,  cleft,  238;  deformities  of,  stigmata  of 
degeneration,  757  ;  diphtheritic  paralysis  of, 
790 ;  hard,  ulceration  of,  250  ;  in  late  syphilis, 
10»;4 ;  soft,  lesions  of,  in  hereditary  syphilis, 
436. 

Pancreas,  ferments  of,  281 ;  syphilis  of,  1057 ; 
tuberculosis  of,  1032. 

Paralysis,  ascending,  781 ;  atrophic  (see  Paral- 
ysis, Infantile,  Splnal),  770 ;  birth,  105, 
741 ;  atrophy  and  sclerosis  following,  742 ; 
meningo-encephalitis,  741 ;  secondary  degen- 
erations following,  742 ;  symptoms,  742  ;  diph- 
theritic, 790;  frequency,  790  ;  time  of  occur- 
rence, 790  ;  extent  and  distribution,  790  ; 
symptoms,  790;  treatment,  792;  Erb's,  110; 
facial,  108, 792 ;  etiology,  793  ;  prognosis,  793  ; 
diagnosis  and  treatment,  794 ;  in  acute  otitis, 
884  ;  hysterical,  688 ;  in  compression-myeli- 
tis, 769  ;  in  multiple  neuritis,  787  ;  in  myelitis, 
767 ;  Landry's,  781 ;  of  face  in  newly  born, 
108 ;  of  the  upper  extremity  in  newly  born, 
109  ;  peripheral,  105  (see  also  Neuritis,  Mul- 
tiple), 785;  post-diphtheritic,  962;  pseudo- 
hypertrophic, 783  ;  simulated  by  scurvy,  214. 

Paralysis,  infantile  cerebral,  105,  740  ;  acute  ac- 
quired, 745;  birth,  741;  of  intra-uterine  origin, 
740 ;  varieties  and  symptoms,  740,  742,  747 ; 
prognosis,  748;  diagnosis,  749;  treatment, 
749. 

Paralysis,  infantile  spinal,  770;  etiology,  771 ; 
symptoms,  772  ;  course,  773  ;  diagnosis,  776  ; 
from  transverse  myelitis,  776 ;  from  mul- 
tiple neuritis,  776  ;  from  cerebral  palsy,  776  ; 
distribution  of  primary  paralysis,  773 ;  elec- 
trical reactions,  774,  777  ;  residual  paralysis 
and  deformity,  774 ;  prognosis,  777  ;  treat- 
ment, 777 ;  mechanical,  778. 

Paraplegia,  Pott's  (see  Mvelitis,  Compression), 
768 ;  spa.stic,  740. 

Paregoric,  dosage  of,  51. 

Parotitis,  epidemic  (see  Mumps),  947. 

Paste,  mustard,  52. 

Pasteurized  milk,  145. 

Pathology,  general  considerations  of,  38. 

Pavor  nocturnus,  694. 

Peliosis  rheumatica,  815. 

Pelvis,  deformities  of,  in  rickets,  227. 

Pemphigus,  gangrenosa,  872;  syphilitic,  105S; 
in  newly  born,  92. 

Pepsin  in  stomach  secretion,  280. 

Peptonized  milk,  preparation  of,  148;  partially, 
148;  completely,  148. 

Pericarditis,  569;  etiology,  569;  acute,  in  bron- 
cho-pneumonia,   506 ;    chronic,   with   adhe-  | 


sions,  573;  diagnosis,  572 ;  dry,  570;  e.xternal, 
570 ;  in  newly  born,  82 ;  in  rheumatism,  1087  ; 
mediastinal,  570 ;  prognosis,  572 ;  purulent, 
570  ;  sero-tibrinous,  570  ;  symptoms,  571 ; 
treatment,  573 ;  tuberculous,  570 ;  with  etfu- 
sion,  570 ;  with  eti'usion  of  blood,  570 ;  with 
lobar  pneumonia,  517 ;  with  pleuro-pneu- 
monia,  532  ;  with  transudation  of  serum,  569. 

Pericardium,  congenital  absence  ot,  565 ;  tuber- 
culosis of,  1031. 

Perinephritis,  631 ;  etiology,  631 ;  symptoms, 
632 ;  diagnosis,  633 ;  diagnosis  from  hip  dis- 
ease, 633;  diagnosis  from  p.soas  abscess,  633; 
prognosis,  633;  treatment,  634;  acute  perito- 
nitis complicating,  416. 

Peritonaeum,  diseases  of,  415;  haemorrhage  into, 
in  newly-born,  97 ;  in  tuberculosis,  1032. 

Peritonitis,  acute,  415;  etiology,  415;  lesions, 
416;  fibrinous,  416;  serous,  416;  purulent, 
417;  symptoms,  417;  prognosis,  418;  treat- 
ment, 418;  chronic,  non-tuberculous,  419; 
with  ascites,  419 ;  fietal,  cause  of  malforma- 
tions, 307 ;  in  intussusception,  385 ;  in  newly- 
born,  81 ;  in  perforative  appendicitis,  391 ; 
pelvic,  from  gonorrhoea,  643 ;  tuberculous, 
420 ;  miliary,  with  general  tuberculosis,  421 ; 
miliary,  with  ascites,  421 ;  fibrous  form,  422; 
ulcerative  form,  423 ;  with  tuberculous  mesen- 
teric glands,  424;  diagnosis,  424;  from  cir- 
rhosis of  liver,  424 ;  from  chronic  peritonitis, 
424;  prognosis,  425;  treatment,  -425;  lapa- 
rotomy in,  425 ;  \yith  intestinal  ulcers,  361 ; 
with  lobar  pneumonia.  517. 

Perityphlitis  (see  Appendicitis),  389. 

Perleche,  240. 

Perspiration  (see  Sweating),  858. 

Pertussis,  936  ;  broncho-pneumonia  in,  .503, 940 ; 
complications,  940  ;  convulsions  in,  941 ;  diag- 
nosis, 942 ;  etiology,  936 ;  haemorrhages  in, 
940 ;  incubation,  937  ;  infective  period,  937 ; 
lesions,  937 ;  nervous  system  in,  941 ;  paraly- 
sis in,  940 ;  predisposition  to.  936 ;  prognosis, 
943 ;  prophylaxis,  943 ;  respiratory  system  in, 
940;  symptoms,  938;  catarrhal  stage,  938; 
spasmodic  stage,  938;  declining  stage,  940; 
treatment,  944;  general,  944;  local,  944;  in- 
ternal, 945. 

Peyer's  patches,  in  typhoid  fever.  1009  ;  swol- 
len, in  acute  ilco-colitis,  340;  tuberculosis  of, 
361 ;  ulceration  of,  in  ileo-colitis,  .342. 

Pharyngitis,  acute,  256  ;  etiology,  256  ;  lesions, 
2.'>7  ;  diagnosis,  257  ;  treatment,  257  ;  uvulitis 
in,  258  ;  chronic  catarrhal,  sypliilitic.  1057. 

Pharynx,  diseases  of,  2.')6  ;  adenoid  vegetations 
of  vault,  2<)3,  431  ;  with  adenitis,  823 ;  diph- 
tlieria  of,  958  ;  diplitheritic  paralysis  of,  791  ; 
lesions  of,  in  hereditary  syphilis,  436 ;  pseu- 


1110 


INDEX. 


do-diphtheria  of,  1003 ;  reflex  cough  from, 
472 ;  retro- pharyngeal  abscess,  260  ;  syphi- 
litic ulceration  of,  1057  ;  syringing  of,  57. 

Phimosis,  635  ;  reflex  phenomena  from,  636. 

Phlebitis,  of  dural  sinuses,  724. 

Phosphorus  in  rickets,  235. 

Photophobia,  in  influenza,  1070 ;  in  measles, 
913  ;  in  tuberculous  meningitis,  717. 

Phthisis,  chronic,  1027,  1047. 

Physical  examination  of  the  child,  35 ;  order  to 
be  adopted  in,  38 ;  questions  to  be  investi- 
gated, 38. 

Pia  mater,  diseases  of  (see  Meningitis),  706. 

Pick's  paste,  870. 

Pigeon-  breast  in  adenoids,  265. 

Pin  worms  (see  Worms,  Intestinal),  400  ;  proc- 
titis from,  404. 

Pityriasis  of  tongue,  240. 

Plasmodium  malarite,  1075. 

Pleura,  efl'usion  into,  in  acute  nephritis,  616 ; 
tuberculosis  of,  1023,  1030. 

Pleurisy,  543  ;  dry,  544 ;  lesions,  544 ;  symp- 
toms, 545  ;  treatment,  545  ;  in  acute  broncho- 
pneumonia, 492 ;  purulent  (see  Empyema) 
548 ;  tuberculous,  dry  form,  544 ;  with  lobar 
pneumonia,  526  ;  with  serous  efl'usion,  545 ; 
lesions,  545  ;  symptoms,  546  ;  physical  signs, 
546 ;  diagnosis,  547 ;  prognosis,  547  ;  treat- 
ment, 547. 

Pleuro-pneumonia,  531 ;  lesions,  532 ;  symp- 
toms, 532  ;  prognosis,  533  ;  diagnosis,  533  ' 
treatment,  533  ;  pericarditis  in,  569,  571. 

Pueumococcus,  in  broncho-pneumonia,  482 ; 
lobar  pneumonia,  515  ;  peritonitis,  416  ;  diph- 
theria, 955,  969 ;  empyema,  548  ;  epidemic 
meningitis,  706 ;  malignant  endocarditis,  578. 

Pneumonia,  477;  anatomical  varieties  and  classi- 
fication of,  477 ;  broncho-  (see  Bboncho- 
PNEUMONiA,  Acute),  481 ;  catarrhal  (see 
Broncho-pneumonia,  Acute),  481 ;  chronic 
interstitial  (see  Broncho-pneumonia,  Chron- 
ic), 534  ;  in  newly  born,  81  ;  in  typhoid  fever, 
1013  ;  mixed  forms,  frequency  of,  478 ;  sources 
of  infection,  480 ;  varieties,  classification,  480 ; 
hypostatic,  534;  in  marasmus,  205;  lob- 
ular (see  Broncho-pneumonia,  Acute),  481 ; 
pleuro-  (see  Pleuro-pneumonia),  531 ;  syphi- 
litic, 1056;  tuberculous,  1025  (see  also  Tu- 
berculosis, Pneumonia)  ;  coui-se,  duration, 
termination,  1044 ;  diagnosis,  1044 ;  physical 
signs,  1043;  chronic,  1042. 

Pneumonia,  lobar,  514 ;  etiology,  514 ;  age, 
514 ;  previous  condition,  515  ;  previous  dis- 
ease, 515;  season,  514;  sex,  514;  crisis,  day 
of,  522 ;  frequency  of,  521  ;  complicating  in- 
fluenza, 1072  :  complications,  526  ;  course,  517 ; 
abortive,  518  ;  cerebral,  518  ;  prolonged,  518 : 


short,  518  ;  typical,  517  ;  diagnosis,  527 ;  from 
scarlet  fever,  528  ;  from  tonsillitis,  528  ;  from 
gastro-enteritis,  528  ;  from  malaria,  528  ;  from 
cerebro-spinal  meningitis,  528  ;  from  menin- 
gitis, 529  ;  from  empyema,  529 ;  from  pleu- 
ritic efl'usion,  529  ;  from  broncho-pneumonia, 
527  ;  lesions,  515 ;  seat  of,  515  ;  stages  of,  516  ; 
variations  in,  516  ;  in  other  organs,  517 ;  lysis, 
frequency  of,  521 ;  pathological  diflerentia- 
tion  from  broncho-pneumonia,  478  ;  physical 
signs,  523  ;  charts  of,  525  ;  in  exceptional  cases, 
524 ;  prognosis,  529 ;  relative  frequency  of, 
479  ;  symptoms,  517  ;  cerebral,  522  ;  convul- 
sions, 523;  cough,  519;  expectoration,  519; 
nervous,  522;  onset,  519;  pain, 519;  respiration, 
519 ;  temperature,  520  ;  termination,  526 ;  treat- 
ment, 530. 

Pneumothorax  in  pulmonary  tuberculosis,  1024. 

Pock,  in  vaccinia,  933 ;  in  varicella,  930. 

Poisons,  gastritis  from,  295,  296. 

Poisoning,  stomach-washing  in,  62. 

Poliencephalitis,  acute,  causing  cerebral  paraly- 
sis, 746. 

Poliomyelitis,  acute  (see  Paralysis,  Infantile 
Spinal),  770. 

Polydactyly,  stigma  of  degeneration,  757. 

Polydipsia  in  diabetes,  insipidus,  604 ;  mellitus, 
1091. 

Polypi,  nasal,  432;  rectal,  432. 

Polyuria,  604;  hysterical,  688;  in  diabetes  insi- 
pidus, 605 ;  mellitus,  1091. 

Porencephalus,  703. 

Pot-belly  in  rickets,  229. 

Pott's  disease  (see  Spine,  Caries  of),  838  ;  cervi- 
cal, causing  torticollis,  684 ;  reflex  cough  in, 
473. 

Poultices,  use  and  preparation  of,  53. 

Powders  for  skin,  4. 

Prsecordia,  bulging  of,  560,  584. 

Pregnancy,  efi'ect  on  woman's  milk,  134,  137; 
eff'ect  on  nursing  child,  168. 

Prematurity,  cause  of  marasmus,  204. 

Prepuce,  adherent,  635. 

Prickly  heat,  861. 

Proctitis,  404 ;  etiology,  404 ;  varieties,  405  ;  ca- 
tarrhal, 405;  membranous,  405;  ulcerative, 
405 ;  symptoms,  406  ;  treatment,  406. 

Prognosis,  general  consideration  of,  40. 

Progressive  muscular  atrophy,  hand  type,  782 ; 
peroneal  type,  783. 

Prolapsus  ani  (see  also  Eectum,  Prolapse  of), 
402  ;  from  proctitis,  405 ;  in  ileo-colitis,  346  ; 
in  membranous  ileo-colitis,  350. 

Prophylaxis,  general  consideration  of,  44. 

Proteids,  determination  of,  in  milk,  133  ;  func- 
tion in  diet,  123  ;  in  the  faeces,  283  ;  of  woman's 
milk,  130;  percentages  of,  in  modification  of 


INDEX. 


1111 


cow's  milk,  171, 179 ;  in  feeding  difficult  cases, 
181 :  vegetable,  124. 

Pseudo-diphtheria,  951,  1002;  bacillus,  978; 
broncho-pneumonia  in,  1005 ;  communica- 
bility,  1003;  diagnosis,  1006;  from  diphthe- 
ria, 974 ;  etiology,  1002 ;  frequency,  1002 ;  in 
measles,  1004;  in  scarlet  fever,  1004;  lesions, 
1003;  membranous  ga.stritis  with,  294;  mor- 
tality, 1007  ;  prognosis,  1006  ;  prophylaxis, 
1007;  quarantine  in,  1007;  streptococcus  in, 
1002 ;  symptoms,  1004 ;  primary  cases,  1004 ; 
secondary  cases,  1004 ;  treatment,  1007. 

Pseudo-hypertrophic  paralysis,  783. 

Pseudo-muscular  hypertrophy,  783. 

Pseudo-paralysis  in  rickets,  229;  in  scurvy, 
210,  214;  in  syphilis,  853, 1061. 

Psoas  abscess  in  spinal  caries,  842. 

Psoriasis  of  tongue,  240. 

Puberty,  delayed,  stigma  of  degeneration,  758 ; 
in  cretins,  754 ;  in  syphilis,  1065 ;  eft'ect  of,  on 
heart  in  valvular  disease,  581,  586;  reflex 
cough  of,  473. 

Pulse,  examination  of,  33 ;  in  early  life,  559. 

Purpura,  809;  arthritic,  815;  blood  in,  812; 
fulmmans,  814;  gangrenous,  815;  haematem- 
esis  in,  315 ;  haemorrhagica,  809,  813 ;  He- 
noch's, 814;  primary,  811 ;  lesions,  811;  pa- 
thology, 812;  clinical  types,  813;  diagnosis, 
815;  prognosis,  816;  treatment,  816;  rheu- 
matica,  815, 1089  ;  simplex,  809,  813 ;  simulat- 
ing scurvy,  214 ;  symptomatic,  810 ;  cachectic, 
810;  infectious,  810;  neurotic,  811 ;  mechan- 
ical, 810;  toxic,  810. 

Pyaemia,  in  newly  born,  79 ;  of  bone  (see  Ar- 
TiiKiTis,  Acute),  835. 

Pyelitis,  627  ;  etiology,  627  ;  lesions,  627  ;  symp- 
toms, 628 ;  treatment,  629. 

Pyelo-nephritis,  608,  627. 

I'ylephlebitis,  410 ;  cause  of  hepatic  abscess,  410. 

Pylorus,  atresia  of,  284 ;  stenosis,  dilated  stom- 
ach in,  303. 

Pyogenic  disea.scs,  acute,  in  newly  born,  79; 
clinical  varieties,  80;  distribution  of  lesions, 
83;  general  symptoms,  84;  prophylaxis,  84; 
prognosis,  85 ;  treatment,  85. 

Pyo-nephrosis  following  pyelitis,  627. 

Pyo-pneumothorax  in  pulmonary  tuberculosis, 
1024. 

Pyo-salpinx  from  gonorrhoeal  vaginitis,  643. 

Pyuria,  600;  in  pyelitis,  628. 

(Quartan  intermittent  fever,  1078. 
Quineke's  lumbar  puncture,  713. 
Quinine,  dosage,  1083;  methods  of  administra- 
tion, 1082;  scarlatiniform  rash,  905. 
Quinsy,  270. 
Quotidian  intermittent  fever,  1078. 


Pace,  influence  of,  upon  rickets,  216. 

Rachitis  (see  Rickets),  215. 

Reaction  of  degeneration,  in  Erb's  paralysis, 
111 ;  in  facial  paralysis,  109,  793  ;  in  infantile 
spinal  paralysis,  774,  777  ;  in  multiple  neu- 
ritis, 789. 

Rectal  injections,  astringent,  353 ;  tannic  acid, 
353  ;  hamamelis,  353 ;  nitrate  of  silver,  353 ; 
in  acute  ileo-colitis,  353;  opium  in,  353; 
saline,  353. 

Rectum,  diseases  of,  402 ;  administration  of 
drugs  by,  65 :  atresia  of,  307  ;  congenital  ob- 
struction of,  115;  enemata,  65;  feeding  by,  65; 
haemorrhage  from  ulcers  of,  406 ;  inflamma- 
tion of  (see  Pkoctitis),  404 ;  malformations 
of,  307;  prolapse  of,  402;  etiology,  402; 
symptoms,  402;  treatment,  402;  ulcers  of, 
405. 

Red  gum  (see  Miliaria  Rubra),  860. 

Regurgitation  of  food,  causes  of,  in  young  in- 
fants, 179;  nasal,  in  diphtheria,  791,  966,  975. 

Remittent  fever,  malarial,  1078. 

Renal  calculi,  630 ;  renal  colic,  630. 

Rennet,  ferment  in  digestion,  280. 

Respiration,  artificial,  methods  of,  70 ;  Cheyne- 
Stokes,  in  meningitis,  acute,  711 ;  in  menin- 
gitis, tuberculous,  718 ;  noisy,  at  night  with 
adenoids,  264;  paralysis  of,  in  diphtheria, 
791 ;  rapidity  and  characteristics,  460. 

Respiratory  system,  diseases  of,  428. 

Restlessness  at  night  in  rickets,  223. 

Rheumatism,  1085 ;  etiology,  1085 ;  symptoms, 
1086  ;  general  and  articular  manifestations, 
1086 ;  cardiac,  1087  ;  diagnosis,  1089  ;  progno- 
sis, 1089  ;  treatment,  1090  :  chorea  in.  674, 
1088 ;  endocarditis  in,  576, 1087  ;  erythema, 
1089;  purpura,  815,  1089;  scarlatinal,  902; 
simulated  by  scurvy,  214;  subcutaneous 
tendinous  nodules,  1088;  tonsillitis,  269, 
1088;  torticollis,  684,  1087. 

Rhinitis,  chronic,  432  ;  simple,  432 ;  hypertro- 
phic, 434;  atrophic,  435;  syphilitic,  435; 
pseudo  -  membranous,  437;  hypertrophic, 
cause  of  asthma,  474. 

Rhino-pharyngitis,  acute,  428 ;  in  influenza, 
1071  ;  with  adenoids,  263. 

Rhino-pharynx,  diphtheria  of,  958;  reflex 
cough  from,  472;  simple  catarrh  of,  in  acute 
otitis,  880. 

Ribemont's  laryngeal  tube,  71. 

Ribs,  beading  of,  early  .symptoms  in  rickets, 
223;  resection  of,  in  empyema,  556. 

Rice  water,  155. 

Rickets,  215;  etiology,  215;  diet,  215;  hygiene, 
216;  race,  216;  pathology,  217;  lesions.  218; 
microscopical,  222;  visceral,  222;  symptoms, 
222;  in  early  stages,  223  ;  course  and  termina- 


1112 


INDEX. 


tion,  231 ;  acute,  ?.32 ;  (see  also  Scorbutus), 
210  ;  congenital,  232 ;  constipation  in,  373  ; 
convulsions  in,  653 ;  diagnosis,  232 ;  from 
hydrocephalus,  232  ;  from  true  paralysis,  232  ; 

•  from  syphilis,  233 ;  from  scurvy,  214,  233 ; 
prognosis,  233 ;  prophylaxis,  233  ;  treatment, 
234 ;  of  deformities,  235 ;  dilatation  of  stomach 
in,  303  ;  late,  232  ;  spleen  in,  833. 

Eidge's  food,  156. 

Ringworm  of  scalp,  877. 

Kobinson's  patent  barley,  156. 

Eotary  spasm  of  head,  681. 

Kotheln  (see  Rubella),  926. 

Round  worms  (see  Worms,  Intestinal),  398. 

Rubella,  926  ;  complications  and  sequelae,  928 ; 
desquamation,  928 ;  diagnosis,  928  ;  eruption, 
927 ;  etiology,  927  ;  incubation,  927 ;  invasion, 
927 ;  post-cervical  glands,  928 ;  prognosis, 
928 ;  symptoms,  927  ;  treatment,  929. 

Rubeola  (see  Measles),  910. 

Saccharomyces  albicans  in  thrush,  251. 

Saint  Vitus's  dance  (see  Chorea),  673. 

Saline  solution,  as  rectal  injection,  353 ;  subcu- 
taneous injection  of,  in  cholera  infantum,  336 ; 
in  acute  inanition,  196. 

Saliva, -279. 

Salivation,  avoidance  of,  in  calomel  fumiga- 
tions, 448 ;  in  mumps,  948 ;  in  ulcerative 
stomatitis,  248. 

Salts,  inorganic,  in  modification  of  cow's  milk, 
172;  mineral,  function  of,  in  diet,  126;  of 
cow's  milk,  14;  of  woman's  milk,  131. 

Sarcoma,  of  brain,  728  ;  of  kidney,  624 ;  of  spi- 
nal cord,  778. 

Scabies,  875. 

Scalp,  pustular  eczema  of,  865 ;  ringworm  of, 
877 ;  seborrhoea  of,  862. 

Scapula,  angel-wing  deformity  of,  776. 

Scarlatina  (see  Scarlet  Fever),  888  ;  anginosa, 
1004. 

Scarlatiniform  erythema,  causes  of,  905. 

Scarlet  fever,  888 ;  adenitis  following,  820  ;  al- 
buminuria in,  901 ;  angina  in,  899  ;  membra- 
nous, 899 ;  gangrenous,  900  ;  cellulitis  of  neck 
in,  900 ;  complications  and  sequelaj,  899 ;  des- 
quamation, 892;  diagnosis,  904;  diphtheria 
in,  899;  disinfection  after,  906;  duration  of 
infective  period,  890  ;  eruption,  891 ;  etiology, 
888 ;  gangrene  in,  903 ;  heart  in,  903 ;  incu- 
bation of,  889 ;  invasion,  891 ;  joints  in,  901  ; 
kidneys  in,  901 ;  lesions,  891 ;  lungs  in,  902 ; 
lymph  nodes  in,  900 ;  mode  of  infection,  889  ; 
mortality  in,  905  ;  mj-ocarditis  in,  588  ;  other 
infectious  diseases  with,  903;  otitis  in  879, 
900 ;  predisposition  to,  888  ;  prognosis,  905  ; 
prophylaxis,  906 ;  pseudo-diphtheria  in,  899, 


1004 ;  quarantine  in,  906 :  relapses,  recur- 
rences, and  second  attacks,  898  :  symptoms, 
891 ;  mild  cases,  893 ;  moderate  cases,  894 ; 
severe  cases,  895  ;  malignant  or  cerebral  cases, 
897 ;  surgical,  897  ;  throat  in,  899 ;  treatment, 
908. 

Schultze's  metliod  of  inducing  artificial  respira- 
tion, 70. 

Sclerema,  116  ;  in  cholera  infantum,  335. 

Scorbutus,  209;  etiology,  210:  symptoms,  211; 
lesions,  212;  diagnosis,  214;  prognosis,  214; 
treatment,  dietetic,  in,  215;  ulcerative  stoma- 
titis in,  248. 

Scrofula  (see  Adenitis,  Tuberculous),  824; 
(see  Tuberculosis). 

Scurvy  (see  Scorbutus),  209. 

Seborrhoea,  862. 

Seborrha?ic  eczema,  865. 

Seller's  alkaline  solution,  56. 

Senses,  special,  development  of,  25. 

Sepsis  in  newly  born,  79. 

Septum  nasi,  ulcer  of,  with  haemorrhage,  439. 

Serous  membranes,  frequency  of  disease,  38. 

Serum  diagnosis  of  typhoid  fever,  1014. 

Serum-therapy  of  diphtheria,  988. 

Sewer-gas,  influence  on  sore  throat,  1003. 

Shock  in  intussusception,  384. 

Shower  bath,  55. 

Sight,  when  developed,  25. 

Sigmoid  flexure,  length,  281. 

Singultus,  682. 

Sinuses  of  dura  mater,  thrombosis  of,  723 ;  lat- 
eral, in  otitis,  883. 

Skin,  diseases  of,  858 ;  anomalies  of,  as  stig- 
mata of  degeneration,  757 ;  of  newly  born, 
858 ;  care  of,  in  newly  born,  4. 

Skull,  asymmetry  of,  in  birth  paralysis,  745; 
sutures,  separation  of,  in  hj'drocephalus,  737 ; 
syphilitic  nodes  on,  856. 

Sleep,  disorders  of,  692;  disturbed,  7,  692;  from 
insutficient  food,  163;  with  hypertrophy  of 
tonsils,  272 ;  in  intestinal  indigestion,  366  ;  in 
rickets,  223 ;  with  adenoids,  264 ;  excessive, 
695;  inspection  during,  32;  proper  periods 
of,  6. 

Sleeplessness,  692. 

Smallpox,  protection  against  (see  Vaccina- 
tion), 931. 

Smegma,  635,  638. 

Smell,  sense  of,  when  developed,  27. 

Snoring,  with  adenoids,  264  ;  hypertrophied 
tonsils,  272. 

Snuffles,  syphilitic,  435,  1059. 

Spasm,  carpo-pedal  (see  Tetany),  668;  haltit, 
679  ;  nodding,  of  the  head,  681 ;  rotary,  of  the 
head,  681. 

Speech,  disorders  of,  690;  when  acquired,  27. 


INDEX. 


1113 


Spina  bifida,  759;  varieties,  760;  symptoms, 
762;  prognosis,  764;  diagnosis,  764;  treat- 
ment, 764;  with  congenital  hydrocephalus, 
736. 

Spina  ventosa  (see  Osteo-myelitis,  Tibercu- 
Lous),  849. 

Spinal  cord  (see  Cord,  Spiral),  759. 

Spine,  angular  curvature  of,  in  caries,  841 ; 
caries  of,  833;  symptoms,  839;  cervical,  839; 
dorsal,  840;  lumbar,  840;  physical  examina- 
tion, 841;  course,  841;  prognosis,  842;  diag- 
nosis, 843 ;  treatment,  843 ;  abscesses  in,  842 ; 
causin"  compression  of  cord,  769 ;  curvature 
of,  in  hip  disease,  846;  hysterical  aftections 
of.  686 ;  in  rickets,  225 ;  lateral  deviation  of, 
843 ;  Pott's  disease  of  (see  Spine,  Caries  of), 
838. 

Spleen,  diseases  of,  832 ;  amyloid  degeneration 
of,  834;  displacement  of,  37  ,  enlargement  of, 
837 :  in  acute  disease,  833 ;  in  chronic  cardiac 
disease,  582 ;  in  chronic  discaflc,  833  ;  in  cirrho- 
sis of  liver,  412 ;  in  leucaemia,  806  ;  in  malaria, 
1079 ;  in  pseudo-leuctemic  anaemia,  801 ;  in 
rickets,  222 ;  in  simple  anaemia,  798 ;  in  ty- 
phoid fever,  1010 ;  with  amyloid  liver,  413 ; 
in  diphtheria,  961;  in  hereditary  syphilis, 
1056 ;  in  late  syphilis,  1065 ;  in  tuberculosis, 
1041 ;  now  growths  and  tumourS  of,  834 ;  posi- 
tion and  methods  of  examination,  832 ;  weight, 
832. 

Sponge  bath,  cold,  55. 

Sponging,  cold,  47. 

Spotted  fever  (see  Meningitis,  Acute),  712. 

Spray,  nasal,  55 ;  steam,  59. 

Sprue  (see  Thrush),  250. 

Spurious  hydrocephalus,  334. 

Stammering,  691. 

Staphylococcus,  in  pseudo-diphtheria,  1002  ;  in 
furunculosis,  871 ;  in  acute  broncho-pneu- 
monia, 482 ;  in  diphtheria,  960  ;  in  empyema, 
549. 

Starch,  in  the  faeces,  test  for,  284;  objections  to, 
a.s  food  of  young  infants,  125. 

Stenosis,  laryngeal,  in  acute  catarrhal  laryn- 
gitis, 442;  in  membranous  laryngitis,  446;  in 
syphilitic,  457 ;  of  pylorus,  dilated  stomach 
in,  303. 

Stercoraceous  vomiting,  in  appendicitis,  392 ;  in 
intussusception,  382. 

Sterilization  of  milk,  143;  changes  produced 
by,  144;  at  212°  F.,  144;  at  low  temperature, 
145;  indications  for,  147. 

Sterno-ma.stoid,  haematoma  of,  94;  spasm  of 
(see  Torticollis). 

Stigmata  of  degeneration,  757. 

Stimulants,  alcoholic,  49  ;  indications,  49  ; 
contra- indications,  49 ;  administration,  49. 


Stomach,  diseases  of,  278 ;  absorption  from,  281 ; 
bacteria  of,  281 ;  capacity  of,  279 ;  congestion 
of,  in  acute  gastro-enteric  infection,  320  ;  de- 
velopment of,  279 ;  digestion  in,  279 ;  dura- 
tion of,  280 ;  dilatation  of,  302 ;  in  chronic 
gastric  indigestion,  299  ;  in  rickets,  229  ;  ha;m- 
orrhage  from,  305 ;  in  newly  born,  103 ;  in 
scurvy,  214 ;  inflammation  of  (see  Gastritis), 
293;  malformations  and  malpositions  of,  284; 
round  ulcer  of,  in  chlorosis,  800 ;  thrush  in, 
252,  tuberculosis  of,  1032;  ulcer  of,  304;  in 
newly  born,  304  ;  from  follicular  ga.stritis, 
304;  tuberculous,  304;  round,  perforating, 
304 ;  symptoms,  305 ;  treatment,  305. 

Stomach-washing,  in  acute  gastritis,  296;  in 
acute  indigestion,  292 ;  in  chronic  indiges- 
tion, 300 ;  in  gastro-intestinal  infection,  328 ; 
method,  60;  indications  for,  61. 

Stomatitis,  aphthous  (see  Herpetic  Stomatitis), 
246  ;  catarrhal,  245 ;  etiology,  245 ;  lesions,  245 ; 
symptoms,  245  ;  treatment,  246 ;  in  measles, 
920 ;  diphtheritic,  253,  959 ;  follicular  (see 
(Herpetic  Stomatitis),  246;  gangrenous,  254; 
etiology,  254;  lesions,  254;  symptoms,  254; 
treatment,  256 ;  gonorrhoeal,  253 ;  treatment, 
253  ;  herpetic,  246  ;  etiology,  246  ;  lesions,  247  ; 
symptoms,  247  ;  treatment,  248 ;  parasitic  (see 
Thrush),  250;  syphilitic,  253;  ulcerative, 
248;  etiology,  248;  lesions,  248;  symptoms, 
248 ;  treatment,  249 ;  vesicular  (see  Herpet- 
ic Stomatitis),  246. 

Stone,  in  the  kidney,  6-30;  in  the  bladder,  650. 

Stools,  blood  in,  from  ulcer  of  stomach,  304 ;  in 
catarrhal  ileo-colitis,  346,  347 ;  in  membra- 
nous ileo-colitis,  350  ;  in  intussusception,  382, 
383 ;  in  purpura,  813  ;  fat  in,  test  for,  314  ; 
green,  explanation  of,  314 ;  in  acute  intestinal 
indigestion,  314;  in  cholera  infantum,  333; 
in  gastro-duodenitis,  297  ;  in  intestinal  indi- 
gestion, chronic,  364,  367;  in  simple  gastro- 
enteric infection,  321 ;  indication  of  improper 
feeding,  163  ;  mucus  in,  in  malnutrition,  200; 
undigested  casein  in,  in  chronic  gastric  indi- 
gestion, 299. 

Strabismus,  in  acute  meningitis,  711  ;  stigma  of 
degeneration,  757 ;  with  tumour  of  crura 
cerebri,  731. 

Streptococcus,  antito.\ine,  1007;  pyogenes,  in 
acute  broncho-pneumonia,  482  ;  in  complica- 
tions of  scarlet  fever,  899  :  in  dernuititis  gan- 
grenosa, 873;  in  diphtheria,  955,  960,  969;  in 
empyema,  548;  in  peritonitis,  acute,  416;  in 
pseudo-diphtheria,  1002  ;  in  scarlet  fever,  888. 

Stridor,  in  catarrhal  spasm  of  laryn.x,  440;  in 
acute  catarrhal  laryngitis,  443. 

Strophulus  (see  Miliaria  Eubra),  860;  (see 
Urticaria),  874. 


1114 


INDEX. 


Struma  (see  Tuberculosis). 

Strychnine  in  acute  broncho-pneumonia,  510. 

Stupe,  turpentine,  52. 

Stuttering,  691. 

Subcutaneous  tendinous  nodules  in  rheuma- 
tism, 1088. 

Sucking,  278 ;  as  a  bad  habit,  G95. 

Sudamina,  860. 

Sudden  death,  chief  causes  of,  42. 

Sugar,  cane,  derivatives  in  digestion,  281  ;  sub- 
stitute for  milk-sugar,  125,  183;  milk,  deter- 
mination of,  133 ;  in  feeding  difficult  cases, 
181 ;  percentage  of,  in  woman's  milk,  131 ; 
milk,  derivatives  in  digestion,  281 ;  percent- 
ages of  in  modification  of  cow's  milk,  171 ; 
solutions,  rules  for  making  175 ;  stools  in 
difficult  digestion  of,  365 ;  symptoms  of  de- 
ficiency of,  in  food,  179  ;  symptoms  of  excess 
of,  in  food,  179. 

Summer  diarrhoea,  316. 

Suppositories,  in  chronic  constipation,  376 ; 
medicated,  376  ;  proctitis  from  long  use  of, 
404. 

Suprarenal  capsules,  in  syphilis,  1057;  tuber- 
culosis, 1032 ;  htemorrhage  into,  98. 

Sutures,  closures  of,  22;  premature  ossification, 
23;  separation  of,  in  hydrocephalus,  737. 

Sweating,  in  infants,  858 ;  of  head  in  rickets, 
223  ;  in  tuberculosis,  1040. 

Symptomatology,  general  considerations,  31. 

Syndactyly,  stigma  of  degeneration,  757. 

Synovitis,  acute  purulent  (see  Arthritis, 
Acute),  835  ;  scarlatinal,  902. 

Syphilis,  1052  ;  acute  epiphysitis  in,  851 ;  symp- 
toms, 852;  diagnosis,  853;  treatment,  853; 
acute  osteo-myelitis  in,  852  ;  bone  lesions  in, 
851 ;  chronic  osteo-periostitis  in,  853  ;  lesions, 
854 ;  symptoms,  856  ;  diagnosis,  856  ;  treat- 
ment, 857 ;  dactylitis  in,  857  ;  of  larynx,  457  ; 
pseudo-paralysis  in,  853  ;  spleen  in,  833  :  ac- 
quired, 1052;  symptoms,  1053. 

Syphilis,  hereditary,  1053  ;  adenitis  in,  823  ; 
bones,  1055  ;  CoUes's  law,  1054;  coryza,  1059  ; 
diagnosis,  1065;  eruption,  1060;  etiology, 
1053 ;  evidences  of,  in  foetus,  1058 ;  fissures 
and  mucous  patches,  1060;  genito-urinary 
organs,  1057;  haemorrhages,  1061;  lesions, 
1055 ;  liver,  1055 ;  nails,  1061 ;  nervous  sys- 
tem, 1057 ;  nose,  1056 ;  organs  of  special  sense, 
1057;  prognosis,  1065;  prophylaxis,  1066; 
pseudo-paralysis,  1061  ;  rhinitis  of,  435 ; 
spleen,  1056  ;  symptoms,  1058  ;  at  birth,  1058  ; 
date  of  appearance,  1059  ;  constitutional, 
1059 ;  local,  1059  ;  treatment,  1067  ;  local, 
1069;  late  hereditary,  1062;  bones,  1063; 
skin,  1064  ;  spleen,  1065  ;  teeth,  1062  ;  tertiary, 
chronic  laryngitis  in,  457  ;  intubation,  458. 


Syringe,  nasal,  56  ;  for  antitoxine,  990. 
Syringo-myelia,  779. 
Syringo-myelocele,  761. 

Tache  c'erehrale  in  tuberculous  meningitis,  718. 

Tachycardia,  590. 

Taenia,  cucumerina  or  elliptica,  396 ;  flava 
punctata,  397  ;  nana,  397  ;  saginata  or  medio- 
cauellata,  396  ;  solium,  396. 

Tannic  acid  as  rectal  injection,  353. 

Tapeworms,  395. 

Tar  ointment  in  eczema,  870. 

Taste,  when  developed,  27. 

Teeth,  27 ;  eruption  of  first  set,  28 ;  permanent 
set,  29 ;  presence  at  birth,  28  ;  care  of,  3  ;  de- 
cayed, cause  of  adenitis,  823 ;  delayed,  in 
rickets,  230;  grinding  of,  in  intestinal  in- 
digestion, 366 ;  Hutchinson's,  in  syphilis, 
1062. 

Teething,  reflex  symptoms  from,  243. 

Temperature,  at  birth,  35 ;  best  taken  in  rec- 
tum, 35;  in  childhood,  35;  subnormal,  36; 
raised  by  artificial  heat,  36 ;  variations  of,  in 
health,  36  ;  general  consideration  of,  46 ;  of 
nursery,  9. 

Tenesmus,  from  proctitis,  405 ;  in  intussuscep- 
tion, 384 ;  in  membranous  ileo-colitis,  350 ; 
treatment  of,  353. 

Tent  for  inhalation  and  vapourization,  58. 

Tertian  intermittent  fever,  1078. 

Testicle,  retraction  of,  with  renal  calculus,  630 ; 
syphilis  of,  1057;  tuberculosis  of,  1032;  un- 
descended, 637. 

Tetanus,  in  the  newly  born,  87;  lesions,  88; 
symptoms,  88 ;  prognosis,  89 ;  prophylaxis, 
89  ;  treatment,  89 ;  antitoxine  in,  90. 

Tetany,  668;  etiology,  668;  pathology,  669; 
symptoms,  669 ;  duration,  669 ;  diagnosis, 
670  ;  prognosis,  671 ;  treatment,  671 ;  in  rick- 
ets, 231 ;  Trousseau's  symptom  in,  669. 

Therapeutics,  general  consideration  of,  45. 

Thirst,  in  diabetes  insipidus,  605 ;  mellitus, 
1091 ;  in  hot  weather,  324. 

Thomsen's  disease,  682. 

Thoracoplasty,  557. 

Thorax,  description  of,  459 ;  measurements  of, 
20,  24 ;  causes  of  deformity,  24. 

Threadworms  (see  Worms,  Intestinal),  400. 

Throat,  diseases  of  (see  Pharynx  and  Ton- 
sils) ;  importance  of  inspection  of,  37. 

Thrombosis,  593 ;  cachectic,  of  dural  sinuses, 
723  ;  in  diphtheria,  961,  971 ;  in  infectious  dis- 
eases, 593;  inflammatory,  of  dural  sinuses, 
724;  of  internal  jugular  vein,  593;  of  lateral 
sinus  in  acute  otitis,  883 ;  of  sinuses  of  dura 
mater,  723 ;  of  the  aorta,  593  ;  of  the  vena 
cava,  593  ;  septic,  of  dural  sinuses,  724. 


INDEX. 


1115 


Thrush,  250 ;  etiology,  250 ;  lesions,  251 ;  symp- 
toms, 252 ;  treatment,  252. 

Thymus,  abscess  of,  syphilitic,  1057  ;  dulness 
due  to,  4G1 ;  enlargement  of,  causing  convul- 
sions, 43  ;  tuberculosis  of,  1032. 

Thyroid  extract  in  cretinism,  755. 

Thyroid  gland,  congenital,  absence  of,  in  cre- 
tinism, 752. 

Tibia,  deformities  of,  in  rickets,  228  ;  enlarged 
epiphysis  in  rickets,  218;  sabre- blade  de- 
formity in  syphilis,  854. 

Tinea  tonsurans,  877  ;  treatment,  878. 

Toes,  clubbing  of,  in  congenital  heart  disease, 
566. 

Tongue,  diseases  of,  240 ;  bifid,  239  ;  congenital 
hypertrophy  of,  239;  epithelial  desquama- 
tion of,  240 ;  geographical,  241 ;  inflamma- 
tion of,  241  ;  malformations  of,  239 ;  ulcer  of 
frenum,  242. 

Tongue-sucking,  698. 

Tongue-swallowing,  242. 

Tongue-tie,  239. 

Tonics,  50. 

Tonsils,  diseases  of,  208 ;  anatomy  of,  268 : 
chronic  hypertrophy  of,  272;  etiology,  272; 
symptoms,  272 ;  treatment,  273 ;  diphtheria 
of,  958,  964  ;  hypertrophy  of,  cause  of  asthma, 
474 ;  hypertrophy  of,  in  rickets,  230  ;  removal 
advised  in  tuberculous  adenitis,  830  ;  with 
adenitis.  823  ;  pseudo-diphtheria  of,  1003 ; 
membrane  upon,  in  scarlet  fever,  891. 

Tonsillitis,  acute  catarrhal,  268 ;  croupous  (see 
Pseudo-Diphtheria),  1002  ;  follicular,  269  ; 
etiology,  269  ;  lesions,  269  ;  symptoms,  269  ; 
diagnosis,  270 ;  treatment,  270 ;  in  rheuma- 
tism, 1088  ;  phlegmonous,  270  ;  etiology,  270 ; 
symptoms,  271 ;  treatment,  271 ;  acute  otitis 
in,  879. 

Tonsillotomy,  273. 

Torticollis,  683  :  etiology,  683  ;  prognosis,  684  ; 
treatment,   685 ;  congenital,  684 ;  from   cer- 
vical Pott's  disease,  684,  840 ;    from  haema- 
toma  of  sterno-mastoid,  94  ;  hysterical,  687  ; 
in   phlegmonous    tonsillitis,   271 ;    in  retro- 
pharyngeal abscess,  260;  malarial,  684,  1079  ; 
rheumatic,  684, 1087  ;  spasmodic,  683. 
Touch,  when  developed,  26. 
Toxaemia,  in    intestinal    indigestion,    chronic, 
365  ;  vomiting  in,  286 ;  in  acute  gastric  indi- 
gestion, 291. 
Toxines,  of  diphtheria,  956. 
Trachea,  diphtheria  of,  959. 
Tracheotomy,  for  foreign  body  in  larynx,  459  ; 
in  membranous  laryngitis,  statistics  of,  449, 
999 ;  in  retro-ffisophageal  abscess,  278. 
Trismus,  in  tetanus,  87. 
Trypsin,  281. 


Tubercle  bacilli  (see  Bacillus  of  Tubercu- 
losis), 1020. 
Tuberculin  test  in  herds,  138. 
Tuberculosis,  1016  ;  age,  1017  ;  anaemia,  1042  ; 
bacillus  of  (see  Bacillus  of  Tuberculosis), 
1016;  of,  in  milk,  145;  brain,  1031;  bron- 
chial lymph  nodes  in,  1020 ;  clinical  forms 
of,   1033  ;    broncho-pneumonia,   1023,    1036  ; 
chronic  phthisis,  1047^  chronic  pulmonary, 
1027  ;    congenital,    1018  ;    cases    resembling 
marasmus,  1033 ;  cases  resembling  a  contin- 
ued fever,  1034 ;  cough,  1040  ;  course,  1044  ; 
chronic,  1027,  1042;   diagnosis  from  maras- 
mus, 208,   1034;  from  typhoid,   1036;   from 
broncho-pneumonia,    1044;    etiology,    1016; 
expectoration,  1041 ;  general,  1033  ;  following 
measles,  922 ;   following  pertussis,  943 ;  fre- 
quency, 1016  ;  h£Emoptysis,  1041 ;  incipient, 
symptoms  in,  1025;  intestines,  360, 1032;  in- 
ti-a-uterine  infection,  1018  ;  kidney,  623, 1032 
lesions,    1022  ;     lesions,    pulmonary,    1023 
lesions,  visceral,   frequency   of,  1022;   liver, 
1031,   1041;    lungs,    calcareous    nodules    in 
1027 ;  caseous  degeneration  of,  1024 ;  cavitie 
in,  1024,  1043;  lymph  nodes,  bronchial,  1028 
1047  ;  diagnosis,  1049  ;  physical  signs,  1049 
mesenteric,  360, 1021  ;  mode  of  infection,  1018 
of  larynx,  456  ;  of  lymph  nodes,  cervical,  824 
of  pancreas,  1032 ;   paths  of  infection,  1020 
pericarditis   in,   571  ;  physical    signs,   1043 
pleura  in,  544, 1030  ;  pleuritic  pain,  1041 ;  pre- 
disposing causes,  1017  ;  prognosis,  1050  ;  pro- 
phylaxis, 1050  ;  spleen,  834, 1031, 1041 ;  stom- 
ach   in,    1032  ;    suprarenal    capsules,    1032 ; 
sweating,  1040;  testicle,  1032;  thymus  gland 
in,    1032  ;    treatment,    1051 ;   ulcerative   ap- 
pendicitis in,  390  ;   uro-genital  organs,  1032  ; 
varieties   at  different    ages,  1032 ;    wasting, 
1040. 
Tuberculous,   adenitis,    824;    meningitis.    715; 
nephritis,  623  ;  ostitis,  836  ;  pericarditis,  570  ; 
peritonitis,  420;  pleurisy,  544;  pneumonia, 
1036. 
Tumour,  abdominal,   in   intussusception,  383 
cerebral,  728  ;  varieties,   728 ;  location,  728 
etiology,  729;  symptoms,  729;  general,  729 
local,  730 ;  diagnosis,  732  :  from  cerebral  ab- 
scess, 733 ;  from  tuberculous  meningitis,  733 ; 
from  chronic  basilar  meningitis,  733;  from 
chronic  hydrocephalus,  733 ;  prognosis,  733 ; 
treatment,  733 ;  tuberculous,  1031 ;  fatty,  in 
cretinism,   754;  of  spinal   cord,   778;  medi- 
astinal, tuberculous  lymph  nodes,  1049;  of 
spleen,  834,  1065. 
Tunica  vaginalis,  hydrocele  of,  639. 
Turpentine  stupe,  preparation  of,  52. 
Tympanites  in  acute  peritonitis,  417  ;  in  intes- 


1116 


INDEX. 


tinal  indigestion,  366  ;  in  rickets,  229  ;  in  ty- 
phoid fever,  1010. 

Typlilitis  (see  Appendicitis),  389. 

Typhoid  fever,  1008  ;  age,  1008  ;  bacillus  of,  in 
milk,  145 ;  baths  in,  1016  ;  complications  and 
sequelae,  1013;  bowels  in,  1010;  diagnosis, 
1014;  duration,  1011;  eruption,  1010;  etiol- 
ogy, 1008;  intestinal  haemorrhage  in,  1012; 
intestinal  perforatioa  in,  1009,  1013;  lesions, 
1009  ;  nervous  symptoms,  1012  ;  onset,  1009  ; 
prognosis,  1015;  relapses,  1012;  scarlatini- 
form  erythema  in,  905 ;  spleen,  enlarged  in, 
1010;  symptoms,  1009;  temperature,  1011; 
treatment,  1015;  ulcerative  appendicitis  in, 
390  ;  Widal's  test  in,  1014. 

Ulcers,  catarrhal,  of  intestine,  841 ;  follicular, 
of  intestine,  341 ;  following  tuberculous  ade- 
nitis, 828 ;  of  stomach,  304 ;  follicular,  294 
tuberculous,  of  skin,  828,  1064;  syphilitic 
1064;  tuberculous,  of  intestine,  361,  1032 
typhoid,  1009. 

Umbilical  vessels,  arteritis  in  newly  born,  80 
phlebitis  in  newly  born,  81 ;  fistula,  112. 

Umbilicus,  hemorrhage  from,  in  newly  born, 
102;  hernia,  113;  inflammation  of  vessels  in 
newly  born,  80;  treatment  of  suppuration, 
85  ;  tumours  of,  111. 

Urachus,  persistent,  enuresis  from,  644. 

Urtemia,  acute,  in  scarlet  fever,  901 ;  in  acute 
nephritis,  617;  in  chronic  nephritis,  021. 

Ureter,  dilatation  of,  607;  supernumerary,  610. 

Urethra,  hiemorrhage  from,  in  newly  born,  104. 

Urethritis,  638;  gonorrhoeal,  638. 

Uric  acid,  in  anaemia,  798  ;  in  chorea,  677  ;  in 
cyclic  vomiting,  289 ;  in  malnutrition,  200 ; 
in  early  infancy,  595 ;  infarctions,  in  kidney, 
610 ;  causing  htematuria,  104. 

Urine,  acetone  in  (see  Acetoncria),  603 ;  ar- 
rest of  secretion  (see  Anuria),  604 ;  albumin 
in,  595 ;  blood  in  (see  H.ematukia),  598 ; 
"brick  dust"  in,  601;  composition  of,  596 ; 
daily  quantity  of,  594;  diacetic  acid  in,  603; 
examination  of,  37  ;  hyperacidity  of,  in  rheu- 
matism, 1091 ;  incontinence  of,  644 ;  with 
adenoids,  265 ;  in  diabetes,  1091 ;  in  myelitis, 
767  ;  in  vesical  calculus,  650  ;  indican  in  (see 
Indicanuria),  602 ;  in  infancy  and  child- 
hood, 594;  methods  of  collecting,  37,  594; 
microscopical  examination  of,  595 ;  physical 
characters  of,  595 ;  pus  in  (see  Pyuria),  600 ; 
reaction  of,  595 ;  specific  gravity  of,  595  ;  su- 
gar in,  596  (see  also  Glycosuria),  599; 
urea  in,  596 ;  uric  acid  in,  596  (see  also  Li- 
thuria),  601. 

Uro-genital  organs,  tuberculosis  of,  1032. 

Uro-genital  system,  diseases  of,  594. 


Urticaria,  874;  following  diphtheria  antitoxine, 
991 ;  in  influenza,  1073 ;  in  intestinal  indi- 
gestion, 367  ;  papulosa,  874 ;  scarlatiniform 
rash  with,  905. 

Uvula,  bifid,  239;  diphtheria  of,  958;  elonga- 
tion of,  258 ;  cause  of  a.sthma,  474 ;  causing 
cough,  472  ;  oedema  of,  258  ;  inflammation  of, 
258. 

Vaccination,  931 ;  choice  of  virus,  932 ;  meth- 
ods of,  932  ;  revaccination,  932. 

Vaccinia,  931 ;  complications  and  sequelae,  935 ; 
variations  in  course  of,  935. 

Vapourizer,  59. 

Vapour  bath,  54. 

Varicella,  929 ;  etiology,  929  ;  symptoms,  929 ; 
complications,  930 ;  diagnosis,  931 ;  gangre- 
nosa, 872,  930  ;  incubation,  929 ;  quarantine, 
931 ;  treatment,  931. 

Vegetables,  allowed  from  third  to  sixth  years, 
188 ;  forbidden  from  third  to  sixth  years, 
189. 

Vegetations  on  valves  in  endocarditis,  578. 

Vein,  internal  jugular,  thrombosis  of,  593  ;  um- 
bilical, 558. 

Veins,  abdominal,  dilated  in  cirrhosis  of  liver, 
412 ;  in  thrombosis  of  vena  cava,  593. 

Vena  cava,  thrombosis  of,  593. 

Ventricles,  cardiac,  relative  thickness  of,  560. 

Vertigo,  in  cerebral  abscess,  726  ;  in  cerebellar 
tumour,  732  ;  in  functional  disorders  of  heart, 
590. 

Vesical,  calculi,  650  :  spasm,  649. 

Viscera,  abdominal,  transposition  of,  308 ;  fre- 
quency of  inflammations  of,  39  ;  haemorrhages 
of,  in  newly  born,  97. 

Voice,  hoarse  or  husky,  with  adenoids,  264; 
nasal,  with  hypertrophy  of  tonsils,  272 ;  with 
adenoids,  264 ;  in  diphtheritic  paralysis,  791. 

Volvulus,  foetal,  cause  of  malformutioils,  307. 

Vomiting,  285;  from  overfilling  the  stomach, 
285 ;  in  acute  gastric  indigestion,  285 ;  in 
acute  intestinal  obstruction,  285;  in  perito- 
nitis, 285  ;  in  nervous  diseases,  285 ;  at  onset 
of  acute  infectious  disease,  286 ;  from  toxic 
substances  in  the  blood,  286 ;  reflex,  286 ; 
from  habit,  286;  chronic,  286;  of  blood,  in 
ulcer  of  stomach,  304 ;  stercoraceous,  in  ap- 
pendicitis, 392 ;  in  intussusception,  382 ;  cy- 
clic, 287  ;  etiology,  288 ;  diagnosis,  289  ;  treat- 
ment, 289. 

Vulva,  herpes  of,  643. 

Vulvitis,  gangrenous,  644. 

Vulvo-vaginitis,  gonorrhoeal,  641 ;  symptoms, 
641 ;  diagnosis,  642  ;  treatment,  643 ;  simple, 
640  ;  symptorns,  641 ;  diagnosis,  642  ;  treat- 
ment, 643. 


INDEX. 


1117 


Walking,  causes  which  prevent,  25 ;  delayed,  in 
rickets,  228;  late,  in  malnutrition,  198;  when 
attempted,  25. 

Wasting,  in  tuberculosis,  1040;  simple  (see 
Marasmus),  204. 

Water,  function  of,  in  diet,  126. 

Weauing,  167 ;  time  for,  107  ;  indications  for, 
167;  sudden,  168. 

Weather,  hot,  prophylaxis  against  diarrhoea  in, 
325. 

Weight,  15;  at  birth,  16;  curve  during  first 
few  weeks,  16;  curve  of  first  year,  17;  from 
second  to  fifth  year,  19  ;  of  older  children, 
19 ;  from  birth  to  si.xteenth  year,  20  ;  best 
indication  of  nourishment,  163 ;  loss  of,  in 
acute  inanition,  195;  stationary,  indications 
in,  179 ;  symptom  of  inadequate  nursing, 
163. 

Werlhof  8  disease  (see  Puepura),  810. 


Wet-nurse,  in  acute  gastro-enteric  infection, 
327;  in  acute  inanition,  196;  selection  of, 
166  ;  dangers  of  syphilis,  1067. 

Wet-nursing,  166  ;  versus  artificial  feeding,  158 ; 
indications  for,  158;  disadvantages  of,  159; 
moral  question  involved  in,  159. 

Wheal,  in  urticaria,  874. 

Wheat  jelly  during  second  year,  186. 

Whey,  152. 

White-swelling  of  knee,  847. 

Whooping-cough  (see  Pektlssis),  936. 

Widal's  test  in  typhoid  fever,  1014. 

Winckel's  disease,  90. 

Worms,  intestinal,  395 ;  tapeworm,  395 ;  symp- 
toms, 397  ;  treatment,  397  ;  roundworm,  398 ; 
symptoms,  399 ;  treatment,  399 ;  thread- 
worms, 400 ;  symptoms,  400  ;  treatment,  401. 

Wrist,  enlarged  epiphyses  in  rickets,  227. 

Wry-neck  (see  Torticollis),  683. 


THE    END, 


(OP) 


SOUTHERN  regToL^/  ^""'^^^^'a 


000  432  636 


WS200 
HT58d 
1897 
Holt,  Luther  E 

The  diseases  of  infancy  and 
childhood;  for  the  use  of 
students  and  practitioners  of 
medicine 


WS200 
HT58d 

1897 
Holt,  Luther  E 

The  diseases  of  infancy  and  childhood; 
for  the  use  of  students  and  practi- 
tioners of  medicine 


CALIFORNIA  COLLEGE  OF  MEDICINE  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE.  CALIFORNIA  92664 


